The analysis yielded four main themes and ten categories. Each theme is illustrated using excerpts from the interviews.
Theme 1: Challenge of discharge transition
1) Unprepared discharge
Participants recognized their unstable state at the time of discharge and wanted to stay longer in the surgery hospital. Older adults (5 of 12) were forced to complete discharge from the surgery hospital despite their limited mobility. They believed that the recovery was delayed owing to the short hospitalization period after surgery. They expressed feeling upset at being discharged so soon.
I was discharged after a mere four and a half days; so, I felt [I received] unfair treatment. How [can you discharge] a person who has [had] a major operation so soon! That’s sad (Interviewee 8).
2) Transfer into other care settings
Most older adults (10 of 12) moved to another care setting after discharge. Four participants faced difficulties in finding their own care setting without help and lacked pertinent information. Participants who moved to another care setting reported that they received care unrelated to the therapeutic instructions.
I said I could exercise, but they said, “no.” When I asked why not, they told me that they would not allow me to do it because they were in a situation where they had to take responsibility about going wrong (Interviewee 6).
Some participants (four older adults) had to make alterations to their living environment because of mobility limitations.
My house is on the fourth floor; so, the thing to worry about now is whether I have to move to a house with an elevator (Interviewee 9).
3) Eagerness for recovery
Older adults (6 of 12) showed eagerness for recovery to cope with the challenge of discharge transition. They commented on nutritional management, rehabilitative exercise, walking, and adhering to physician's orders.
I have to walk using a walker now and turn around. I have to focus on this. I’m ready to make it fast. I have to exercise, eat well, and get better every day (Interviewer 12).
Two participants tried to understand and accept their diseases instead of denying them to improve their recovery process.
When I think that even young people fall and come to the hospital, I can also do that! Anyone can experience that! It is nice to have a new artificial joint inserted. After the surgery, I said to myself to get along with the artificial joint (Interviewee 2).
Theme 2: Physical and psychological distress against recovery
1) Frail physical state
Participants were in a frail physical state. Ten out of the twelve participants had multiple or severe underlying diseases including osteoporosis. They were using polypharmacy before the fracture owing to serious underlying diseases and had poor health status. Severe underlying diseases affected the patients’ recovery process after hip fracture surgery, and they continued to be in a poor state post discharge.
I have diabetes, poor kidneys, higher blood pressure, and bad eyes. Diabetes has been around for 50 years. Only 30% of my kidneys remain (Interviewee 8).
They did not eat enough owing to a limited appetite, digestion, or diet due to the underlying disease.
Actually, I do not eat well. I say, “I do not want to eat” when my child asks me what I want to eat. Whenever I try to eat, I get tired easily. I’m going to ask for some medicine [to improve my] appetite (Interviewee 5).
2) Psychological difficulties
Some participants also experienced psychological difficulties. Frail physical state negatively affected their confidence in recovery. The worse the frail physical state, the more they fell into despair (6 of 12), which hindered their recovery. The following interviewee was informed that her walking should be limited for a month due to severe osteoporosis, and she showed frustration related to movement restriction.
I [was] unpleasantly surprised when I heard that I should not walk for a month or so. I knew I would walk if it is possible to walk little by little. Then, I wanted to go to the bathroom. I wanted to do it gradually. I took a leak and shat in my bed without moving. Oh! How wasIchanged miserably like this? (Interviewee 4)
Other older adults (2 of 12) perceived their current health condition as a punishment.
“Did I commit [a] sin?” People said repeatedly “it is not a sin.”… Getting sick like this? I think I was punished (Interviewee 9).
Theme 3: Dependent compliance
1) Absolute trust in healthcare providers
Participants sought care at a tertiary hospital because the secondary hospitals were reluctant to perform surgery for patients who may have had underlying diseases, or they had had successful experiences—directly or indirectly—at tertiary hospitals. Most participants (10 of 12) expressed gratitude for undergoing surgery and were satisfied with the successful surgery.
What if I get broken and do not get surgery? I'm feeling good because I got surgery (Interviewee 12).
Older adults (6 of 12) showed strong trust in healthcare providers and noted their willingness to follow their therapeutic instructions.
All I can do is listen to the doctor’s words and do it. There is only that (Interviewee 10).
2) Indispensable support from the family
All participants received supported from family members throughout the discharge transition. Some (2 of 12) had home-visit care services including support for physical and household activities in their homes. This help was also available to older adults. However, they could not continue their daily life without family support. Family members were primary caregivers who mainly helped activities of daily life and encouraged exercise and diet.
My son brought some meat for me, saying I should eat beef, beef, beef. I should eat because of my son. I’m about to [shed] a tear when I think of my son (Interviewee 5).
Older adults felt grateful for family support, while some older adults (3 of 12) also felt the burden of being cared for.
I’m sorry for my child. My child would not suffer that way if I died early. I’m worried about how much the hospital bill will be (Interviewee 8).
3) Passive participation in care
Most participants (8 of 12) received insufficient information about postoperative management owing to staff members’ busy schedules or lack of interest. Some participants had difficulty in reading text-based discharge information.
Even if my son asked me to keep reading, I didn't read the text because it was difficult to read (Interviewee 9).
Nevertheless, they expressed a vague expectation that it would get better with time. Some medical staff explained the surgery process to the caregivers instead of the older adults.
I do not know well because my daughter is listening (Interviewer 7).
Theme 4: Walking for things they took for granted
1) Hope of walking
The participants (6 of 12) experienced their physical recovery, while others did not. Physical recovery indicated reduced pain, improved physical condition, and starting to move little by little.
I have a little more energy now than when I was discharged, and the hips hurt less. (Interviewee 11).
Most participants (9 of 12) described that being able to walk was their main wish during the discharge transition. Their expectations for walking ranged from using toilet independently or with walking aids, returning to their home to going to the farm according to the current status of the physical recovery.
Can I walk or not, getting hurt like this?Walking around on feet. Right, it would be better if I go to the bathroom with my feet (Interviewee 4).
The purpose of improving the walking ability was that participants could perform simple daily chores. Performing tasks they had earlier taken for granted was an essential part of daily life.
I just want to go home and cook for the poor youngest (Interviewee 1).
2) Poor walking ability
Despite the hope of walking, the walking ability of the participants was poor during the discharge transition period; some older adults (4 of 12) had mobile status indoors or outdoors using walking aids, while most (7 of 12) had immobile status indoors and outdoors. In addition to the frail physical state, there were some direct factors affecting walking ability. Severe pain hindered their recovery (7 of 12). Most older adults (9 of 12) were also afraid to move owing to fear the of falling and subsequent re-fracture, even though the pain significantly reduced.
There is nothing painful now. But I’m afraid to take a step.I can’t take a step. I do not think I can get up (Interviewee 9).