We identified 2045 articles: CINAHL (n=446), EMBASE (n=1087), PubMed (n=379), PsycINFO (n=125) and PsycEXTRA, OpenSIGLE and HMIC database (n=7). A search of reference lists and abstracts of the included studies identified a single study. In Endnote and Covidence, 427 and 183 duplicates, respectively, were excluded. A total of 1436 articles were retrieved and assessed for eligibility; 1326 articles were excluded after a review of their titles and abstracts, leaving 110 studies for full-text reading. Sixteen studies met the inclusion criteria (Figure 1).
Study characteristics
Six studies had been conducted in Sweden, three in the UK, two in Canada; the remaining five in Denmark, Norway, New Zealand, Australia or the USA. The studies covered data gathered at admission [23, 24], two weeks [25], one month [26], two to four months [27-30] or six to 12 months after discharge from hospital [31-33]. One study had a time frame from three months to 22 years after fracture [34]; the remaining four studies gave no indication of the time of interviewing [35-38]. In total, 286 participants were interviewed, 211 females and 59 males aged 65 99 years (Table 2).
Various techniques were employed for data collection: semi-structured, in-depth and telephone interviewing. The data analysis techniques appeared to be heterogeneous; the most frequently used were phenomenological approaches, content or thematic analysis.
Quality assessment
With CASP quality scores of 6.5‒9.5, the quality of the studies ranged from low (below 7.5), to moderate (7.5‒9) to high (9‒10) [22]. Methodological shortcomings mainly concerned the omission of considerations on the researcher–participants relationship and ethical issues (CASP, Questions 6 and 7). Several studies provided no clear justification of methodological choices, in which case Can’t tell was assigned. Details are presented in Table 3.
That hip fracture patients find important
Health-related outcomes
Health-related outcomes included 1) symptoms and complications, 2) physical health, 3) mental health and 4) social relationships and 5) personal goals.
1) Symptoms and complications
Mentioned in several studies [23, 26, 30-33, 35-37], pain provided the core theme of two studies [35, 37]. Pain occurred immediately after the injury [37], and for some continued to be a problem 6‒12 months after the injury [26, 31, 33]{, 1997 #1449}. Patients described their pain in various ways, e.g. as intense or stabbing, in the hip, radiating towards the groin, numbness of the leg [35]; however, it was typically described simply as extreme and intense. Patients perceived the hip pain to be worst during movement; when they laid still, the pain disappeared except initially in the hospital stay, when it was constant [35]. Pain was cited as one of the main reasons for avoiding exercise, thus hindering recovery.
Unexpected postoperative medical or surgical complications were among the other symptoms and complications mentioned by patients as major barriers to recovery [31, 33]. Complications also included hallucinating, sleeping problems, constipation, a lack of appetite and low blood count [35, 36], fatigue and tiredness [26, 28, 32, 33] and subsequent falls [31].
When addressing leg-specific symptoms and complications, swelling [35], stiffness [26], reduced leg length [28] and problems with balance, strength and speed were pinpointed [28, 32, 33]. The patients saw these factors, or pre-existing health issues, combined with hip fracture, as impediments to recovery [31, 38].
2) Physical health
The patients’ mobility was reduced, and they felt restricted by both the fracture and the physical symptoms and complications listed above [26, 28, 32, 35, 37].
Mobilization in particular was found to be difficult and harrowing during the first few days [35]. Everyday functions that had earlier been taken for granted, such as walking freely, had suddenly become difficult. The patients were thus wary of performing common daily activities, such as using a low armchair, worrying that they might not be able to rise from it, or cleaning, doing the laundry, shopping, going for a walk outdoors, driving a car or using public transportation [26, 28, 38]. Overall, the unreliability of their body and their sense of fragility left them feeling vulnerable [23, 26, 27, 29, 30, 37].
For some patients, the physical consequences of the hip fracture persevered 12 months after the injury [32].
3) Mental health
Patients described the hip fracture as a shocking, or even life-shattering event that had put their life on hold [23, 26, 28, 29]. They addressed their new situation very differently, however; some were able to stay active or seek others’ help in trying to remain in control of their life, while others felt resignation, hesitant and unable to actively take control and plan for the future [23, 26-28, 30, 33, 38]. Regaining control was perceived crucial to recovery.
Physical limitations caused insecurity, confidence loss and mistrust of own physical ability. Many reported worries about falling again [26-28, 30, 32, 35, 37]. They were also anxious about relapse [30] and treatment [36], adverse events and overmedication [35]. Concern was also expressed about further complications [38], their future ability to walk [23], dependency [23, 27, 38], the discharge and return to the home [23, 25, 27, 35] and the future in general [26, 29, 38].
Some patients’ mood was negatively affected by the changed life situation brought about by the limitations in agility and their increased insecurity and fear [32]. They felt a sense of meaninglessness and had lost hope for the future [26, 32]. Some reported being depressed [29] or losing “the spark of life” [26, 32].
Patients saw it as essential to maintain a positive attitude and engage fully in the recommended rehabilitation activities [25, 31].
4) Social relationships
After hip fracture, patients spoke of a more restricted everyday life and being prevented from performing normal activities, such as cooking, washing, cleaning, shopping and gardening, which caused periodic feelings of dependence on others [26, 37]. For those living with a spouse or other family members, family was described as being instrumental for support with daily activities and encouragement to engage in rehabilitative exercises [33]. Many singles enjoyed support from neighbours [35]. Some spoke of their belief that their recovery process had been facilitated by others’ actions [29, 31]. Yet, they found it difficult to balance between their need and expectations for help and not burdening their family [28, 30, 32, 34, 35, 38].
As they became housebound, the physical limitations had led to an isolated everyday life for some patients [26, 28, 32, 37], and the lack of energy made them abstain from inviting or visiting neighbours and friends [28]. Overall, their life had suffered from the diminished social contact [32].
5) Personal goals
The patients’ goals included returning home, regaining independence, getting well and being able to walk again. These goals were perceived useful to facilitate the recovery process [31]. Hip fracture patients, regardless of health status or ability, expressed a strong desire to recuperate [23, 32]. However, patients admitted from and returning to their own homes were especially determined to regain their independence [25, 28-31, 37] and return to normality [27, 29, 30, 34].
Patients described a need for information on what to expect, including time to recover and train and to keep on fighting to achieve their goals [25, 29]. Unrealistic expectations would increase the risk of disappointment and dissatisfaction, some said [33].
Most patients expected a return to life as it was before the injury, although some spoke of having had to gradually lower their expectations and adjust to life with disability [26, 32, 34].
Healthcare-related experiences
Several studies mention patients’ experiences in relation to waiting time [35], information [23-25, 30, 32, 33, 35, 36, 38], being treated with respect [25], participation [24, 25, 34, 36] and discharge [23-25, 31, 35, 38].
1) Waiting time
Waiting times was a core theme of one study, which reported that elderly patients with hip fracture found the waiting time for surgery protracted and stressful. It is noted, however, that when it was time for surgery, many patients still did not feel mentally prepared because they felt that “everything happened very quickly”[35].
2) Information
Eight studies indicated as especially important various aspects of information, such as the need for it [24, 38], the lack of it [33] as well as information content [23-25, 27, 32, 35, 38] and method [27].
Patients indicated their interest in information on a range of issues, such as hip fracture [23, 27, 35], surgery [35], current and potential complications [35, 38], rehabilitation and training [23, 32, 35], care decisions [24] and discharge [25]. Being informed also covered feedback, advice or reassurance from healthcare professionals regarding progress [27]. Overall, there was a strong desire to be able to know what to expect during the course of treatment [25].
However, hip fracture patients differed in their conceptions of their need for information [23]. Some were aware of the importance of information and requested it. Others appreciated and were grateful for any information offered, but made no requests for elaboration, although they seemed to want this [23]. The causes of their reluctance are unknown, although the authors conjecture this could stem from not knowing what to ask about [33]. Others showed no interest in receiving or discussing potentially useful information [23].
Patients frequently reported the need for more information about their condition, about what to do and how to act, [23, 30, 38]. Among the oldest persons, many were made to feel cognitively floundering, disempowered, a lack of confidence and anxious about their capabilities as a result of not being informed or not recalling being informed, or being unable to understand the information provided [30]. Yet, some patients were satisfied with the given information and experienced its calming effect [35].
Overall, patients expressed a wish for sufficient information at the right time [32]. Mentioning e.g. verbal and written information, weekly information sessions on the ward about hip fracture, they requested it be given from various sources, and employing different modes [35].
3) Being treated with respect
The patients’ sense of well-being appeared to depend on dialogue and their experience of empathy [36]. One informant expressed her humiliation at not being treated humanely [25].
4) Participation
Four of the included studies referred to participation and involvement as important issues. Participation was requested with regard to processes during hospitalization and discharge planning [25] and in relation to own healthcare [24]. Overall, many patients perceived their participation as lacking [24, 25, 36]. The younger among the patients, and those living independently prior to the hip fracture, were more likely to insist on being involved [34].
5) Discharge
Returning home was considered a main goal by the informants [31], but several felt insecure or even anticipated discharge with anxiety [23, 25, 35]. In a study in which being “ready or not” was a core theme, an informant vividly described the rushed nature of her discharge and her feeling of being unprepared [24].
Patients’ sense of insecurity was aggravated by limited information about the pathway and what to expect after discharge. This left them unable to image their situation on returning home [25]. There was a widespread desire to be involved in discharge plans [25].
Level of evidence
As recommended by Pearson et al. (2004), each finding was assigned a level to indicate the quality of evidence. Three levels were used: (a) Unequivocal (“evidence is beyond reasonable doubt and includes findings that are factual, directly reported/observed and not open to challenge”); (b) Credible (evidence, while interpretative, is plausible in light of the data and theoretical framework; conclusions can be logically inferred from the data but, because the findings are essentially interpretative, these conclusions are open to challenge”); and (c) Unsupported (“findings are not supported by the data and none of the other level descriptors apply”) [39].
A total of 140 findings were made. The majority (88) were categorized as level a evidence; of those, 51 justified inclusion as core themes or subthemes, while 37 were included as citations. Level b evidence was also well represented (42), whereas level c evidence was relatively scarce (10). Level a evidence was represented in both PRO and PREM categories; however, the majority of level a (72) and level b (35) findings related to PRO. Details on evidence levels are shown in Table 4 (supplementary).