Patient perspectives of recovery after hip fracture: a systematic review and qualitative synthesis

Figures & data

Table 1. Eligibility criteria.

	Inclusion	Exclusion
Participants	Age ≥ 60 years	Age < 60 years
	Isolated hip fracture	Multiple fractures
	First hip fracture	Subsequent hip fracture
	Non-pathological hip fracture	Pathological hip fracture
Intervention	Receipt of hospital and/or community rehabilitation	No rehabilitation received
Outcome	Post-operative patients’ perceptions of recovery after hip fracture (and/or rehabilitation as a key component to recovery)	Perceptions of recovery from persons other than those who incurred a hip fracture
Design	Qualitative semi-structured interview study	Other qualitative studies, e.g., ethnography
		Quantitative study
Other	English language	Non-English language

Figure 1. Thematic synthesis approach. Pink nodes reflect activities completed independently by three reviewers, blue nodes those completed through discussion, and green node final decision.

Figure 2. Study selection.

Table 2. Study and participant characteristics.

Study	Country, city	Setting	Timing of interview	Duration of interview	Sample size	Participants
Archibald 2003	UK, Bradford	Community	No mean reported; on discharge from community rehabilitation hospital	25–50 min	5	4 women, 1 man >65 years No cognitive impairment
Asplin 2019	Sweden, Molndal	Acute	Mean 8.8 days post-surgery	25–67 min; mean 42 min	19	13 women, 6 men 70–94 years Living at home No cognitive impairment
Brunn-Olsen 2018	Norway, near Olso	Community	3–4 months post-hip fracture	40–60 min	8	6 women, 2 men 69–91 years Living at home No cognitive impairment
Fox 2017	UK, North Bristol	Community	1st interview 8–12 weeks post-hip fracture; 2nd interview 6 months post-hip fracture; 3rd interview 12–15 months post-hip fracture	Phase 1: 25–105 min; mean 62 min; Phase 2: 36–71 min; mean 55 min; Phase 3: 28–70 min; mean 50 min	1st interview – 11; 2nd interview – 8; 3rd interview – 7	5 women, 6 men 69–92 years Living at home No cognitive impairment
Griffiths 2015	UK, West Midlands	Community	Two interviews 1st at 4 weeks post-surgery 2nd at 4 months post-surgery	20–90 min	31 23 patients 8 patient carer dyads	20 women, 11 men 61–96 years Living at home (28), residential (1) or nursing (2) home 12 participants with cognitive impairment.
Healee 2017	New Zealand, Auckland	Community	3 months–22 years post-hip fracture	60–90 min	16	70–92 years
Langford 2018	Canada, Vancouver	Community	4 months post-hip fracture	Not reported	23	12 women, 11 men 61–97 years Living at home alone (9), home with spouse/family (14) No cognitive impairment
Pol 2019	The Netherlands	Community	6–8 months post-hip fracture	∼1 h	19	12 women, 7 men 65–94 years Living at home alone in community (16), or alone in senior residence (3) No cognitive impairment
Schiller 2015	Canada, Vancouver	Community	Man 2.5 years post-hip fracture; Range 0.25–8 years	30–90 min	11	10 women, 1 man 60–90 years Living at home alone (10), home with spouse/family (3), or facility (2)
Segevall 2019	Sweden, mid Sweden	Community	3–5 weeks post-hospital discharge	32–128 min; median 59 min	13	7 women, 6 men 66–98 years Living at home No cognitive impairment
Sims-Gould 2017	Canada, Vancouver	Community	6 and 12 months post-hip fracture	5–30 min; mean 20 min	48; data analysed 45	32 women, 18 men >65 years Living at home alone (21), home with spouse (29) No cognitive impairment
Southwell 2020	UK, London	Acute	Mean 8.2 days post-surgery	20–57 min; mean 37 min; SD 10 min	15	7 women, 8 men >60 years Living at home No cognitive impairment
Stott-Eveneshen 2017	Canada, Vancouver	Community	6–12 months post-recruitment	5–30 min; mean 20 min	48 – 1st interview; 45 – 2nd interview	32 women, 18 men 65–98 years Living at home
Ziden 2010	Sweden, Gothenburg	Community	One month after hospital discharge and one year after hospital discharge	15–39 min; mean 27 min	18 – 1st interview; 15 – 2nd interview	13 women, 2 men 66–93 years Living at home No cognitive impairment

Table 3. Critical appraisal of study quality using the CASP qualitative appraisal tool.

Study	Aims	Method	Research design	Sampling	Data collection	Reflexivity	Ethical issues	Data analysis	Findings	Value of research
Archibald 2003	Y	Y	Y	N	N	N	Y	Y	Y	Y
Asplin et al. 2019	Y	Y	N	Y	Y	Y	Y	Y	Y	Y
Brunn-Olsen et al. 2018	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Fox et al. 2017	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Griffiths et al. 2015	Y	Y	N	Y	Y	Y	Y	Y	Y	N
Healee 2017	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Langford et al. 2018	Y	Y	Y	Y	Y	Y	N	Y	Y	Y
Pol et al. 2019	Y	Y	Y	Y	Y	N	N	N	Y	Y
Schiller 2015	Y	Y	N	Y	Y	N	N	Y	Y	Y
Segevall et al. 2019	Y	Y	Y	Y	N	N	Y	N	Y	Y
Sims-Gould et al. 2017	Y	Y	N	Y	Y	N	N	Y	N	N
Southwell et al. 2020	Y	Y	N	Y	Y	Y	Y	Y	Y	Y
Stott-Eveneshen 2017	Y	Y	N	Y	N	N	Y	Y	Y	Y
Ziden et al. 2010	Y	Y	N	Y	Y	Y	Y	N	Y	N

Table 4. Collating themes as described by original authors of qualitative interview into review themes: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support.

Author, year	Theme (sub-themes)	Supporting quote/text
Review theme: recovery as participation
Archibald, 2003	The recovery experience (the operation, beginning the struggle, regaining independence)	“By the time I moved to [the community hospital], I’d already got onto [walking] sticks. So I could go under my own steam to the toilet. [In the community hospital] I didn’t have any help in a morning with washing. They just gave me a bowl of water and I could do all that was necessary. Yes, it was nice being independent.”
Asplin, 2019	Ask me, I have goals	While participants expressed their rehabilitation goals clearly during the interviews, few experienced that they had been asked about their goals by PTs and OTs.
		“For me it is obviously, first and foremost, that I become independent in every way.”
		“That I can go to the toilet and take care of myself without having to always press the call button.”
		“I want to have full movement and be able to walk, cycle when it’s time, and maybe collect a dog from England …to be able to collect the dog I need to get around better than I do today. For me it’s all about getting back to a normal life, to do all the things that I want to do …I want to be fully mobile, I want to be able do everything myself.”
Bruun-Olsen, 2018	A span between self-reliance and dependency (a gap between expectations and reality, recovery self-reliance, recovery dependent on actions from others)	“I’m rather impatient as a person, so I would have liked to know how long it would take for me to be back to normal again …. I’d expected more follow-up at the short-term stay”
Griffiths, 2015	Mobility	“I can’t rush round like I did, but eventually that will come…I mean it’s pretty normal now, but I think it’s going to be a while before I can actually walk as I did and I probably won’t walk as I did…when I came home[from hospital] I was still hobbling…but now I’m more or less…walking normal, especially with the stick.”
	Valued day to day activities	“I’m back on what I call domestic duties—washing up! But the thing that is frustrating is I can’t get outside and do gardening”
		“I just miss getting up and getting out. I never stayed in. I’d go out in the morning and come back and then I’d go out again, I just used to go out looking round the shops. I just get these crossword books and I do those.”
	Recovery as a return to the pre-fracture state or as part of ageing and decline	The interviewee had difficulty distinguishing decline due to old age and change due to the fracture.
Healee, 2017	Restoring normalisation: regaining by pacing (time, age, perception, and compromise)	“Returning to normal [is] very important e it's getting back to [being] useful”
	Restoring normalisation: reasserting by permissioning (developmental life stage, diverse expectations)	Reasserting was restoring the older adult's usual psycho-social behaviours. These were the patterns and routines that underpinned the older adult's normal life behaviours.
	Restoring normalisation: reasserting by connecting (familiar situations and unfamiliar situations)	“Back with familiar things helps you become normal again. [It's] important to get back to your own bed and own toilet, your own pad. Back to your own routines.”
Langford, 2018	Loss of independence	“My frustration level of not being able to accomplish things that I did before this injury is still quite high.”
	Long recovery time	“I get so frustrated with myself because I can’t do a little bit of gardening and various things like that”
	Personality traits	Older adults also spoke of their motivation coming from their desire to do the things that they used to do, such as gardening or sports. One older adult was happy to be physically capable of doing what she enjoyed again, such as cooking.
Pol, 2019	Restrictions for everyday life (being less mobile, being dependent on mobility aids, being tired, being careful and concerned about falling again)	“Activities take up much more time; I did the gardening in a single day, and now I need three or four days because I get tired a lot sooner, and therefore, I divide up the activities”
	Performing everyday activities (doing activities in the same manner as before or differently, ceasing to do actives)	Most of the participants mentioned that they performed their everyday activities as before the hip fracture, but in a different way and in a way to cope with the implications of the hip fracture.
Segevall, 2019	Preparing to return home	Participants described that the work toward regaining independence started after surgery, with early mobilization, training with the physiotherapist, and preparing to return home.
Sims-Gould, 2017	Managing expectations	Most participants expected to be fully recovered within 6 months or less after their surgery for hip fracture, as told by their surgeon.
	This is life after fracture	One participant responded that “there is life after fracture,” and although she did not meet her mobility goals, she sees her recovery as a long-term journey requiring long-term engagement in her rehabilitation activities.
		“I’m realistic about my goals. I know at my age I can’t go back to all the activities I used to do.”
Southwell, 2020	Anxiety about the future	Participants who anticipated a short period of recovery projected their goals to the near future with the most frequently reported goal to return home and to return to previous activities.
		“I don’t mind if I can’t do a lot more than I did before…. If it doesn’t get any worse. I know I can’t be around forever, I’d like to, but.”
Stott-Eveneshen, 2017	Recovery goals (recovering mobility, return to pre-fracture activities, obtaining stable health)	The majority of participants who identified goals for themselves described targets that were broader and more fixed throughout their recovery. Recovering their mobility (60%), returning to pre-fracture activities (22%), and obtaining stable health (16%) were the most common goals identified. For some participants, these goals were specific (e.g., improving sleep habits, driving again, being able to do housework independently), yet fluid to change depending on how their recovery was progressing.
		Participants described a good social support network (34%), access to PT (34%), and a positive attitude (22%) as factors that supported their post-operative recovery and ability to implement their recovery goals.
Ziden, 2010	Experienced consequences one year after discharge (isolated life with more restricted activity and fewer social contacts, more insecure and afraid, disappointed and sad that identity and life have changed, satisfied with the situation or feeling even better than before)	“I was, how should I put it, very outgoing [before]. I wanted to be out. I wanted to go places and have visitors. I wanted to go to the theatre, cinema and stuff like that. Yes, on the whole to be out in society … And I can’t anymore.”
Review theme: feelings of vulnerability
Archibald, 2003	The recovery experience (the operation, beginning the struggle, regaining independence)	“I hated using the bedpan and I got very constipated. But it was easiest for the nurses. They preferred you to use a bedpan rather than a commode. And that really annoyed me when I was pressurised into using a bedpan.”
	The disability experience (disability, depending on others, housebound)	“I must have a Zimmer in front of me, because my legs are a bit wobbly. And I’m frightened, you know, of falling and ending up on the floor.”
		“[Before hip fracture] I could get to the shops; have a little three- quarters of an hour walk around the district. I always used to go down then I could finish going downhill home! [After fracture] I can get about the house, go up and down stairs but not go out, oh no. I couldn’t go out now”
Asplin, 2019	Accepting the situation whilst trying to remain positive	“You can’t expect, when you are old, that it will be as it was when you were younger … I’ll be 94 this month… so I am no youngster … if I am to carry on living it’s good to be able to manage reasonably well.”
	Uncertainties concerning the future	“…I’m worried about how it will be when I come home, and I know that I won’t be able to go out…I haven’t said this to anyone before now, but that’s how I feel, I am, I’m worried about it”
Bruun-Olsen, 2018	Feeling vulnerable (feeling of subservience, feeling of gloominess)	“I felt like being in another world. Suddenly other people decided on what I should do, and I did precisely what they told me, I did not dare to do otherwise”
		“I have been down in a black hole and I do not seem to get up again”
	Disrupted from a normal life (less independence and mobility, the impact of age)	“After the fracture, my children decided that I had to sell the house and move out. Naturally, that was necessary …… Everything was well before the fracture. After the fracture the consequences was a disrupted life, I have to say…..suddenly I was under surveillance.”
		“I will never be the person I was before the fracture. I used to be in good shape, despite my age. Now I ask myself: What is there really to look forward to when you are ninety?”
Fox, 2017	Effect on lifestyle (getting out of the house, informal social interactions, transport, family relationships, visiting family and friends, change in role, looking after others, want to be back to normal, spontaneity, independence, hobbies, ability to forget)	“Makes me feel awful… I’m missing out on such a lot. I mean it was my granddaughter’s – well I said, her birthday today. And they’re gone out, you know. Lots of things… I didn’t want to get like this. I wanted to be, when I finished work, I wanted to carry on and do things”
Fox, 2017	Emotional response to circumstances (prisoner, burden, mood change, fear of falling and doing further damage, frustration and boredom, building confidence, want to be back to normal, perseverance, is it part of a permanent decline, don’t want to be like this, unable to forget, acceptance)	“It’s really got me down. I was depressed before, but I’ve got a depression now (sighs) that’s really bad. But there you are.”
Griffiths, 2015	Mental well-being	“For me it was a massive problem and caused me depression. To me is the most important thing, the mental aspect of taking away somebody’s freedom to be able to move around and go to the shops and do all that sort of thing.”
	Fear of falling	“I’ve got to watch what I’m doing. If I catch my foot on [paving stone], I can go over again”
Langford, 2018	Loss of independence	“My frustration level of not being able to accomplish things that I did before this injury is still quite high.”
	Multimorbidity	“‘I’m just not receiving the same kind of attention or treatment or even interest … I know that you’re focusing on the hip surgery recovery … the shoulder issue is much more annoying and upsetting to me than the hip. The hip recovery is basically straightforward … but [my shoulder is] not really being taken care of.’”
	Engaging in physical activity	“I am walking around with a walker because it gives me security. So I used to walk with a cane but I don’t know … I just walk with a walker because it gives me 100% security”
Pol, 2019	Performing everyday activities (doing activities in the same manner as before or differently, ceasing to do actives)	“So yes, you become older, and old age comes with restrictions, so I have to accept that I can’t do some things anymore.”
Schiller, 2015	Seek support (ask others for help, ask key questions, identify peer support)	“But nobody comes, no nurse, no nothing. No public health, to see if you are just dying or rotting or lying there”
	Move more (engage in physical activity, engage in physiotherapy)	“I mean, I was pretty nervous about moving or doing anything because I didn’t want it to break, but it had already been fixed.”
Segevall, 2019	Preparing to return home	“Well, I’ll tell you something. It wasn’t fun to need help, but I couldn’t do it on my own. That’s the fact.”
	Needing adjustment and support at home	“I didn’t want the walking aid in the beginning, but now I think I will keep it in case of future needs.”
	Struggling to manage at home	“Well, I have never been afraid of anything before, but now I have become a bit fussy. I mean, I wouldn’t like to fall again.”
		The things that they feared could be a hindrance were their age and other health issues.
Southwell, 2020	Anxiety about the future	“‘They keep telling me that, the more I do, the better I’m going to be at it. But I think at the age I am it’s not going to be that easy you know? I’m hoping I’m wrong’”
		“My health was getting my body back into order, and then I could start thinking about my feet and legs.”
Southwell, 2020	Reliance on social capital	“Nobody’s living with me, all the help I’ve been having in the hospital will stop ….I won’t be able to move about by myself with the walker without someone bringing me the walker …and to get to bed I need somebody to help me in lifting my left leg up to the bed, and there’s nobody living with me …. and like, when I want to use the toilet, yet I cannot go to now, I won’t be able to stand up to walk to get to the bottles to use for my urine.”
		“I was worried my health was going to get worse and worse, and I didn’t want that because I didn’t want to put anyone out.”
Ziden, 2010	Experienced consequences one year after discharge (isolated life with more restricted activity and fewer social contacts, more insecure and afraid, disappointed and sad that identity and life have changed, satisfied with the situation or feeling even better than before the fracture)	“You think, why didn’t I put the light on when I got up [at night]? … So, I’m very careful now, almost excessively so… I’m careful when I’m out walking … Then I take it really easy! Look down at the ground … Now I’m afraid that it will happen again. And [that I will] break something else”
		“I have always thought that I should recover. I mean, I didn’t expect to have so much pain when so long time had passed … I’ve almost never been sick in my whole life! Flue, or so, maybe, but nothing else … So it’s a total change … It was like a shock, when this happened … I’ve become so afraid.”
Review Theme: Driving Recovery
Archibald, 2003	The recovery experience (the operation, beginning the struggle, regaining independence)	“The physio(therapist) said ‘Do you think you can make it to the top of the ward?’ And I said ‘No. I’d like to go to the toilet!’ [laughs]…As soon as I possibly could, I went by myself with the Zimmer [frame].”
Asplin, 2019	Interaction affects trust and security	“I thought that they know what is best…and what we should do now and what we should do later… when you are not familiar with things, so you accept what you have to do ….”
	Information is key to understanding	“It’s really important with good information and don’t, don’t hide anything, just tell it as it is… I feel that it’s very important, just tell it as it is, and don’t hide anything. But you maybe can’t say that to everyone, of course you can’t, but it means a lot.”
	Encouragement is essential to promote activity	“…otherwise I would have lain flat in bed all the time … without them I wouldn’t have managed.”
	The greener the better, but it’s up to me	“I had these physiotherapists … and I think they are good at their job and very ‘pushy’, so I’m very happy for the help they have given me. It’s so that even if I get medical help, it’s me myself that has to, I have to heal my wounds and get going.”
Bruun-Olsen, 2018	A span between self-reliance and dependency (a gap between expectations and reality, recovery self-reliance, recovery dependent on actions from others)	“My expectations for my own recovery were much higher than reality, and that have made me frustrated and impatient”
		“The physiotherapist, and the way she treated and encouraged me and explained things, has been vital for my recovery”
Fox, 2017	Emotional response to circumstances (prisoner, burden, mood change, fear of falling and doing further damage, frustration and boredom, building confidence, want to be back to normal, perseverance, is it part of a permanent decline, don’t want to be like this, unable to forget, acceptance)	“I’ve done it now, I’ve walked to the post box and I’ve walked to the shop and I’ve walked down to the library so I’ve – and back, so I – I’ve done that now… When you’ve done it, yeah, you – you – you feel, “Oh good, you know, that’s another mile gone, another milestone gone”
		Others accepted their physical limitations or changes to their lifestyle despite it not being what they had hoped. “Not normal but a manageable situation”
Healee, 2017	Restoring normalisation: regaining by relying (self-reliance, marshalling resources, helping)	“I mean this is how it is … deal with it … nobody else can do it for me”
	Restoring normalisation: reasserting by permissioning (developmental life stage, diverse expectations)	“Staff should explain the other aspects of recovering from hip fracture such as time it will take; the adjustments one will need to make, the potential impact on a person, what to expect. Having these non-physical aspects would help increase confidence post discharge and assist recover”
	Restoring normalisation: reasserting by reconciling (attitudes, routines, accepting)	“Because I think positive … it doesn't matter what happens there is a silver lining in every cloud and I figure well, when I did fall and break my hip … I just have to get on with it”
Langford, 2018	Personality traits	“I do want to get better and I’m not going to push it but I’m going to make sure that I’m not sitting there and doing nothing about it. That’s not a me thing. So, I did get up and move around. And the more I did, the more I became capable …”
Pol, 2019	Recovery process (trying and practicing and successful experiences)	“I hardly walk outside because I’m scared to fall; I feel more isolated because I can’t go to the gym or go to the shopping center anymore.”
Pol, 2019	Resources for recovery (“myself,” supporting and coaching, technological support)	“The most helpful thing was my own positive approach and me, who truly wanted to go for it.”
		“The aftercare has been important; we discussed what I had done, and I felt more confident in doing difficult activities.”
Schiller, 2015	Move more (engage in physical activity, engage in physiotherapy)	“How do you know what you’re not getting? Does that make sense, you know? How do you know to say, okay, you should be doing this for me when you don’t know what they should be doing for you?”
		“You went to exercises, that was that. And I think that’s good. I mean, you can’t lie in bed and expect your leg to get better if you’re not going to exercise. And that’s what people told me, too. Do your exercises.”
	Preserve perspective (be positive, be patient)	“[…] don’t stop. Don’t – just keep your mind strong and your body will be strong. And keep believing you can do it.”
Segevall, 2019	Preparing to return home	“You see, it was difficult for me to know what kind of help I could need when I came home. I guess that’s why they decided that they [staff from social services] would come check up on me four times a day to begin with, and that was fine by me.”
	Struggling to manage at home	They were convinced that it was important to think positively during recovery, and they believed that the hip fracture would not stop them from getting back to living their previously active lives.
Sims-Gould, 2017	Managing expectations	“The doctor said in 3 weeks I’d be feeling fine and in 6 weeks I’d be back to everything, and I’m not. It’s a bit depressing. It’s been a long time”
		The source and type of information patients receive preoperatively has an important role in the formation of realistic expectations for their recovery.
	Engaging in physical activity	“‘I would say the attitude mentally is very important. When talking to other people about the study and why I am involved, some don’t want to … they say it hurts, but I don’t say that, I just work at it. It’s what the physio says is for your own good, and that positive mental attitude is important’.”
Southwell, 2020	Importance of self-determination	“It’s the only way of getting through that barrier, is pushing. Physios can’t help you doing that, you’ve got to do that yourself”
	Reliance on professional support	“I wanted somebody to give me directions, and what to do for the exercise. I can’t just do an exercise by myself.”
	Importance of meaningful feedback	“I’ve tried and I know I’m not doing too badly if they [physiotherapists] are telling me the truth. And I think what is helping me is ego boosting me.”
Stott-Eveneshen, 2017	Access to information and resources [information on progress to inform recovery, access to professional support (physiotherapy)]	“… my expectations were whatever the surgeon told me … that sometimes they take the screws out and sometimes they don’t. And that was it; I didn’t know what else to ask”
		“The access to information is important … to promote the recovery programs, because many of us don’t know what to do or what is to be expected. Many of us are older and living alone; we can’t know what to do or where to go by ourselves.”
Stott-Eveneshen, 2017	Social support and participant experience (support through enrolment in the study enabled positive perspective, motivation through enrolment in the study, feedback on progress enabled positive perspective)	Some participants reported joining the study as a way of motivating themselves to adhere to their rehabilitation exercises.
		“It was nice to have someone rooting for me [and] gauging my level of activity”
Ziden, 2010	Experienced consequences one year after discharge (isolated life with more restricted activity and fewer social contacts, more insecure and afraid, disappointed and sad that identity and life have changed, satisfied with the situation or feeling even better than before)	“I maybe don’t have that same ability to take the initiative like I wanted to do more before than I do now”
	Conceptions of what influences recovery (own mind and actions, treatment and actions from others, you cannot)	“I’m not afraid when it hurts, you just have to get on with it … I think that if you get scared, then everything becomes much worse. And I look positively at things … And then I don’t worry … Everything goes so much better if you take it easy and don’t get worked up … Because, if you start to be afraid of something, then it just continues”
Review Theme: Driving Recovery
Archibald, 2003	The disability experience (disability, depending on others, housebound)	“And in the cold weather, if it was raining, I didn’t go and she brought my dinner round for me.”
Asplin, 2019	Interaction affects trust and security	“They make me out to be better than I am… that I should be able to do things myself … I’m not that good … and I can’t walk as I could before… I don’t have the courage …so no, something is wrong here.”
Fox, 2017	Physical and functional recovery (pain, stiffness, and swelling, balance, limp, stamina, physical activity, sleep, environment, equipment, functional activities, social support, coping strategies, walking and standing, bending and kneeling, stairs, activities of daily living and hobbies, alternative strategies, tiring, take it steady)	“My daughter’s coming in the week, next week to do it for me, but it’s not the same. (laughs) And when you’ve gotta depend on them like to get you some shopping”
Fox, 2017	Emotional response to circumstances (prisoner, burden, mood change, fear of falling and doing further damage, frustration and boredom, building confidence, want to be back to normal, perseverance, is it part of a permanent decline, don’t want to be like this, unable to forget, acceptance)	“If I went to the toilet I had to wake her up, break her sleep for her to get me back into bed you know, its things like that you know, it’s like being back in your second childhood again like you know”
Griffiths, 2015	Personal care	“I’m…not able to put a sock or anything on my injured leg. I can manage now with my trouser leg and throw these jogging trousers and hook my leg into them but I have to ask my husband if I need to put a sock or a shoe, or my slipper.”
	Recovery through adaptation	For some participants who had been experiencing decline in their mobility pre-fracture, the fracture precipitated adaptations that they had not previously considered but made their life easier. These included using a wheelchair for shopping, having a new ramp built for getting in and out of the house in a wheelchair, using a walking aid or employing professional carers.
Healee, 2017	Restoring normalisation: regaining by spacing (symbolic security, role shifting)	“Ok, so I use a stick when I go out … I need secure hold … yes it's a symbolic thing, which means [it] just gives me space”
	Balancing	“Generally went with the flow unless something arose however, glad to have someone take over but did object to some things, happy to be told what to do e happy to co-operate”
Langford, 2018	Loss of independence	“My frustration level of not being able to accomplish things that I did before this injury is still quite high.”
	Long recovery time	“I get so frustrated with myself because I can’t do a little bit of gardening and various things like that”
	Social support	“I think the key for me was the physio people that I dealt with… [my PT] was great. I liked [their] approach to it and the reality that [they] brought to it – a bit of a Sergeant Major which was good – a delightful person who really gave me some clues as to how to handle it.”
		“No, I wasn’t okay alone, [I needed help] to do the cooking and this and that”
		“I didn’t want to start unburdening anything that I did on a day-to-day basis unto someone else.”
Pol, 2019	Resources for recovery (“myself,” supporting and coaching, technological support)	“The change of going home was disappointing at first. All of a sudden, you have to do it all by yourself, and there is no protection around you.”
		“It made me feel happy because something is keeping an eye on me, and that is reassuring to me. I thought when something is going wrong, they will keep an eye on me.”
Schiller, 2015	Seek support (ask others for help, ask key questions, identify peer support)	“Even though you want to be independent, accept the help when it’s there because it helps other people feel like they’re helping you. So like I said it was hard for me to do and as soon as I could do without the help I did”
Segevall, 2019	Preparing to return home	“Well, I’ll tell you something. It wasn’t fun to need help, but I couldn’t do it on my own. That’s the fact.”
	Needing adjustment and support at home
	Struggling to manage at home	“I think that they have failed with the information. It is difficult to be a patient under such circumstances.”
Sims-Gould, 2017	This is life after fracture	While caring for health care staff was important to most participants, those who lived alone express the greatest appreciation for this source of support.
		“I felt safe and secure knowing that you and other [research assistant] girls were following my progress and that if anything went very wrong I could call – I don’t’ know if it would do any good, but it gave me a good feeling”
Southwell, 2020	Reliance on social capital	“Nobody’s living with me, all the help I’ve been having in the hospital will stop ….I won’t be able to move about by myself with the walker without someone bringing me the walker …and to get to bed I need somebody to help me in lifting my left leg up to the bed, and there’s nobody living with me …. and like, when I want to use the toilet, yet I cannot go to now, I won’t be able to stand up to walk to get to the bottles to use for my urine.”
		“I was worried my health was going to get worse and worse, and I didn’t want that because I didn’t want to put anyone out.”
Southwell, 2020	Reliance on professional support	“Well I could do with more to be honest … more physio”
Southwell, 2020	Reliance on social capital	“Nobody’s living with me, all the help I’ve been having in the hospital will stop ….I won’t be able to move about by myself with the walker without someone bringing me the walker …and to get to bed I need somebody to help me in lifting my left leg up to the bed, and there’s nobody living with me …. and like, when I want to use the toilet, yet I cannot go to now, I won’t be able to stand up to walk to get to the bottles to use for my urine.”
		“I was worried my health was going to get worse and worse, and I didn’t want that because I didn’t want to put anyone out.”
Stott-Eveneshen, 2017	Access to information and resources [information on progress to inform recovery, access to professional support (physiotherapy)]	“I saw other people in the hospital recovering faster. I believe it was because they were getting more physiotherapy and more intense physiotherapy after the hospital … I would have liked to have had more physiotherapy but couldn’t afford it. I was eventually able to find something, but it would have been better to have had it sooner … I jumped at the study hoping for extra physiotherapy”
Stott-Eveneshen, 2017	Social support and participant experience [support through enrolment in the study enabled positive perspective, motivation through enrolment in the study, feedback on progress (reducing falls risk) enabled positive perspective]	Although the description of study staff as a source of social support was greater among those living alone, it was still common among the 29 (58%) participants who were married or living with a family member or friend.