"If only had I known": a qualitative study investigating a treatment of patients with a hip fracture with short time stay in hospital

Coming home: older patients' and their relatives' experiences of well-being in the transition from hospital to home after early discharge

BACKGROUND

This study aims to investigate the lived experience of well-being among older patients and their relatives in the transition from hospital to home after early discharge. Research has shown that the transition brings severe challenges to their everyday lives. However, to date, there has been a lack of research focusing on the lived experiences of well-being during this process.

METHODS

The data collection and analysis followed the phenomenological approach of Reflective Lifeworld Research. Ten in-depth interviews with older patients and their relatives were conducted in Austria up to 2-5 days after hospital discharge.

RESULTS

The essential meaning of the phenomenon of well-being in the transition from hospital to home is marked by security and confidence to face the challenges following the discharge. Four constituents emerged: being calm and in alignment with the homecoming, being in familiar surroundings at home-a sense of belonging, striving towards independence-continuity of life and having faith in the future.

CONCLUSION

Our findings point to the importance of recognizing the vulnerability associated with the transition from hospital to home, as it impacts the existential aspects of space and time. Facilitating a sense of continuity and belonging can foster well-being during this critical period.

Stressors and coping strategies in older people hospitalised for hip surgery following a fall: a multiple case study

BACKGROUND

More than half of older persons admitted to an emergency department after a fall have a hip fracture and require surgery for a total hip replacement. This procedure has a high risk of postoperative complications and consequences for older persons, their informal caregivers, and the healthcare system. This study aimed to explore the perceptions of older persons, their informal caregivers and health professionals about intra-personal, inter-personal and extra-personal stressors arising from hip surgery following the fall of an older person hospitalised in orthopaedics, as well as the coping strategies used and the results obtained.

METHODS

A qualitative multiple case study. The sample consisted of eight cases. Each case consisted of one older person, their informal caregiver and the professionals involved in their care: a nurse, an orthopaedic surgeon and a physiotherapist. A total of 32 participants were recruited. Data were collected between August 2018 and February 2019 in a public hospital in French-speaking Switzerland. Intra- and inter-case analyses were performed.

RESULTS

Five topics emerged: two concerning stressors for older persons (the physical and psychological consequences of the fall and hospitalisation; the loss of relational and environmental markers and habits); two relating to the coping strategies used to face the stressors (being resilient and involved in their own care; partially meeting the older person's needs); and one regarding the results of the strategies used (reassurance through consideration of some of their needs).

CONCLUSIONS

Older persons hospitalised for hip surgery after a fall are confronted with various intra-, inter- and extra-personal stressors and have to explore, together with their informal caregivers, strategies to cope with the consequences of these stressors. Healthcare professionals should possess efficient intervention strategies to help identify and support older persons who experience various types of stressors during hospitalisation for hip surgery following a fall.

Association between patient activation level and functional outcomes in older adults with hip fractures

BACKGROUND

Hip fractures can significantly impact older adults' mobility and function. Effective rehabilitation is crucial to help them regain independence and quality of life. However, little is known about the association between patient activation and hip fracture rehabilitation. This study aims to assess the association between the PAM-13 scores and the level of physical function, mobility, and activities of daily living in older adults following a hip fracture rehabilitation program.

METHOD

An exploratory outcome study from a cluster-randomized stepped-wedge clinical controlled trial. Two hundred thirty-nine patients were classified into four Patient Activation Measure-Levels (PAM-13) according to their PAM-13 scores, reflecting their confidence and preparedness to manage their health. Level 1 represents the lowest level of confidence. The patient's mobility, function, and daily activities were evaluated at discharge and after 12 and 24 weeks.

RESULTS

The cohort had a median age of 78; 67% were female, and 50% lived alone. There were no significant differences in demographics between the PAM-Levels. PAM-Level 1 patients had longer hospital stays and lower mobility scores than PAM-Level 4 patients. However, all patients improved over time, and higher initial PAM levels resulted in better outcomes. PAM-Level 1 patients improved in Time Up and Go score from a median score of 54 seconds to 14 seconds at 24 weeks, while PAM-Level 4 patients improved from 26 to 9 seconds.

CONCLUSION

Our study found an association between PAM levels and functional outcomes in hip fracture rehabilitation. Patients with higher activation levels had better mobility and functional outcomes.

Hip fracture has profound psychosocial impacts: a systematic review of qualitative studies

BACKGROUND

Hip fracture is a common and serious traumatic injury for older adults characterised by poor outcomes.

OBJECTIVE

This systematic review aimed to synthesise qualitative evidence about the psychosocial impact of hip fracture on the people who sustain these injuries.

METHODS

Five databases were searched for qualitative studies reporting on the psychosocial impact of hip fracture, supplemented by reference list checking and citation tracking. Data were synthesised inductively and confidence in findings reported using the Confidence in the Evidence from Reviews of Qualitative research approach, taking account of methodological quality, coherence, relevance and adequacy.

RESULTS

Fifty-seven studies were included. Data were collected during the peri-operative period to >12 months post fracture from 919 participants with hip fracture (median age > 70 years in all but 3 studies), 130 carers and 297 clinicians. Hip fracture is a life altering event characterised by a sense of loss, prolonged negative emotions and fear of the future, exacerbated by negative attitudes of family, friends and clinicians. For some people after hip fracture there is, with time, acceptance of a new reality of not being able to do all the things they used to do. There was moderate to high confidence in these findings.

CONCLUSIONS

Hip fracture is a life altering event. Many people experience profound and prolonged psychosocial distress following a hip fracture, within a context of negative societal attitudes. Assessment and management of psychosocial distress during rehabilitation may improve outcomes for people after hip fracture.

Adult patients' experiences after a distal radius fracture - A qualitative systematic review

BACKGROUND

Distal radius fractures are a common presentation in emergency departments. Synthesis of qualitative research of treatment, care and rehabilitation this fracture presents from the patient perspective could improve clinical practice and care. The purpose of this systematic review was to synthesize the qualitative literature on patient experiences after sustaining a distal radius fracture.

METHODS

We searched Embase, MEDLINE, CINAHL, Psycinfo and CINAHL to identify qualitative studies published from database conception to May 2023. All studies were screened, extracted, analysed and quality assessed by two blinded reviewers. A thematic synthesis approach was used to analyse the findings from included studies.

RESULTS

A total of 9 studies interviewing 160 unique patients were included. We identified 3 themes in relation to patient experiences after sustaining a distal radius fracture: 1) Concerns about dependency, 2) Fear and pain and 3) Motivators for recovery. The themes did not exist as sharply demarcated topics but were intertwined with patients reflecting that more information and knowledge could assist in managing expectations and the recovery period.

CONCLUSION

Our synthesis highlighted that adult patients with DRF experience a lack of information about the care and treatment inhibiting independence and successful management of expectations due to pain, fear and lack of motivation. Our findings can inform orthopaedic units and assist in tailoring information to patient needs.

Epistemological aspects of participatory design studies conducted in the field of health science

AIM(S)

To discuss the methodological aspects of participatory design, arguing for a three-phase approach and the suitability of situating participatory design within a phenomenological-hermeneutical tradition in health science.

DESIGN AND METHODS

Methodological discussion based on participatory design theory, epistemology and research studies.

RESULTS

The epistemological and methodological discussions show how the core values and key elements of participatory design align with the phenomenological-hermeneutical approach. In addition, examples of participatory design studies are provided to illustrate how it can be conducted in health science.

CONCLUSION

Participatory design is a flexible framework based on genuine participation, defined by three core values: having a say, mutual learning and democratization. The iterative processes allow for adjustments in alignment with the core values and the scientific stance that defines the choice of methods, tools and techniques. A phenomenological-hermeneutic approach in participatory design studies is relevant and aligned with the core values of participatory design. Thus, this paper argues for a close integration between the participatory design methodology and the phenomenological-hermeneutic scientific approach within health science.

IMPLICATIONS FOR THE PROFESSION

Participatory design is a powerful methodology with core values that can co-design sustainable health technologies with potential to impact patient care and the clinical practice of nurses. When combined with qualitative research methods, patients' lived experiences serve as the foundation for improving clinical nursing practice. Discussing the epistemological aspects of participatory design provides nurse researchers with a coherent methodological understanding, essential for the continual development of nursing research.

IMPACT

This paper discusses the research methodology of participatory design within health sciences. It aims to address the lack of understanding of the methodology, particularly within a specific scientific stance. The main finding is the elaboration on participatory design and the relevance of a phenomenological-hermeneutical approach. The paper has the potential to impact researchers, master's and PhD students, as well as others engaged in participatory design or other methodologies related to user involvement within health science.

REPORTING METHOD

No available EQUATOR guidelines were applicable to this methodological paper, as no new data were created or analysed.

PATIENT OR PUBLIC CONTRIBUTION

There was no direct patient or public contribution, as this is a methodological paper.

Association of the @ctivehip tele-rehabilitation with the fear of falling of older adults with hip fracture and their family caregivers: Secondary analysis of a non-randomised controlled trial

INTRODUCTION

Osteoporotic hip fracture is a major health problem. Falls, the primary cause, might lead to a persistent fear of falling (FoF) among older adults, affecting their daily activities and rehabilitation. While in-person interventions exist, limited research is available on the effects of tele-rehabilitation on the FoF after a hip fracture. Thus, this study aims to test the association of the @ctivehip tele-rehabilitation programme on reducing the levels of FoF experienced by both older adults with hip fracture and their family caregivers.

METHODS

A non-randomised controlled trial (ClinicalTrials.gov; Identifier: NCT02968589) that compared a webpage-based tele-rehabilitation (@ctivehip) against usual care. Fear of falling was assessed using the Short Falls Efficacy Scale-International. Patients' functional status was evaluated using the Functional Independence Measure. Physical performance was assessed by the Timed Up and Go test and Short Physical Performance Battery. We conducted a per-protocol analysis as the primary outcome, and an intention-to-treat approach as secondary analysis.

RESULTS

A total of 71 patients with hip fracture (78.75 ± 6.12 years, 75% women) and their family caregivers participated. Participants in the intervention showed a higher decrease in FoF in comparison to those in the usual care (0.5 Cohen's d; p = 0.042). The reduction in FoF resulting from participation in the tele-rehabilitation programme was mediated by improvements in functional status by 79%. The @ctivehip programme did not decrease FoF of family caregivers.

DISCUSSION

@ctivehip is associated with a reduction of the FoF in older adults with hip fractures, but not in their family caregivers, with the reduction being mostly explained by improvements in the patients' functional status. Although the intervention seems promising, it should not be applied in clinical settings until confirmed by appropriate-designed randomised clinical trials.

Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study

INTRODUCTION

The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization.

METHODS

This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed.

RESULTS

The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit.

CONCLUSION

Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.

From fear to control: Older adults' thoughts and feelings about empowerment-oriented rehabilitation after a hip fracture

BACKGROUND

It is essential to focus on how older adults remain active and regain control of their daily lives after hip fractures. 'Rehabilitation of Life' is an empowerment-orientated hip fracture intervention focused on continuous rehabilitation and care between sectors in Denmark. We aimed to understand and explore older adults' experience participating in the intervention 'Rehabilitation of Life' and how this relates to their sense of empowerment.

METHOD

Qualitative data were generated from 16 semi-structured interviews with patients experiencing a hip fracture and subsequent rehabilitation in the program "Rehabilitation of Life' The data was analysed using Graneheim and Lundman's concept-guided qualitative content analysis method.

RESULTS

The analysis revealed five themes that the participants emphasised as vital to their rehabilitation: getting information and care when hospitalised, early visits from healthcare professionals after returning to their homes, the social aspect of training together with others, rehabilitation provision by skilled and empathic staff, and acceptance of a new me. The five themes indicated that adults aged >65 years generally experienced rehabilitation after hip fractures as motivating and reassuring.

CONCLUSION

Social support and peer programs can significantly improve the rehabilitation of older adults with hip fractures. The Rehabilitation of Life intervention has shown that promoting successful rehabilitation requires patient-centred strategies that encourage collaboration between different sectors. To increase patients' empowerment and engagement in their health journey, it is important to consider changes in patients' behaviour, increase their autonomy and ensure their independence after rehabilitation.

Co-creation of mHealth intervention for older adults with hip fracture and family caregivers: a qualitative study

PURPOSE

Hip fracture results in an older person's loss of independence. Limited healthcare resources make mobile Health (mHealth) an alternative. Engaging key stakeholders in health technology development is essential to overcome existing barriers. The aim of this study was to establish perspectives of older adults with hip fracture, family caregivers and health professionals (stakeholders) on the development of a mHealth system.

MATERIALS AND METHODS

Qualitative study guided by user-centered design principles with focus groups to engage stakeholders during the development. Seven focus groups were conducted [older adults with hip fracture (n = 2), caregivers (n = 3), and health providers (n = 2)] with 45 participants (14 older adults, 21 caregivers and 10 health providers). Inclusion criteria were older adults ≥ 65 years who sustained a hip fracture in the previous 3 months; family caregiver of a person with hip fracture; and health providers with 2+ years of clinical experience working older adults with hip fracture. We followed standard methods for focus groups, including recording sessions, transcription and conducting an inductive content analysis. The same moderator, with clinical and research experience, conducted all focus groups.

RESULTS

Three themes were generated to consider for a future mHealth intervention: (1) user-friendly design; (2) content to include recovery and prevention information; and (3) implementation factors. Our mHealth system was developed based on feedback from participants.

CONCLUSIONS

Co-creating mHealth technology with stakeholders is essential for uptake and adherence. We provide an overview of the development of ActiveHip+, an mHealth system for the clinical care of older adults with hip fracture.

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

BACKGROUND

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs.

METHODS

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture.

RESULTS

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

CONCLUSIONS

Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Lingering challenges in everyday life for adults under age 60 with hip fractures - a qualitative study of the lived experience during the first three years

PURPOSE

We aimed to illuminate the lived experiences and the path of recovery for adults sustaining a hip fracture before the age of 60.

METHODS

Participants were purposively sampled from a prospective multicenter cohort study in Sweden and Denmark, and narrative interviews were conducted with 19 individuals 0.7-3.5 years after the fracture. We used a phenomenological hermeneutic method to describe the participants' expressed essential meaning.

RESULTS

The experience of sustaining a hip fracture was expressed as a painful and protracted process of regaining self-confidence, function, and independence. It also implied a sense of growing old from one day to the next. Participants were afraid of new falls and fractures, resulting in an increased wariness. When expressing fears and persisting symptoms, participants described being neglected and marginalized by the healthcare system, which was perceived as non-receptive and routinely driven by a notion that hip fractures affect only the elderly. Rehabilitation targeted towards needs different from those of elderly individuals was requested.

CONCLUSION

The lived experience of sustaining a hip fracture in individuals under 60 includes substantial challenges in everyday life, even up to 3.5 years after the injury. Rehabilitation pathways tailored to the needs of younger patients are requested.

Information needs and preferences of patients with an ankle fracture: User involvement study creating an mHealth solution

OBJECTIVE

The aim of this study was to employ a user-driven participatory design (PD) approach to develop an mHealth solution that addresses patients' information needs after surgical or non-surgical treatment for an ankle fracture.

METHODS

Patients with an ankle fracture and health care professionals along the treatment pathway in both the hospital and municipality participated in four workshops (WS).

RESULTS

We found that patients with an ankle fracture need information on topics such as "a typical course," "bandages and assistive devices," "what can I feel," "what may I do," "what to usually worry about," "medicine," "tips and tricks," and "contact information." Moreover, patients requested diverse modes of dissemination, preferably a combination of text, timelines, pictures, animations, and videos. Alpha and beta testing of the digital platform was conducted, and content-related improvements were made. A readability analysis showed reading ease of 40.1 of 100, meaning that it should be easily understood by 15-16 year-olds.

CONCLUSION

Involving representatives of future users in creating this mHealth solution using PD demonstrates the benefits of creating a solution that aligns with users' needs.

PRACTICE IMPLICATIONS

The mHealth solution is now ready for implementation and large-scale evaluation in phase three of the overall PD study. An mHealth usability questionnaire will be employed to assess usability by future patients with surgically or non-surgically treated ankle fractures.

Perception of Goals and Expected Outcomes in Older Hip Fracture Patients and Their Medical Staff: A Cross Sectional Study

Background

Goal-oriented patientcare is a key element in qualityhealthcare. Medical-caregiver's (MC) are expected to generate a shared decision-making process with patients regarding goals and expected health-outcomes. Hip-fracture patients (HFP) are usually older-adults with multiple health-conditions, necessitating that agreed-upon goals regarding the rehabilitation process, take these conditions into consideration. This topic has yet to be investigated by pairing and comparing the perception of expected outcomes and therapeutic goals of multidisciplinary MCs and their HF patient's. Our aim was to assess in a quantitative method whether HFPs and their multidisciplinary MCs agree upon target health-outcomes and their most important goals as they are reflected in the SF12 questionnaire.

Methods

This was a cross-sectional, multi-center, study of HFPs and their MCs. Patients and MCs were asked to rate their top three most important goals for rehabilitation from the SF12 eight subscales: physical functioning, physical role limitation, bodily pain, general health, vitality, social functioning, emotional role limitation and mental health, and indicate their expected outcome. Descriptive statistics and mixed effect logistic-regression were used to compare concordance of the ratings. Agreement between patients and MCs was assessed using interclass coefficients (ICCs).

Results

A total of 378 ratings were collected from 52 patients, 12 nurses, 12 physicians and 6 paramedical personnel. Each patient had between 3 and 9 raters. Patients considered physical functioning and physical role limitation more important than did MCs. Physicians and nurses emphasized the importance of bodily pain while patients referred to it as relatively less significant. The total ICC was low (2%) indicating poor agreement between MCs and patients. With the exception of physical-functioning, MCs predicted a less optimistic outcome in all of the SF12's subscales in comparison to HFPs.

Conclusion

Effective intervention in HFPs requires constructive communication between MCs and patients. The study suggests that caregivers have an insufficient understanding of the expectations of HFPs. More effective communication channels are required in order to better understand HFPs' needs and expectations.

Being well? A meta-ethnography of older patients and their relatives' descriptions of suffering and well-being in the transition from hospital to home

BACKGROUND

As the average length of hospital stay decreases, more and more older patients will need support during and after the hospital transition, which will mainly be provided by their relatives. Studies highlight the enormous effect such a transition has on the lives of older patients and their relatives. However, research is lacking regarding in-depth understanding of the complexities and the notions of suffering and well-being the older patients and their relatives describe in the transition from hospital to home. Therefore, this study aims to examine the description of suffering and well-being on a deeper, existential level by drawing on existing phenomenological research.

METHODS

In order to synthesize and reinterpret primary findings, we used the seven-step method for meta-ethnography. Following specific inclusion criteria and focusing on empirical phenomenological studies about older patients and their relatives experiences of hospital to home transitions, a systematic literature search was conducted. Data from ten studies have been analyzed.

RESULTS

Our analysis identified three intertwined themes: i) 'Being excluded vs. being included in the transition process', ii) 'Being a team: a call for support and a call to support' and iii) 'Riding an emotional rollercoaster'. The last theme was unfolded by the two subthemes 'Taking on the new role as a caregiver: oscillating between struggling and accepting' and 'Getting back to normal: oscillating between uncertainty and hope'. Within those themes, older patients and their relatives described rather similar than contradictory aspects.

CONCLUSIONS

This study offers insights into the tension between existential suffering and well-being described by the older patients and their relatives during the transition from hospital to home. Especially, the description of well-being in all its nuances which, if achieved, enables older patients and their relatives to identify with the situation and to move forward, this process can then be supported by the health care professionals. However, there is still lack of knowledge with regards to a deeper understanding of existential well-being in this process. Given the increasing tendency towards early hospital discharges, the findings underpin the need to further investigate the experiences of well-being in this process.

Understanding the Experiences of Rural- and Remote-Living Patients Accessing Sub-Acute Care in Queensland: A Qualitative Descriptive Analysi

Introduction

The challenges associated with equitable healthcare access are often more pronounced for individuals living in rural and remote locations, compared to those in metropolitan locations. This study examined the health care transitions of rural- and remote-living patients with on-going sub-acute needs, following acute hospital discharge. This was done with the aim of exploring these patients' experiences of client-centeredness and continuity of care, and identifying common challenges faced by rural and remote sub-acute patients accessing and transitioning to and through sub-acute care in a non-metropolitan context.

Materials and Methods

Semi-structured interviews were conducted with 37 sub-acute patients. A qualitative descriptive approach was used to analyze the interview data and explore key emergent themes in relation to client-centeredness, continuity of care, and sub-acute transition challenges.

Results

Interview participants' average length of stay in sub-acute care was 31.6 days (range = 8-86 days), with most transitioning from larger regional and metropolitan hospitals to on-going rural or remote sub-acute care (n = 19; 53%). Client-centeredness was primarily characterized by the quality of interpersonal experiences with staff, patient and familial involvement in care planning, and the degree to which patients felt their wishes were respected and advocated for. Continuity of care was characterized by access to and participation in rehabilitation services, and access to family and social supports. Challenges associated with sub-acute transitions were explored.

Discussion

The findings suggest important implications for health care providers, including the need to implement earlier and more frequent opportunities for patient involvement throughout the sub-acute journey. The results offer a unique perspective on the way that continuity of care is experienced and conceptualized by rural and remote patients, suggesting a revision of what is required to achieve equitable care continuity for rural and remote residents receiving care far from home.

Conclusion

It is pertinent for health care providers to consider the unique complexities associated with accessing on-going health care as a rural or remote Australian resident, and to develop mechanisms that support equitable access and continuity and facilitate continuity of care closer to home.

Barriers and Enablers to the Use of Web-Based Applications for Older Adults and Their Caregivers Post-Hip Fracture Surgery: A Descriptive Qualitative Study

Purpose

The purpose of this study was to describe the barriers and enablers to the use of web-based applications designed to help manage the personalized needs of older adults and their caregivers post-hip fracture surgery while transitioning from hospital to geriatric rehabilitation to home.

Methods

This was a descriptive qualitative study consisting of semi-structured interviews informed by the Theoretical Domains Framework. The study took place between March 2021 and April 2022 on an orthopaedic unit in a large academic health sciences centre and in a geriatric rehabilitation service in Ontario, Canada. The transcripts were analyzed using a systematic 6-step approach.

Results

Interviews were conducted with older adults (n = 10) and with caregivers (n = 8) post-hip fracture surgery. A total of 21 barriers and 24 enablers were identified. The top two barriers were a need for basic computer skills (n = 11, 61.1%) and a preference for direct verbal communication (n = 10, 55.6%). The top two enablers were having no concerns with using web-based applications (n = 12, 66.7%) and having ease of access to information (n = 10, 55.6%).

Conclusion

We described the key barriers and enablers to the use of web-based applications from the perspectives of older adults and their caregivers. These factors will inform further developments of web-based applications aimed at improving the care transition from hospital to geriatric rehabilitation to home post-hip fracture surgery.

A WeChat-Based Mobile Platform for Perioperative Health Education for Gastrointestinal Surgery

Appropriately instructing and guiding patients before and after surgery is essential for their successful recovery. In recent years, however, the development of the enhanced recovery after surgery (ERAS) protocol has restricted the opportunity for healthcare professionals to spend time with their patients before and after surgery because of efficiency-driven, shortened hospital stay. Here, we embedded health education information of the perioperative period for gastrointestinal surgery on a WeChat-based mobile platform and evaluated the platform through medical staff evaluation, patient volunteer evaluation, and quantitative grading rubric. Clinicians and nurses believed that the mobile platform was attractively designed and easy to navigate, valuable, and adequate for patient health education. The content of health education was embedded into the WeChat-based mobile platform, thereby allowing patients and caregivers to access information at their own pace and enable repeat reading.

Developing an individualised cross-sectoral programme based on activities of daily living to support rehabilitation of older adults with hip fracture: a qualitative study

OBJECTIVES

To develop an individualised rehabilitation programme for personal and instrumental activities of daily living (ADL) tasks, enabling older adults with hip fractures to perform ADL safely and independently.

DESIGN

Qualitative study inspired by the complex intervention development (Medical Research Council framework phase I) using literature search and research circles.

SETTINGS

University Hospital of Copenhagen, Herlev and Gentofte, and Herlev and Gentofte municipalities.

PARTICIPANTS

One research circle with seven older adults with hip fractures, and one with seven healthcare professionals (occupational therapists and physiotherapists).

RESULTS

Three generic categories were identified: (1) 'Challenge older adults with goal-oriented ADL tasks', (2) 'Implement strategies to enhance independent and safe performance of ADL tasks', and (3) 'Communicate the important information to the target group and across sectors'. A programme was developed and an intervention to enhance usual rehabilitation was designed comprising: an individualised intervention component consisting of five additional therapy sessions; one during hospitalisation, four in the municipality and a follow-up phone call.

CONCLUSIONS

Engaging and integrating activities into rehabilitation treatment may support rehabilitation. Our study highlighted the need for setting individual goals and challenging older adults with hip fracture by providing guidance in strategies to enhance safe and independent performance of ADL tasks. Furthermore, the need for providing older adults with hip fracture and healthcare professionals with written and oral information about goal setting during the transitional rehabilitation phase was emphasised. Including the perspectives of older adults with hip fracture and healthcare professionals added value to the rehabilitation, and thus ensured an adequate, tangible and implementable rehabilitation programme.

TRIAL REGISTRATION NUMBER

This article is the first of three articles inspired by Medicial Research Council guidelines. The next study is a feasibility study with the trial registration: ClinicalTrials.gov ID: NCT03828240. The results are right now being written in article. The third study is a randomised controlled trial with the trial registration: ClinicalTrials.gov ID: NCT04207788; Pre-results.

Early mobility after fragility hip fracture: a mixed methods embedded case study

BACKGROUND

Following a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of ambulation loss. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory before their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade.

METHODS

A descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation.

RESULTS

Activity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18 h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; themes external to the person and themes unique to the person. We identified four factors that can influence mobility; a patient's pre-fracture functional status, cognitive status, medical unpredictability, and preconceived notions held by healthcare providers and patients.

CONCLUSIONS

There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. An increased risk of poor outcomes occurs with compounding multiple factors, such as a patient with low pre-fracture functional mobility, cognitive impairment, and a mismatch of expectations. The study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful healthcare provider and patient-centred interventions to address the risks of poor outcomes.

Development of a Questionnaire to Assess Patient Priorities in Hip Fracture Care

Background:

Patient reported outcome measures (PROMs) are becoming well recognized as an important component of health care outcomes and determinants of value in patient-centered care. Yet, there is emerging recognition that guidance is lacking in the utilization of PROMs in hip fracture patients. The aim of this study was to collect input from hip fracture patients and their health care advocates as proxies to identify outcomes that are important and to gain insight into which ones are of greatest importance.

Methods:

A cross-section of patients aged 65 and older treated for hip fractures at a single level 1 trauma center within the previous 3 to 9 months was identified. Semistructured telephone interviews of patients and/or health care proxies were performed in 2 phases: (1) concept identification and conceptual framework development and (2) item generation and assessment of relative importance of health care outcomes. Each phase was completed by separate patient cohorts.

Results:

Sixty-four interviews were completed. Eighteen interviews with 13 patients and 5 proxies were completed for framework development. Forty-six interviews with 33 patients and 13 proxies were completed for the assessment of relative importance. Care team and communication were reported as important in hip fracture patients. Physical outcomes were ranked as most important by only 9% of respondents. “Having confidence that I/my loved one received the best care possible” was perceived as very important by 98% of respondents and “Having access to the surgeon” was perceived as very important by 76% of the respondents.

Conclusions:

In our study, communication between patients and care providers as well as collaboration among patients’ care providers ranked as the most important postoperative preferences in our cohort. Notably, physical outcomes were ranked as most important by only 9% of respondents.

Empowerment of whom? The gap between what the system provides and patient needs in hip fracture management: A healthcare professionals' lifeworld perspective

AIMS AND OBJECTIVES

To use a Habermasian lifeworld theoretical perspective to illuminate a treatment gap for hip fracture patients in a Danish university hospital to guide future healthcare services.

BACKGROUND

Most healthcare systems focus on systematised guidelines to help reduce hospital length of stay in response to increasing demand because of the ageing of the global population. For patients with hip fractures, a previous study demonstrated that there is a lack of patient empowerment and a gap between patients' needs and wishes and what was provided by the healthcare system.

DESIGN

In this follow-up study, the previous findings were introduced to a mixed group of health professionals (HPs) who participated in focus group discussions (n = 3, with a total of 18 HPs).

METHODS

Data were analysed using qualitative content analysis. By analysing the discourse of the discussions using Habermas' perspective, the lack of patient-empowerment was illuminated and facilitated, describing it in terms of the gap it creates in communicative actions between HPs and patients.

RESULTS

Information and education of patients in systematised pathways, such as those for patients with hip fractures, are dominated by a biomedical discourse. Patients are overwhelmed by the psycho-social implications of the hip fracture, leaving them in a shock-like state of mind.

CONCLUSION

Empowerment of patients should involve empowerment of HPs by providing them with skills to support patients in a shock-like state of mind. There is also a need to provide HPs with a more individually targeted means of informing and educating patients.

Older adults' perceptions of early rehabilitation and recovery after hip fracture surgery: a UK qualitative study

Purpose: To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture.Methods: In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework.Results: Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants.Conclusions: This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self.Implications for rehabilitationHip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions.Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital.Healthcare professionals need to educate and empower older adults to take charge of their own recovery.For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self.

Cocreation of a digital patient health hub to enhance education and person-centred integrated care post hip fracture: a mixed-methods study protocol

INTRODUCTION

Older people with hip fractures often require long-term care and a crucial aspect is the provision of quality health information to patients and their carers to support continuity of care. If patients are well informed about their health condition and caring needs, particularly posthospital discharge into the community setting, this may support recovery and improve quality of life. As internet and mobile access reach every household, it is possible to deliver a new model of service using a digital education platform as a personal health hub where both patients and their providers of care can establish a more efficient information integration and exchange process. This protocol details proposed research, which aims to develop a 'model of care' by using a digital health solution that will allow delivery of high quality and patient-centred information, integrated into the existing process delivered within the community setting.

METHODS AND ANALYSIS

This phase of the study uses a pragmatic mixed-methods design and a participatory approach through engagement of patients, their carers and healthcare providers from multiple disciplines to inform the development of a digital health platform. Quantitative methods will explore health literacy and e-health literacy among older people with hip fractures admitted to the two public tertiary care hospitals in Adelaide, South Australia. Qualitative methods will provide an understanding of aspects of content and context required for the digital health platform to be developed in order to deliver quality health information. The study will use appropriate theoretical frameworks and constructs to guide the design, analysis and overall conduct of the research study. The scope of the study intends to ultimately empower patients and their carers to improve self-management and to better use coordinated services at the community level. This could prevent further falls including associated injuries or new fractures; reduce new hospital admissions and improve confidence and engagement by limiting the psychologically restrictive 'fear of falls'.

ETHICS AND DISSEMINATION

The study has been approved by the Human Research Ethics Committee of the Central Adelaide Local Health Network, South Australia (SA) Health, Government of South Australia and the University of Adelaide Human Research Ethics Committee. Findings from the study will be published in suitable peer-reviewed journals and disseminated through workshops or conferences.

Patient and caregiver experiences on care transitions for adults with a hip fracture: a scoping review

Purpose: The purpose of this scoping review was to explore the literature on experiences and perspectives of patients with hip fractures and their caregivers during transitions in care.Methods: Seven databases were searched for studies published between 1 January 2000 and 3 July 2018. Grey literature was also searched.Results: Eleven articles met the inclusion criteria. The scoping review found that patients and caregivers encounter several challenges during care transitions including the following: lack of information sharing, role confusion and disorganized discharge planning. Common suggestions reported in the literature for improving care transitions were: increasing written communication, offering a patient representative role, using technology for knowledge dissemination and increasing geriatrician involvement.Conclusions: The results of this scoping review provide a useful foundation from which to build strategies to address challenges such as lack of information sharing, role confusion and disorganized discharge planning experienced by patients and caregivers during care transitions. Further research needs to explore the development of strategies to promote patient-centered care especially during discharge from an acute care facility.Implications for rehabilitationEncourage health care providers to collaborate with patients with hip fracture and caregivers on decision-making about rehabilitation and recovery goals, discharge planning and safe patient transfer.Assess the needs of patients with hip fracture and caregivers before, during and after a care transition to deliver patient and family-centered care across multiple care settings.Provide patients with hip fracture and caregivers standardized information-exchange tools to increase timely, accurate exchange of information during care transitions.Encourage formal discussions about roles and responsibilities in the transitions in care process among patients with hip fracture, caregivers and health care providers.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series

INTRODUCTION

The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures.

MATERIALS AND METHODS

This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre.

RESULTS

A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015).

DISCUSSION

The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed.

CONCLUSION

While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Can Tele-Health Support Self-Care and Empowerment? A Qualitative Study of Hip Fracture Patients' Experiences With Testing an "App"

Telemedicine or tele-health is increasingly used to help meet challenges in health care linked to demographic changes and an aging population. This study aimed to investigate whether a tele-health solution, an "app" presented on a tablet, can assist patients in their recovery following a hip fracture and accommodate individual learning and health literacy needs to support them in self-care and empowerment. Twenty patients with a hip fracture were informed and educated using an app during hospital admission and for 3 to 4 weeks after discharge. A qualitative approach employed field observation and individual interviews with patients and their relatives. Data were analyzed using qualitative content analysis. Patients found that the app supported their ability to perform self-care and their desire for autonomy. They would not have downloaded the app by themselves but found the use of the app presented on a tablet very supportive in their everyday life while rehabilitating after a hip fracture. Findings indicate that health-care professionals can support information and education for patients with a hip fracture using an app that accommodates different learning styles. This demonstrates that apps used for the dissemination of health knowledge can be used by elderly hip fracture patients even if they are not used to technology.

Post-discharge use of assistive devices following hemiarthroplasty: comparison of fracture patients with or without hip precautions

Purpose: To describe which types of assistive devices prescribed and actually used, either due to precautions or due to true functional reasons, after hip fracture-related hemiarthroplasty.Materials and methods: About 394 patients cluster-randomized 2010-2014 at a university hospital. Control group with standard postoperative precautions to reduce dislocations, mandatory assistive devices and knee brace for 6 weeks (in cognitively impaired) compared to non-precaution group with assistive devices only if needed. Postal questionnaire at 6 weeks and 3 months.Results: Both prescription and usage of reacher were higher in the precaution group. About 55% of patients with precautions was instructed to use stocking aids, 21% continued to do so. Significantly fewer without precautions, 11%, used it at 3 months. Raised toilet seat was used by ∼40% of all pre-fracture and was prescribed to 79% with precautions. It was unchanged at 42% in non-precaution group. Nevertheless, 64% in non-precaution group used a raised toilet both at 6 weeks and 3 months. The usage persisted around 70% in precaution group. Usage of raised chair/bed were similar, even if non-precaution patients was not prescribed such. In the precaution group, 102 were prescribed a knee brace, only 5 used it at 6 weeks.Conclusions: The use of assistive devices did not follow what was prescribed from the hospital, regardless of precautions or not. The use of higher furniture was similar regardless of precautions or not. Other devices were more common in the precaution group. The compliance of knee bracing was low, and bracing should not be standard-of-care.Implications for rehabilitationHemiarthroplasty is the most common treatment of displaced femoral neck fracture in elderly. Dislocation occur in 2 to 10% of these patients, and traditionally patients have been instructed to be careful when moving their leg and to use a number of assistive devices, in order to reduce the dislocation risk.The evidence base for such precautions is weak and occupational therapy and assistive devices may be costly. The current study shows that prescriptions and instructions from occupational therapists in hospital is more or less not follow after dismissal.Assistive devices should be prescribed based on the hip fracture patient's true functional needs, and not routinely or due to arthroplasty precautions.

Bridging the gap: A user-driven study on new ways to support self-care and empowerment for patients with hip fracture

Objectives

In future healthcare systems, individuals are expected to be more involved in managing their health and preventing illness. A previous study of patient empowerment on a hip fracture pathway uncovered a gap between what the healthcare system provided and patients' needs and wishes. The aim of this study was to investigate whether a user-driven approach and a participatory design could provide a solution that would bridge this gap.

Methods

Four workshops and a laboratory test were conducted with healthcare professionals to co-create a final prototype. This was performed in iterative processes through continuous interviews and face-to-face evaluation with patients, together with field studies in patients' homes, to maintain relevance to end-users, that is, patients and healthcare professionals. The data were analysed according to the plan, act, observe and reflect methodology of iterative processes in participatory design.

Results

Our results contribute to a key research area within patient involvement. By using participatory design, patients and healthcare professionals gained a mutual understanding and collaborated to create a technological solution that would encompass needs and wishes. Patient empowerment also involved giving healthcare professionals a means of empowerment, by providing them with a platform to support patient education. We found that one solution to bridging the aforementioned gap could be an app, including a range of educational features that would accommodate different learning styles.

Conclusion

In developing a technological solution, user involvement in a participatory design ensures usability and inclusion of the requested functionalities. This can help bridge the gap between what the healthcare system provided and patients' needs and wishes and support patients' individual empowerment needs and self-care capacity. Together with the tools and techniques, the setting in which PD unfolds should be thoughtfully planned.

The Model for Assessment of Telemedicine (MAST): A scoping review of empirical studies

The evaluation of telemedicine can be achieved using different evaluation models or theoretical frameworks. This paper presents a scoping review of published studies which have applied the Model for Assessment of Telemedicine (MAST). MAST includes pre-implementation assessment (e.g. by use of participatory design), followed by multidisciplinary assessment, including description of the patients and the application and assessment of safety, clinical effectiveness, patient perspectives, economic aspects organisational aspects and socio-cultural, legal and ethical aspects. Twenty-two studies met the inclusion criteria and were included in the review. In this article, research design and methods used in the multidisciplinary assessment are described, strengths and weaknesses are analysed, and recommendations for future research are presented.