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

Abstract

Purpose

The purpose of the current review is to synthesize the evidence of patients’ perspectives of recovery after hip fracture across the care continuum.

Methods

A systematic search was conducted, focusing on qualitative data from hip fracture patients. Screening, quality appraisal, and a subset of articles for extraction were completed in duplicate. Themes were generated using a thematic synthesis of data from original studies.

Results

Fourteen high-quality qualitative studies were included. Four review themes were identified: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support. Patients considered recovery as a return to pre-fracture activities or “normal” enabling independence. Feelings of vulnerability were observed irrespective of the time since hip fracture and only diminished when recovery of function and activities enabled participation in valued activities, e.g., outdoor mobility. Participants expressed a desire to engage in recovery with realistic expectations and the benefits of meaningful feedback reported. While reliance on healthcare professionals decreased towards a later stage of recovery, reliance on social support persisted until recovery was perceived to have been achieved.

Conclusion

Patient perspectives highlighted hip fracture as a major life event requiring health professional and social support to overcome feelings of vulnerability and enable active engagement in recovery.

IMPLICATIONS FOR REHABILITATION

• Rehabilitation professionals should ensure expectations and goals are set early in the recovery process.

• Rehabilitation professionals should ensure goals set with patients are tailored to the individual’s pre-fracture activities or “normal” promoting independence.

• Rehabilitation professionals should monitor goals ensuring they are providing support, motivation, and managing expectations across the care continuum.

• Rehabilitation professionals should address patients’ feelings of vulnerability, particularly in the absence of social support, and ensure appropriate ongoing input to maximize recovery.

Keywords:

• Fracture neck of femur
• rehabilitation
• experience
• attitudes
• recovery

Introduction

In the United Kingdom (UK), an estimated 70 000 older adults experience hip fractures each year [1]. These fractures contribute to reduced mobility and independence affecting an individual’s health-related quality of life [2]. Outcomes are often even worse for those with pre-existing conditions, such as dementia [3]. In 98% of cases, older adults with hip fractures undergo surgery and subsequent rehabilitation in hospitals and the community [4]. These interventions target a theoretical construct of “recovery” from hip fracture to determine the endpoint for care.

Recovery may be perceived differently depending on an individual’s role in the recovery process and more specifically, the point at which their role is completed. For example, a surgeon may consider recovery as “from fracture” achieved with fixation and bone healing or arthroplasty [5] while physiotherapists may consider recovery as the attainment of pre-fracture function (e.g., mobility, activities of daily living) [6]. These definitions of recovery highlight the time at which these professionals withdraw their care, rather than the time at which a patient and/or carer may consider themselves “recovered.”

More contemporary definitions of recovery were driven by the International Classification of Functioning with healthcare professionals, hospital administrators, and policymakers acknowledging the need to consider the role of body functions and structures as well as activities and participation in recovery [7]. For hip fracture, previous quantitative research identified several domains of recovery including physical, instrumental, cognitive, affective, and social domains [8]. Researchers highlighted variation in the time for recovery by domain informing a need for ongoing targeted healthcare professional support in the year post-fracture [8]. This early research was based on quantitative evaluation using standardised outcome measures. While beneficial, in isolation it limits the potential for person-centred care as patients were not allowed to contribute by expressing their perspectives of recovery after hip fracture.

In 2011, a literature review of older adults’ recovery from hip fracture suggested patient recovery outcome is influenced by physical function and psychosocial factors [9]. Since this time, there has been an influx of qualitative evidence exploring both patient and carer’s perspectives of recovery at different stages after hip fracture [10–13]. This evidence adds depth to previous understanding of quantitative trajectories for recovery [11,12] as well as patient and carer’s perspectives of care received in support of recovery after hip fracture [10,13]. This evidence has been recognized through the publication of reviews synthesizing the evidence related to care about hip fracture from the informal carer’s perspective [14] and the patient’s perspective of community-based rehabilitation [15].

The purpose of the current review is to build upon previous work by considering patients’ perspectives of their recovery (encompassing but not restricted to rehabilitation) across the care continuum. More specifically, we will explore which patients are included in qualitative interview studies of recovery after hip fracture, when these interviews take place (about time since fracture), and which perspectives have been reported by patients about recovery after hip fracture.

Methods

We conducted a systematic review of qualitative studies in adherence with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement [16], and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [17]. We registered the protocol for this review on the International Register of Systematic Reviews, PROSPERO ID: CRD42020205858 [18]. This review did not require ethical approval as all data is extracted from published literature available in the public domain.

Eligibility criteria

A summary of the eligibility criteria for studies included in this review is presented in Table 1.

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

Inclusion criteria

We selected studies of “older adults” defined by the World Health Organization as those 60 years or older [19] in receipt of rehabilitation after hip fracture surgery at any point along the care continuum [12]. We included qualitative semi-structured interview studies as we sought to synthesize the evidence for patient perspectives after hip fracture which may not be captured by other qualitative designs, e.g., ethnography and/or quantitative design.

Exclusion criteria

We excluded studies of older adults who experienced multiple fractures [20,21], pathological hip fracture [22], and those treated conservatively [23], as their rehabilitation pathways and outcome vary from those with an isolated non-pathological hip fracture treated surgically. We excluded studies not published in English due to limited resources to cover translation costs.

Search strategy

We employed a pre-planned comprehensive search strategy to seek all available studies. We adopted previously published search terms for our strategies based on terms for “qualitative evidence” and “hip fracture” [24–26], outlined in Supplementary File 1. The following databases were used to search for published literature: Medline, Embase, Psychinfo, and PEDro, Base, and OpenGrey were used to search for grey/unpublished literature. Searches were run from database inception to between 9 and 19 June 2020. We completed citation tracking of selected studies in Google Scholar on 10 July 2020 to identify any additional studies that may have been overlooked in our searches.

Screening

Two reviewers (NB and AR) independently screened the title and abstracts against eligibility criteria in Covidence software for managing systematic reviews. The same two reviewers independently screened the full text of potentially eligible articles against eligibility criteria. Reasons for exclusion were documented at full-text screening. Conflicts were resolved by consensus.

Quality appraisal

The conduct of the studies, their reporting, as well as the content and utility of their findings were appraised using the Critical Appraisal Skills Programme checklist for qualitative research [27]. This checklist includes the following domains: aims, methodology, research design, recruitment strategy, data collection, researcher relationship, ethical considerations, data analysis, findings, and research contributions. The appraisal was conducted independently by two researchers (NB and AR). Conflicts were resolved by consensus.

Data extraction

We extracted study characteristics and results onto data extraction templates created a priori in Excel. Two reviewers (NB, AR) piloted the data extraction template on one study and refined the template before completing the extraction for the remaining studies. Two additional studies were extracted in duplicate. The remaining 11 studies were extracted once. The following study characteristics were extracted: the paper details (author, year published, country, and city of study), the methods and analytical approach (study design and data collection method), study details (where and when the study took place, length of interviews, interview details, topic guide, and type of analysis), participant details (sample number and participant characteristics) and key discussion points. Data on patients’ perspectives were extracted from the results sections of individual studies (themes identified and supporting quotes).

Data synthesis

We adopted a thematic synthesis approach, outlined by Thomas and Harden which provides a clear link between conclusions and text of studies analysed (Figure 1) [28]. This approach enables researchers to explore the perspectives of patients and highlight similarities and differences between their accounts. Three researchers (NB, AR, and KL) conducted thematic analysis independently. All authors individually read through all included papers first for familiarisation, and then generated concepts from the research data before coming together to discuss and finalise review themes. Themes in the current review were identified using data that included quotations from participants and text by the authors in the original papers. Data in each original paper were compared and organised into review themes and, where relevant, subthemes. The authors used an inductive approach to generate themes by observing patterns in the data within the original papers. Data in the original papers were collated and synthesised into variations of concepts defined by the original authors, and new concepts were created where deemed necessary. It was recognised that variations of the same concepts appeared in multiple studies, which informed the development of a new interpretation of the findings and the generation of novel and inclusive themes. Themes evolved further through discussion, re-reading of original papers, and re-evaluating content. Any conflicts were discussed until consensus occurred. Analysis was conducted using Excel and the NVivo qualitative data analysis computer software.

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.

Results

Search results

The results of the searches completed for this review are displayed in Figure 2. We identified a total of 8115 potentially relevant studies. In total, 2357 were duplicates leaving 5759 studies to be screened. At this stage, 5736 title/abstracts were excluded, and 23 studies were brought forward to the full-text screening. Full-text copies of the 23 studies were acquired and evaluated against our predefined eligibility criteria. At this stage, nine studies were excluded as they did not meet the eligibility criteria. One additional study published after the search date was identified through citation tracking of the remaining 13 studies. Therefore, 14 studies met the criteria for inclusion in this review.

Figure 2. Study selection.

Study characteristics

Study characteristics are presented in Table 2. Four studies were conducted in the United Kingdom [10,12,29,30], three in Sweden [13,31,32], four in Canada [11,33–35], one in Norway [36], in New Zealand [37], and one in the Netherlands [38]. Two studies were carried out in the hospital setting [10,13], one a rural community setting [31], and the remaining studies in urban community settings [11,12,29,30,32–38]. Six studies selected their sample from participants of a randomized control trial [11,13,32,33,36,38]. Studies conducted included qualitative semi-structured interviews face to face [10,12,13,29,31,32,36–38], via telephone [11,33,35], or face-to-face and/or by telephone [30,34]. Where reported, the mean interview duration ranged from 5-min [33] to 90-min [34,37]. Included studies made sense of their qualitative data by looking for patterns and coding using both inductive and deductive approaches. Five studies used thematic analysis [10–12,30,33,35], one used thematic and cross case analysis [12], four used a phenomenological approach [12,13,29,36], two used qualitative content analysis [13,31], two used a constant comparison analysis (as part of grounded theory approach) [37,38], one used topic coding [34], one used a phenomenographic method [32], and one a systematic text condensation [36].

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

Participant characteristics

14 studies included in this review reflect a total of 279 participants. Where reported, the mean age of participants ranged from 80 years [32] to 81.5 years [12]. One study included participants with cognitive impairment [12]. Four studies did not mention cognitive status of participants [11,34,35,37]. The remaining studies excluded patients with cognitive impairment, scoring <15 [36], or <21 [38] on the Mini-Mental State Examination (MMSE), or <8 [10] on the Abbreviated Mental Test Score. Other measures of cognitive impairment included ensuring that the patient was orientated cognitively to person, time, space, and situation [31]. Three studies stated the exclusion of patients with cognitive impairments without a description of how this was determined [13,29,32]. Two studies followed eligibility criteria from a parent study excluding potential participants who could not provide informed consent [30] or with a prior diagnosis of dementia [33]. Three studies included participants admitted from or discharged to residential care [12,34,38]. The time since participants hip fracture varied from 8 days [10,13] to more than 1 year [33–35,37] across studies.

Quality assessment

Results of quality assessment using the CASP tool are presented in Table 3. There was 100% agreement (Cohen’s Kappa 1.0) between reviewers for all domains. All studies included in this review clearly outlined their aims and objectives. Studies clearly stated themes and subthemes and selected appropriate methodology to answer their research questions. Two studies successfully fulfilled all appraisal sections [30,36]. Reflexivity was considered in seven studies [10–13,30,32,36]; data saturation was discussed in six studies [10,12,30,34–36]. All studies had ethical approval. Eleven studies considered all ethical components of analysis, including a clear explanation of obtaining informed consent, maintaining confidentiality, and debriefing participants [10,12,13,29–33,36,37]. Fourteen studies provided clear finding statements and discuss the clinical impact of findings [10–13,29–34,36–38].

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

Patient perspectives of recovery after hip fracture

Themes and subthemes

The themes and subthemes from the 14 studies included in this review are summarised in Table 4. From the data, we generated four review themes related to patient perspectives of recovery after hip fracture: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support.

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.

Theme 1: recovery as participation

Across studies, participants considered recovery as a return to pre-fracture activities [11,32,33,35,38] or “normal” [13,36,37] enabling independence [10,29,31,34,36].

“For me it is obviously, first and foremost, that I become independent in every way.” [66-year-old woman lived alone at home prefracture, interviewed 7 days postoperatively in hospital] [13].

These activities were often described in terms of mobility [12,13,37], such as walking outdoors [13,32]; activities of daily living [29], such as going to the toilet [13], gardening [11,12], cooking [11] and housework [32,33]; as well as participation in social events [37], such as meeting friends and family [13,32,33], attending the theatre [32], working as a volunteer [32], shopping [12,32], and participation in sport [11,13].

“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” [92-year-old woman living alone at home, interviewed at home 5 weeks postoperatively] [12].

The participants in some studies indicated they were willing to accept new normal if it enabled a sense of identity [30] or preserved their ability to complete previous activities albeit in a different manner [10,38].

“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” [78-year-old man living alone at home prefracture, interviewed at home 6–8 months post-fracture] [38].

For two studies, several participants struggled to define recovery as the hip fracture was perceived as part of their decline with age with uncertainty over the future [10,12].

“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” [82-year-old woman living alone at home prefracture, interviewed in hospital] [10].

Theme 2: feelings of vulnerability

Participants across studies reported new anxieties related to fear of falling, ability to cope at home, and feasibility of recovery enabling a return to valued activities, such as going out in the community and attending social events. These anxieties were particularly evident among older adults, those with poorer mobility, and with multiple long-term conditions. This often led to poor mental health which diminished only when valued activities resumed.

Participants in several studies highlighted a fear of falling as they felt they had a reduced capacity to overcome a subsequent injury in the future [12,30–32,38]. Several participants reported adapting activities or avoiding them completely to minimize their risk of falls [30,31,38]. Participants reported these fears at 1-year follow-up in one study [30].

“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” [66-year-old woman, living with spouse at home, interviewed at home 1-year post-discharge] [32].

Participants in two studies reported concerns around home life on discharge from hospital whether they would be able to cope [10,13]. In particular, participants highlighted anxieties related to becoming housebound and unable to engage in activities meaningful for their recovery.

“…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” [89-year-old man living with wife at home, interviewed in hospital] [13].

Concerns around coping and being able to return to previous activities often were often interwoven with fear of gradual and permanent decline in functioning following a hip fracture [10,30]. Anxieties related to declining were more apparent in older patients who often characterised their experience as a consequence of ageing [10,30], those with poorer mobility [10], and those with multiple long-term conditions [11,30,31]. Compounding these fears, participants felt if their hip fracture was treated in isolation (and not considered in the context of additional morbidities) their ability to recover would be impaired [10,11].

“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” [76-year old, interviewed at home 4 months post-fracture] [11].

Participants described experiencing negative consequences, such as boredom, distress, loneliness, and depressive symptoms [12,30,32,36] up to 1-year after fracture [30,32]. Many attributed these feelings to reduced mobility and inability to attend activities outside of their home with friends and family [12,30,36] which persisted in the longer term [30].

“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” [80-89 year old woman living alone at home, interviewed at home 2.5 months post-operatively] [30].

These negative consequences diminished overtime for some participants with increasing ability to return to valued activities [30,34].

“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’” [80–89 year old woman living alone at home, interviewed at home 7 months post-operatively] [30].

Theme 3: driving recovery

Participants across studies acknowledged a need for a positive outlook and active engagement in their recovery process. This engagement was reliant on a clear understanding of their recovery process with specific realistic expectations and goals tailored to their needs and activities. These expectations fueled motivation for engagement and coupled with positive feedback enabled transition to independent ownership of their recovery process. Unrealistic expectations or perceived generalized feedback were detrimental to recovery leading to feelings of frustration, disappointment, and reduced engagement.

Setting expectations for recovery trajectory

Participants discussed the importance of establishing realistic expectations and goals early with healthcare professionals as well as friends and family [13,33–35,37]. Information received from staff, patients, and informal carers needed to be clear to facilitate confidence in expectations for their recovery [10,37] particularly at the point of discharge home [31,34].

“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 recovery.” [interviewed at home] [37].

Misalignment between expectations and reality of the recovery process led to frustration, disappointment, depressive symptoms, and reduced engagement with the recovery process [32,35,36].

“My expectations for my own recovery were much higher than reality, and that have made me frustrated and impatient” [85–89 year-old woman, interviewed at home 3-4 months post-fracture] [36].

“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” [80-year-old woman, interviewed at home 6-months post-operatively] [35].

Motivation

Participants viewed the recovery process as a collaboration with health professionals [10,34,38] but recognized the need for internal locus of control as self-efficacy was paramount to their recovery [33–35].

“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” [84-year-old woman living at home alone prefracture, interviewed in hospital] [10].

They reported the need for a positive outlook [10,11,31,33–35,38] and self-reliance [11,30,36–38] to maintain motivation and ensuring success in their recovery [32,37]. This motivation was positively reinforced through meaningful feedback on activity and participation goals from healthcare professionals [10,13,33,36,38].

“It was nice to have someone rooting for me [and] gauging my level of activity” [66-year-old woman living at home with spouse, interviewed at home 6 and 12 months postfracture] [33].

Participants sometimes reported needing to drive their own recovery independent of healthcare professionals when their care was not focused on their expectations and goals for recovery [31]. This was particularly evident where participants described feeling passive towards recovery with decisions made for them rather than with them [31,36] failing to consider their individual priorities [13]. To overcome this, participants reported completing activities independently they felt were in support of their recovery [36].

“I went by myself to training and got out of the high walker entirely by myself, …….and I said to the nurse that now I have to start washing myself because I am going home. Yes, the nurse said, − without showing any interest” [85–89 year-old woman, interviewed at home 3–4 months post-fracture] [36].

Theme 4: reliance on support

Participants reported reliance on both professional support and social support across studies included in the current review. The reliance on professional support was strongly observed for those in the early post-operative phase and decreased over time, which may reflect service withdrawal rather than a decrease in the need. Increased reliance on social support was observed for studies across the care continuum and was highlighted more for participants who were living alone.

Professional support

Participants reported a reliance on healthcare professional support for successful recovery in eleven studies [10,11,13,29,31,33,34,36,38].

Access to support from healthcare professionals (in particular physiotherapy) during the hospital stay was considered a facilitator of recovery [36]. Participants reported a desire for “more” rehabilitation during this stage to support their recovery [10,31]. Participants reported frustrations when rehabilitation was not commenced early or regularly, feeling that this impeded their recovery, yet this decision was out of their control [36,37]. Participants in the study by Stott-Evenshen et al., indicated access to more regular rehabilitation was their rationale for enrolment in the rehabilitation research study [33].

“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” [69-year-old man living alone, interviewed at home 6 and 12 months postoperatively] [33].

Follow-up from healthcare professionals in the community was perceived to advance participants recovery [33,38]. Support from healthcare professionals was particularly important to those living alone [10,33,35].

“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.” [71-year-old, interviewed at home 4 months postfracture] [11].

Social support

Participants in several studies considered hip fracture as a disruption to their normal life leading to a new reliance on others to perform activities of daily living [10,11,29–31,33,34,36,38]. Participants reported feeling grateful at being able to return home acknowledging this was often only possible with the support of family and carers [29,31,33]. Many participants expressed frustrations and feelings of guilt related to these new levels of dependency and feeling of burdening their family and carers [10,11,30,32,34]. For example, participants reported feelings of frustration due to reliance on family for support for activities they were previously able to complete independently [10,11,30–32].

“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” [<70-year-old man, living with wife and child with disability, interviewed at home 2.5 months post-fracture] [30].

The perceived reliance on social support persisted for many individuals after hip fracture from the early post-operative phase to later stages of recovery. Participants often identified this reliance through a comparison of their current and pre-fracture activity levels [35].

“[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” [interviewed at home in first 3 months post-fracture] [29].

However, for many, a new normal evolved which led to perceived reductions in the degree of dependency on social support in later stages of recovery [13,29]. This new normal was often facilitated by the use of mobility aids, changes in the home, and adjusting activities [12,30,31,35,37,38].

“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” [interviewed at home] [37].

Discussion

Main findings

We identified 14 qualitative interview studies which explored patient perspectives of recovery after hip fracture. The overall quality of included studies was high. We identified four review themes from our synthesis of data from the 14 studies: recovery as participation, feelings of vulnerability, driving recovery, and reliance on support. Patients considered recovery as a return to pre-fracture activities or “normal” enabling independence. Feelings of vulnerability were observed for patients irrespective of the time since hip fracture and only diminished when recovery of function and activities enabled participation in valued activities. Participants expressed a desire to actively engage in recovery with realistic expectations and benefits of meaningful feedback reported. Reliance on healthcare support varied by time since fracture with patients highlighting a greater reliance on professional support in the early vs. late stages of recovery, particularly for those living alone. In contrast, reliance on social support persisted until recovery was perceived to have been achieved, irrespective of time since fracture.

Interpretation

For the current review, patients described activities/goals for recovery in terms of mobility, activities of daily living, and participation in social events. These descriptions align well with the International Classification of Functioning which outlines the role of body functions and structures as well as activities and participation in recovery [7]. Of note, patients indicated the need for mobility to support activities of daily living and participation, e.g., outdoor mobility rather than as a goal in itself. These definitions were consistent across studies for those patients able to articulate what recovery means to them. However, a recent analysis of 24 492 patients indicated a weighted probability of up to 10% for recovery of mobility at 30-days among those able to walk outdoors pre-fracture [39].

This poor early recovery may relate to contextual factors reported in the current review including multiple long-term conditions [10,12], and fear of falling [8]. This fear of falling was often related to a perceived lack of reserve to overcome a subsequent injury. Indeed, up to 65% of older adults report low fall-related self-efficacy after hip fracture [40]. Previous home-based rehabilitation intervention studies have demonstrated promise for improving falls-related self-efficacy after hip fracture [41,42]. Crotty and colleagues demonstrated patients enrolled for an average of 28 days on a target-orientated rehabilitation programme saw improvements in the Falls Efficacy Scale [41]. Ziden et al. programme of balance confidence, physical function, and activities at daily living for 3 weeks following discharge also saw improvements in the Falls Efficacy Scale [42]. The authors reported marked differences in the change in instrumental activities of daily living items of the Falls Efficacy Scale between groups (19.7 for intervention, 7.1 for control) which may signal a potential impact on the recovery of participation [42]. Addressing poor self-efficacy for falls after hip fracture may better enable recovery through independence and participation in social events [43].

Many considered their hip fracture as an event in a wider decline in their “normal” abilities. This “new normal” was acceptable to many if a sense of independence could be preserved. However, a definition for this “new normal” was not explored by any of the studies in the current review. Ensuing uncertainty may serve to reinforce feelings of vulnerability as, without a clear positive view of who they will become after their fracture, many patients consider the worst-case scenario – decline, loss of independence, transition to nursing care, and death [44]. This perspective can lessen one’s self-image and increase feelings of alienation and social withdrawal [45]. There is a need for rehabilitation professionals to set transparent realistic expectations, ensure they preserve patient choice in decision-making, and work towards patient specified valued activities. This will give hope and empower patients to define an evolving fresh narrative of self that preserves their desired self-image while reducing feelings of loss and restriction in everyday life [46].

Value in healthcare relates to outcomes achieved, i.e., what matters to patients [47]. In the current review, participants across studies acknowledged a desire for active engagement in their recovery across the care continuum. This finding is in keeping with previous reviews which identified a need for self-determination [48] and a positive patient perspective in community rehabilitation as key drivers of recovery [15]. For the current review, patients highlighted a desire for setting expectations and goals early, collaborative working with healthcare professionals to enable this active engagement to meet expectations, and a sustained positive outlook. However, this desire was not always met. This was particularly evident for the early post-operative period where patients reported feeling passive and lacked trust in decisions made “for them” and not “with them.” Moreover, patients reported anxieties related to preparedness for discharge home. The studies included in the current review did not identify reasons for the perceived absence of shared decision-making. As this was particularly evident in the early post-operative phase, it may reflect organisational pressures to reduce the length of stay transitioning patients to the community setting earlier [49–51]. It is important that person-centered care is not compromised in efforts to meet these pressures [52].

The current review supports a wealth of evidence indicating the patient-reported need for professional and social support after hip fracture [15,48]. The current review extends our understanding of support after hip fracture by highlighting patient-perceived needs vary by time since fracture for healthcare professional support. In contrast, patients' perceived need for social support varied by degree of recovery achieved irrespective of time since fracture. This discrepancy may be due to patient’s reflections on the withdrawal of healthcare services over time since their hip fracture, opposed to their perceived need for ongoing care. Indeed, several patients reported ongoing feelings of vulnerability, fear of falling, and fear-avoidance up to 1 year after their fracture – long after healthcare services ended. Of interest, a participant related their need for social support to both physical domains of health (e.g., going to the toilet, ability to walk outdoors to the shop), psychological domains (e.g., fear of falling), and social domains (e.g., attending a granddaughter’s birthday party). Many of these domains may be supported by health and social care services and align with previous quantitative research indicating a need for longer-term rehabilitation after hip fracture [8,53,54].

The current review highlighted a lack of representation for patients with cognitive impairment and hip fracture in qualitative research. Up to 30% of hip fracture patients present with cognitive impairment [55]. Physiotherapists recently reported a lack of confidence in using standardised care protocols with patients with cognitive impairment, expressing a desire for specialist training to enable a more patient-centered approach for these patients [56]. An important step in developing more appropriate care for patients with cognitive impairment is gaining an understanding of what matters to them in their recovery after hip fracture. A previous systematic review of carers of patients with hip fracture identified 21 qualitative interview studies which reported extensive caregiver burden among those trying to support a person after hip fracture with cognitive impairment [14]. Future research should consider the inclusion of patients with cognitive impairment and/or carers for those with severe cognitive impairment to better understand what is important in the recovery journey. This research may draw upon previous strategies to enable persons with dementia to take part in qualitative research, such as simplifying the structure of questions, allowing additional time for responses, and redirecting dialogue [57].

Limitations

We updated our eligibility criteria from the protocol registration to include only adults surgically treated for hip fracture and irrespective of time since fracture (protocol indicated adults and carers in the first post-operative year). We did not include studies published in languages other than English nor did we search conference proceedings or for published dissertations which may have increased the risk of publication bias [58]. We adopted a thematic synthesis approach. A limitation of this method is that data from the original studies are analysed out of context and concepts identified in one setting may not apply to another [28]. We further acknowledge there is a level of uncertainty around our conclusions as we cannot be sure the data is completely representative of the older population recovering from a hip fracture. We did not have information regarding participants excluded from the study, for example, participants with cognitive impairments, or those too unwell to take part in interviews. Therefore, conclusions made from this review may not be representative of the underlying population with hip fractures. Finally, all studies included in the review were from countries with high Gross Domestic Product (GDP) [59], and are therefore not globally representative.

Conclusions

Patients considered recovery as a return to pre-fracture activities or “normal” enabling independence. Patient perspectives highlighted hip fracture as a major life event that requires health professional and social support to overcome feelings of vulnerability and enable active engagement in recovery. Future research should investigate the recovery perspective of patients with cognitive impairment, and further consider perspectives on recovery from carers.

Disclosure statement

KS received funding from the NIHR Research for Patient Benefit, the Chartered Society of Physiotherapy Charitable Trust, and the UKRI Future Leaders Fellowship for hip fracture health services research. KS is the current Lead of the International Fragility Fracture Network’s Hip Fracture Recovery Research Special Interest Group. NB, AR, BV, KL, and DW report no conflicts of interest.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.