See me, teach me, guide me, but it’s up to me! Patients’ experiences of recovery during the acute phase after hip fracture

Abstract

Aim

To explore patients’ experiences of their recovery after hip fracture surgery and the use of Traffic Light System-BasicADL in their rehabilitation process.

Method

Nineteen patients (13 females and 6 males), aged 66–94, were interviewed. A qualitative content analysis method was used for analysis of data.

Results

Two categories were identified: ‘Being seen as a person’ with subcategories; Interaction affects trust and security; Information is key to understanding; and Encouragement is essential to promote activity. And ‘Striving for Independence’, with subcategories; Accepting the situation while trying to remain positive; The greener the better, but it’s up to me; Ask me, I have goals; and Uncertainties concerning future.

Conclusion

The findings of this study mirror clinical reality. There is a continued need for organisations to reflect over existing practise and question routines and procedures. In order to improve services and provide better quality of care, it is essential to acknowledge the patients’ experiences, needs and preferences and make efforts to accommodate these where possible. Health care professionals must recognise that patients with hip fracture are individuals, with varying needs that change across the continuum of recovery.

Keywords:

• Aging
• hip fractures
• rehabilitation
• patient participation
• recovery of function
• qualitative research

Introduction

Hip fracture is considered the most serious osteoporotic fracture in the elderly with a 20%–30% mortality rate within a year, and only approximately, 50% regaining previous levels of autonomy and mobility [1,2]. The worldwide age-standardised incidence of hip fracture varies considerably with the highest incidence found in northern Europe, with 574, 563 and 539 per 100 000 in Denmark, Norway and Sweden, respectively [2]. A wealth of research has been performed leading to advances in care for this vulnerable group. Implementation of multidisciplinary clinical pathways, have resulted in improvements including; decreased mortality, time to surgery, post-operative complications, length of stay as well as facilitating functional recovery [3–9].

Care pathways that promote patient participation have also shown to improve outcomes with increased motivation and greater likelihood of patients achieving their rehabilitation goals [10], higher quality of care, and a more positive impression of the health care system [11]. As described by Sahlsten, participation can be promoted by establishing a relationship with the patient, surrendering of control by the health care professional (HCP), sharing information and knowledge and actively engaging in intellectual and/or physical activities with the patient [12]. While acknowledging the positive aspects of participation Thórarinsdóttir and Kristjánsson also challenge earlier concepts by describing situations, which patients experience negatively, for example, having to comply with healthcare routines, instructions and expectations placed on them by HCPs. This can be conflicting with the patient’s own needs and wishes, be perceived negatively and thus limiting participation [13]. A further study highlights the risk of staff focussing on following care pathways and not allowing time to reflect over and recognise the patient’s personal needs [14].

The value of the patients’ perspective has attracted increasing interest over the past decade to further improve care pathways, quality of care and outcomes for patients. To gain a better understanding of the concepts of practice of relevance to patients, we must first know how patients experience care and adapt processes accordingly [13,15]. Studies have highlighted the need for HCPs to understand the psychological factors that can impact on the recovery process [16,17], to acknowledge differences in patients willingness to participate in rehabilitation [18]. It is furthermore important to recognise patients’ preferences [14,15], their perceptions of their own capability to regain pre-fracture function [19], and what patients consider important to enhance their recovery [20,21].

A recent clinical trial evaluating a model of early coordinated rehabilitation in acute phase after hip fracture reported increased patient participation and increased independence in activities of daily living (ADL) compared to standard care [22]. This intervention focussed on earlier and closer collaboration between the patient, the occupational therapist (OT), and the physiotherapist (PT). The aim was to establish a closer relationship with the patient, providing information regarding the rehabilitation process, personalised to the patients’ needs and wishes, and encouraging patients to take greater responsibility for their training. These strategies were assisted by the use of Traffic Light System-BasicADL (TLS-BasicADL) [23], which was used to improve communication, by gathering information regarding the individual patient’s previous and present functional status. TLS-BasicADL is comprised of 13 activities; six items showing ability to transfer and walk and 7 P-ADL items. Three colour-coded markers are used to indicate level of dependence; red = physical assistance, yellow = supervision and green = independent. As the patient’s ability to perform activities changes during in-patient rehabilitation, the colour-coded markers are changed correspondingly. This is done in collaboration with the patient with the aim of promoting increased participation. TLS-BasicADL is also used as a tool for discussing in-patient goals as well as future rehabilitation needs/goals after discharge with the patient.

While positive results were reported in the form of increased patient participation and greater independence in ADL in this study [22], there is limited knowledge concerning patients’ experiences, and factors influencing their recovery, and no study performed investigating the impact of TLS-BasicADL on promoting patient participation in the acute phase after hip fracture.

The aim of this study was to gain a better understanding of factors impacting on patients’ recovery during the acute phase following a hip fracture. We have focussed on exploring patients’ experiences during in-patient rehabilitation after hip fracture surgery and the use of TLS-BasicADL in their rehabilitation process.

Method

Study design

The qualitative method of content analysis according to Graneheim and Lundman has been adopted [24].

Setting

The study took place at Sahlgrenska University Hospital, Mölndal, Sweden.

Sampling

A purposeful sampling procedure was used. To reflect the normal rate of incidence for patients with hip fracture and varying age span the aim was to recruit approximately 75% women and 25% men, aged ≥65 years. Patients were eligible for inclusion if they met the following criteria: age 65 years or older, admitted due to hip fracture, no cognitive impairment, and spoke and understood either Swedish or English. Patients from nursing homes were excluded due to short length of hospital stay. Patients were informed verbally about the study by the OT or PT treating them and asked if they would be interested in participating in an interview towards the end of their hospital stay. All participants were given verbal and written information by the first author (GA) regarding the study, signed a consent form and a time of the patient’s choice was set for interview. The authors were not involved in the treatment of the participants included in the study.

A total of 19 patients participated in the study, 13 (68%) women and six (32%) men, mean age 82.3 (±8.1) years. All 19 patients were admitted from their own home and previously independent in walking indoors with or without walking aid, as well as independent in basic ADL (Table 1). Of the 19 patients, 11 (58%) sustained a cervical fracture and 8 (42%) a trochanteric fracture. The choice of surgical treatment varied as follows; hemiarthroplasty – 7 patients (37%), total hip replacement – 4 patients (21%), LIH pins – 1 patient (5%), plate and screw – 4 patients (21%), and intermedullary nail – 3 patients (16%).

Table 1. Demographic and clinical characteristics of participants.

Participant	Gender (female/male)	Age (years)	Type of fracture/surgical procedure	Living status	Day of interview (post-op)	Length of stay (days)	Discharge destination
1	F	81	Cervical/Hemi-arthroplasty	With husband	5	11	Home
2	F	88	Cervical/Hemi-arthroplasty	Alone	10	23	Home
3	F	66	Cervical/Total Hip Replacement	Alone	7	12	Home
4	F	90	Cervical/Hemi-arthroplasty	Alone	11	16	Home
5	F	89	Trochanteric/Total Hip Replacement	Alone	16	21	Intermediate stay
6	F	81	Trochanteric/Plate and screw	Alone	11	12	Home
7	M	88	Cervical/Hemi-arthroplasty	Alone	12	13	Home
8	M	73	Trochanteric/Intermedullary nail	Alone	12	13	Home
9	F	93	Trochanteric/Intermedullary nail	Alone	9	18	Intermediate stay
10	F	77	Trochanteric/Plate and screw	With son	3	8	Home
11	F	70	Cervical/LIH pins	With husband	3	8	Home
12	F	91	Trochanteric/Intermedullary nail	Alone	13	14	Home
13	F	81	Cervical/Hemi-arthroplasty	Alone	9	11	Home
14	M	74	Cervical/Total Hip Replacement	Alone	6	12	Home
15	M	89	Trochanteric/Plate and screw	With wife	8	12	Home
16	M	77	Cervical/Total Hip Replacement	With wife	9	11	Home
17	M	75	Cervical/Hemi-arthroplasty	Alone	8	13	Home
18	F	87	Cervical/Hemi-arthroplasty	Alone	8	9	Home
19	F	94	Trochanteric/Plate and screw	Alone	8	10	Home

Procedure

Semistructured individual interviews with 19 patients were conducted between April and September 2016, prior to their discharge from hospital. The first author (GA) performed 18 of the 19 interviews, with the last author performing one interview (LZ). All interviews were performed in a quiet room where disturbances were kept to a minimum, with the aim of allowing the patient to speak more openly about their experiences. The interviews were recorded using a dictaphone and lasted between 25 and 67 minutes (average 42 minutes) and thereafter transcribed verbatim. The interview commenced with asking the patients to give a brief description of the fall event and subsequent hospital admission. A semistructured interview guide (Supplementary Appendix 1) was thereafter used, which included questions concerning the following areas; experiences of recovery and participation in their rehabilitation process including the use of TLS-BasicADL.

Data analysis

The method of qualitative content analysis described by Graneheim and Lundman was followed [24]. The analysis was performed by the first (GA) and last author (LZ) separately then discussed until a consensus was met. All four authors were involved in the discussions leading to final agreement of categories. The transcribed interviews constituting the unit of analysis were first read several times in order to gain a sense of the whole. Analysis began by finding meaning units that were related to the aim of the study, that is, patients’ experiences of their recovery, rehabilitation and TLS-BasicADL. Thereafter, these units were condensed, abstracted and labelled with a code while still preserving the core meaning. The codes were then compared based on differences and similarities and sorted into categories and subcategories to highlight nuances of the essential sense of each category. Citations have been used throughout the results section to give the reader a better understanding of the results. The number after each citation shows the participant who has provided it and the use of ‘…’ refers to words or sentences that have been omitted.

Ethics

This study was approved by the Regional Ethics Board at the University of Gothenburg, Gothenburg, Sweden, Dnr 351-10.

Results

Analysis of the interviews resulted in two main categories ‘Being seen as a person’ and ‘Striving for Independence’. These two categories were derived from three and four subcategories respectively as described in Table 2.

Table 2. Categories and subcategories.

Categories	Being seen as a person	Striving for independence
Subcategories	Interaction affects trust and security	Accepting the situation whilst trying to remain positive
	Information is key to understanding	The greener the better, but it’s up to me^a
	Encouragement is essential to promote activity	Ask me, I have goals Uncertainties concerning future

^a“The greener the better” refers to patients’ experiences of becoming more independent in activities included in TLS-BasicADL.

Patients’ experiences of their recovery after hip fracture surgery varied depending on which part of the recovery phase they were describing. Two main phases were identified; the first phase referring to the initial period of dependence experienced post-operatively and the second phase, the transitional period from being dependent on others to regaining independence in basic activities of daily living. While for some patients the initial post-operative period went well or better than expected, others described situations when they felt particularly vulnerable and helpless with staff not recognising their basic needs.

Being seen as a person

Interaction between healthcare professionals and the patient was described by patients as a prerequisite for recovery. Their experiences of interaction and need for support varied throughout the recovery process depending on the context, recovery phase and the patients’ degree of dependency on others. However, being seen as an individual, with HCPs showing an interest in, and trying to meet their needs and preferences was important for patients.

Interaction gives trust and security

Being made to feel welcome on the ward by the HCP was important for patients when finding themselves in an unfamiliar situation and environment. HCPs that were positive, happy, friendly and showed compassion when giving support or assistance were perceived positively by the patients. Furthermore, PTs and OTs who took time to share their knowledge with the patient, giving support and information, as well as guiding in the right direction during their hospital stay was also greatly valued by the participants by instilling 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… I believe that they have taken it in the order that is normal and necessary for things to get better.’ [1]

However, participants also highlighted times when they felt helpless, vulnerable and unsure, that HCPs were not seeing the needs of the person behind the patient with hip fracture. This was experienced in particular when patients were reliant on help from others, affected by pain or lacked the energy to participate.

‘I feel, how shall I say? 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. I can’t manage like they want me to, I am just a normal person, old and frail…I wasn’t given the help I wanted…so I feel, now I feel I have been taken advantage of in a way, that I should do it. I mean it was easy for them to take me under the arm and lift me up, THEN I could walk!’ [2]

Patients explained that they were at times reluctant to press their call button as they felt the HCPs were often short staffed, stressed running between patients, and did not have the time to help them. This was expressed particularly in situations when patients were dependent on staff for help to transfer and walk, going to the toilet, when requiring assistance to lift up exercise equipment to follow the exercise programme as well as help to reach items on their bedside table.

‘…and I didn’t dare to disturb them too much because they are running and working so hard, so in a way I felt I would be disturbing them by asking them to put the roll on the bed and then to take it away again.’ [5]

Information is key to understanding

Patients valued being given information to help them understand their new situation. They referred to information in varying forms and contexts: verbal information concerning care procedures, a printed booklet with written information about the fracture and rehabilitation process, as well as the visual instrument, TLS-BasicADL, to assess and communicate level of dependence in activities of daily living (ADL) and goals setting. Patients emphasised the importance that information should be kept simple and not overwhelming.

‘…I have been given very good information and they tell you what you should do and how it is, and how it is going to be…so I’m really impressed with all the staff here.’ [10]

Several of the participants were not familiar with TLS-BasicADL and unaware that they had been given information. Others however, described it as easy to understand and to follow progress using the simple colour-coding system. They felt the activities included in TLS-BasicADL were pertinent, and important to manage as independently as possible prior to discharge. Having the protocol visible for HCPs by the patients’ bedside was also valued by patients, highlighting their need for help or supervision in specific activities.

‘… I think it’s a really good idea, because it means that you don’t have to explain everything, all the time, to the staff! They can just take a quick look at it.’ [11]

While the benefits of systematically collecting and communicating information regarding ADL ability were identified, several patients felt they were not involved in the process. They expressed that it was an instrument for the HCP and not for them, others were indifferent, they understood the concept but did not feel the need to be involved.

In situations where medical problems or complications following surgery arose, receiving personalised information was regarded particularly important to acknowledge the patients’ specific symptoms, to decrease their anxiety, and help them understand and come to terms with their situation, in order to move forward.

‘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.’ [9]

The ability for patients to process information varied, which was most evident during the early post-operative period. Some patients were unaware that they had been given information, or forgotten what was said, others described that they were at times aware they had been given information; however, they did not feel able to take in and retain what was said at that point in time. They did however want the HCP to believe that they were listening and taking in information, but in reality, this was not always the case.

‘…in the beginning it was a bit so-so! I looked like I understood everything, I just nodded and things like that!’ [3]

Patients who underwent surgery on a Friday expressed that they would have appreciated meeting a PT over the weekend to give them information and exercises, to get them started in their rehabilitation process.

Encouragement is essential to promote activity

According to the interviewees, HCPs, in particular PTs and OTs played an important role in helping them through the transition from being dependent on physical assistance, to requiring supervision, and finally becoming independent. Encouragement and support in the form of information, guidance, and positive feedback regarding their efforts and progress, were particularly valued. Several patients described the importance of being given a ‘nudge’ in the right direction, which assisted them in becoming more active and continuing to strive after increased independence.

‘…now you can manage this, now you can manage this, and now you can manage this’…it’s great, that you get a nudge from behind, you know! …you are not so brave when you are my age, to have the courage to do it yourself…as you were when you were young…I mean when you are given the nudge and you see that you can…the nudge is important, it has been for me, and I think it is for everyone, just this that you manage to do it.’ [18]

‘…otherwise I would have lain flat in bed all the time… without them I wouldn’t have managed.’ [16]

Over and above the verbal encouragement given by HCPs, the patients described the visual feedback, seen through the use of TLS-BasicADL, as positive and giving them a boost in self-confidence.

‘You really feel happy with yourself when you have been able to do it.’ (achieving independence in a TLS activity) [14]

Suggestions of methods for improving physical activity were expressed, including providing a checklist for the patient to tick off when they performed exercises or activities, as well as HCPs, particularly PTs, reminding patients to do exercises to increase compliance.

‘…I would have liked something that I could have put a tick to, that now I have done that exercise and now I have done this exercise…that would have been better for me…as you shut your eyes and forget, and fall asleep and things like that…they (PTs) could have come more often to me…I would have liked that, like if they had said ‘do this now’. Even if they didn’t stay but were there reminding me…that’s what would have felt best for me’ [1]

Striving for independence

Strategies adopted by patients in the transition from dependence to independence varied depending on their experiences of recovery. Some patients described being surprised how well and quickly they were progressing while others with more complex needs expressed an understanding that recovery will take time. No matter the speed of recovery, participants emphasised the importance of maintaining a positive attitude, and an inner strength to assist them in their recovery process.

Accepting the situation while trying to remain positive

It was regarded important by patients to maintain a positive attitude, not to lose heart, and retain the ability to fight for regaining independence, even if the recovery process was slower than they wished or expected. It was important to adapt to the situation, to accept help when required whilst retaining a positive outlook towards the future.

‘It’s better to believe that things will work out, or be better…not to put yourself down…it is as it is…there is no point in worrying. I believe that yesterday is past, and tomorrow you haven’t seen yet and today you get help, that’s what I think, but it’s difficult at times of course…’ [19]

‘…not to lose heart…to give as much as you can…and to strive after the best in your recovery.’ [5]

Participants who expressed that they were aware that their recovery could take time and that they may not reach their previous level of independence often referred to complications and/or decline caused by the natural aging process. They still however, conveyed the importance of maintaining a positive attitude to move forward.

‘Of course, you want to recover…so you are mobile again. But of course, you can’t think that it’s going to happen in a week…it can take time, and you don’t need to rush it so much. Rather it will take the time it takes, as long as you don’t lie down to it…then there will be a problem, but I’m not going to do that.’ [10]

‘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.’ [19]

However, finding the ability to remain positive was a struggle for some participants who were more physically and psychologically affected by the trauma of the hip fracture.

‘…Soon I won’t be able to think…it will end up being the way it will be…but just so I manage, so I’m of a little use, then I’ll be happy…there is a lot that needs to happen here…but I think it will sort itself out somehow.’ [2]

The greener the better, but it’s up to me

Recognising improvements in functional status was greatly valued by patients, stimulating them to continue to strive for independence. The patients described that it was satisfying and motivating when they could see the colour coding changing in TLS-BasicADL, as they were able to manage more themselves, and required less assistance from HCPs.

‘It’s more green now than it was in the beginning…it’s more fun to get green…I think it’s encouraging…if you see it’s getting better, or at least in the right direction.’ [5]

‘…because you understand that the greener the better, and when I see that everything is green then I think” YES”, it’s really good and then everyone else says the same, says “oh, that’s great!” I think it’s great actually!’ [3]

While participants valued the support given to them by PTs and OTs and appreciated seeing the progress they were making, they were aware that in order to enhance their recovery, they themselves, had to actively participate in their rehabilitation. Taking the initiative and responsibility to participate in their rehabilitation and becoming more active was recognised as essential by participants. Patients with limited resources expressed the importance for them to participate at a level that was suitable for them, that HCPs were sensitive to their limitations, adapting care accordingly to give them time to participate. It was important that these patients felt that they had been allowed to do as much as they were able.

‘I have had these physiotherapists who came, two of them, and I think they are good at their job and very ’pushy’, so I’m very happy for the help they have given me, both in bed and in the corridor…it’s really good as they help me an awful lot. 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.’ [16]

While patients valued becoming ‘greener’, they also described situations when they were apprehensive about changing colour-coding, from supervision to being independent in an activity. They referred mainly to the activities: walking and going to the toilet.

“I could of course be green there (referring to walking), I could have taken green there but, ’Wait a day!’ I said, ’and see!’…She (PT) is coming this afternoon so we can talk about it.” [14]

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.

Regaining mobility was the common goal described by all the participants. However, the content and context of mobility goals varied depending on the patients’ resources and recovery phase referred to. For those patients who were dependent on others in basic transfers and ADL, short-term goals including getting back on their feet as soon as possible in order to regain ability to go to the toilet independently were often referred to.

‘…something that I feel that I need to be able to do is to be able to get out of bed and back into bed. To be able to get up, and walk, and back into bed.’ [15]

‘That I can go to the toilet and take care of myself without having to always press the call button.’ [6]

Others talked more about long-term goals, including getting back to how they were before the fracture, getting back to a normal life, to be able to cycle, travel, cook, meet friends and being able to walk outdoors again.

‘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.’ [3]

‘For me it is obviously, first and foremost, that I become independent in every way.’ [5]

The participants who had experience of using TLS-BasicADL for goal setting expressed that they found it easy to understand and follow progress. Patient number 17, whose interview was not recorded due to technical reasons, also reported the instrument to be well-structured, providing a logical way of thinking and for following progress.

‘Yes, the goal, yes, they have shown me…when I saw it the first time I thought ‘this isn’t so daft’, it’s not so daft the way they have put it together.’ [9]

Uncertainties concerning future

Participants expressed concern regarding their future after discharge from hospital. They felt unsure how they were going to manage their lives outside of the hospital environment. Despite feeling these concerns not all patients felt able to talk about them with their significant others, they did not want to be a burden on them and rather kept these thoughts to themselves. They questioned whether they would be able to return home, when they are discharged home will they be able to move about in their homes, will they be able to come out or will they be stuck indoors. These questions left them feeling worried and insecure in for discharge.

‘…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.’ [15]

‘You don’t know how it will be when we come home…my son would rather I went into a home, so I get help. I can come home if the firemen carry me up…then I can come home, but I can’t walk on my own.’ [2]

Discussion

Our findings highlight the complex needs of patients with hip fracture and the challenges that HCPs meet in the clinical setting. The great variation of experiences expressed by the participants is in accordance with previous research underlining the heterogenic nature, with varying individual needs and preferences of this patient group [14,18,19].

The events of the fall and subsequent hip fracture left them feeling upset and in chock. In order to regain a sense of trust and security, it was important for patients to be met and taken care of by staff who were positive, friendly and showed compassion by seeing them as a person. It is important to be recognised as an individual with a disease and not a disease in itself [25]. This has also been described by Rasmussen and Uhrenfeldt who refer to the need for ‘supportive interaction’ from HCPs to establish well-being, through dialogue, information and feedback to promote self-confidence [26].

However, patients described situations when they felt helpless and vulnerable and experienced staff insensitive to their needs, particularly in situations when dependent on staff, for example, when requiring help to go to the toilet. This has also been recognised in earlier studies with patients experiencing being overruled, feeling insignificant, which can lead to distrust in the HCPs [26]. Participants in this study described how they found it difficult at times to get the help they needed, which is an issue expressed by patients in other studies who perceived staff to be often very busy, running between patients and were therefore reluctant to press their call buttons to ask for help [14,27].

The participants’ ability to take in and process information in this study varied considerably during the transition of recovery, which has also been reported by Malmgren [14]. While some patients reported feeling well informed, others were unaware they had been given information, aware but had forgotten, or did not feel able to listen at that point in time. This highlights the need for information to be adapted to the individuals’ needs, kept as simple as possible, given in batches, and followed up in order to determine if the patient has understood or not [14,18]. In this study, all of the participants were in agreement that information should be kept simple and not overwhelming.

While participants acknowledged that being active was the way forward to increased independence, patients described that had it not been for the support of HCPs they would not have been as active and progressed as much. They experienced finding difficulties motivating themselves without ‘nudging’ from HCPs, particularly PT and OT. Previous research has highlighted the importance of support [28] and having the ability to understand and respect situations when patient’s capacity or willingness is low, for example, due to illness, pain or lack of energy [16].

Participants who were operated on a Friday felt that their rehabilitation could have progressed more quickly had they had access to allied health staff, in particular PTs at the weekend. They requested information concerning the rehabilitation process and to be taught exercises that they could perform themselves. This is a need that has been highlighted by patients in other studies [27,29]. While small improvements in length of stay and function have been reported more research is recommended in this area to find the most cost-effective methods of delivering weekend services [29].

Accepting the situation, while maintaining a positive attitude was voiced by participants as essential during their recovery, especially when progress was not proceeding as quickly as the patient would have liked or expected. Similar findings have been reported, where patients who experienced self-confidence, being positive and taking life as it comes found it easier to come to terms with their new situation [30,31]. However, patients with more complex health conditions or complications following surgery found it more of a struggle to accept their new-found situation and remain positive, highlighting their need for more support and encouragement, to maintain or preserve perspective [21]. It is essential that rehabilitation is adapted to a level where the patient feels they can partake, where they can recognise improvements, no matter how small, in order to regain self-confidence and an inner belief in recovery [18,19,30].

Over and above verbal and physical support, participants experienced the visual feedback through the use of TLS-BasicADL as positive. Recognising that their level of function was improving was expressed as encouraging and assisted in increasing patients’ self-confidence. This is in line with the study performed by Proctor et al. who reported that careful monitoring of activities and planning a graded programme to suit the patients’ needs can increase self-efficacy and ensure continued progress [16].

The use of charts to monitor progress has been suggested to improve self-efficacy and promote continued progress [16]. One of the purposes of using TLS-BasicADL is to monitor progress by visually informing patients of their present functional status and to highlight when change has occurred. This was experienced both satisfying and stimulating, with participants expressing that they found it easy to understand and seeing the colour coding changing as they made progress was both enjoyable and gave feelings of increased self-confidence.

Goal setting is recognised as a central component of rehabilitation, enhancing self-confidence, motivation, participation, team communication as well as the likelihood of goal achievement [32]. During the interviews, patients were able to express clearly what their goals were, including activities they considered important. However, few experienced that they had discussed their goals with HCPs. Although a function of TLS-BasicADL is to assist discussion of concrete short-term goals concerning mobility and ADL, this has not been utilised fully. It is unclear if PTs and OTs discussed goal-setting with patients. A reason for this could be lack of time or co-ordination between staff [32].

Regaining stable mobility in order to be able to participate in valued activities is a goal most commonly expressed by patients following hip fracture surgery [20]. This was also conveyed by participants in this study. During the initial phase of dependency post-operatively, they commonly expressed the wish of being able to get up out of bed and going to the toilet independently, without having to rely on staff. While for others who were making progress, more long-term goals were referred to, valued activities they could associate with getting back to normal after discharge.

As in previous studies, patients expressed concerns regarding their future, and how they will manage after discharge, and becoming a burden to significant others, which left them feeling worried and insecure [28,33]. A further study by Zidén et al. reported that patients continue to experience these feelings of uncertainty at one month after discharge [34]. This highlights that more attention is required to identify, and address patients concerns in order to minimise their worries and adapt discharge planning to better fit their needs [18]. A recommendation described by van Der Meide et al. involves HCPs giving patients the opportunity to talk by showing a willingness and openness to listen. This can be accomplished simply by HCPs regularly showing up in the patient’s room, indicating to the patient that they have time and are interested in their situation [35]. Another option to decrease anxiety is to consider implementation of a supportive discharge team, with HCPs who follow patient home at discharge, to assess the patient in their own environment, provide assistive aids as required, and plan need for continued rehabilitation.

Methodological considerations

The aspect of trustworthiness is important when performing and presenting research using a qualitative approach [36,37]. To enhance trustworthiness of the results quotations were used to illustrate the categories. Furthermore, triangulation was used in the analysis process whereby two of the authors performed the analysis separately and regular consensus meetings were held with the collaborating authors to ensure the findings were robust and well-developed. While the data analysed in this study have been collected from interviews with patients treated for a hip fracture in a geriatric unit, the results of this study are similar to earlier research examining patient experiences of care. This should therefore increase the transferability of the results to other geriatric wards.

Strengths and limitations

Patients were recruited from three wards in the geriatric unit to give a greater variation in our data. It may be that, had we recruited patients from other hospitals, the results would have been different. We also acknowledge that the participants in this study were community dwelling, with intact cognition and independent walking indoors prior to fracture, while this is not representative for all patients recovering from hip fracture, the results of this study can be compared with previous research studying similar patient groups [18,19,38]. The interviews were performed by two researchers, who are PTs with clinical experience of working on the three wards. This may have led to bias of the results and influenced patients to adapt their descriptions to what they thought they were expected to talk about, that is, did not talk as freely. To compensate for this and increase trustworthiness, the interviews were performed out with the ward setting, in civilian clothing.

Conclusion

Patients with more complex needs require more attention and care adapted to fit their individual physical and psychological needs. To improve services and provide better quality of care and rehabilitation, it is essential to continue to acknowledge the patients’ experiences, needs and preferences, which includes their individual rehabilitation goals. HCPs must recognise that patients with hip fracture are individuals, with varying needs that change across the continuum of recovery.

Acknowledgements

The authors gratefully acknowledge the study participants for their time and willingness to share their experiences.

Availability of data and materials

This article does not include any additional materials as this is a qualitative study.

Disclosure statement

The authors report no declarations of interest.

Additional information

Funding

This work was supported by funding from the Research and Development Fund, Göteborg and South Bohuslän, Renée Eanders Fund and Hjalmar Svensson Fund.

Notes

1 “The greener the better” refers to patients’ experiences of becoming more independent in activities included in TLS-BasicADL.