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The Journey Toward Taking the Day for Granted Again

The Experiences of Rural Older People's Recovery From Hip Fracture Surgery

Segevall, Cecilia; Söderberg, Siv; Björkman Randström, Kerstin

doi: 10.1097/NOR.0000000000000608
Original Articles
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BACKGROUND: A hip fracture is an unexpected, subjective, traumatic experience that affects the person in both physical and emotional ways.

PURPOSE: The purpose of this study was to describe rural older people's experiences of recovering after hip fracture surgery.

METHODS: Thirteen individual interviews were conducted with older people. The interview texts were analyzed with qualitative content analysis.

RESULTS: Patients described finding themselves in a new and vulnerable situation, dependent on others for simple everyday chores. They struggled to regain independence while staying positive, convinced that they would recover. Fear of another fall, as well as lack of information, made recovery at home difficult.

CONCLUSION: Older people who experience hip fractures need support during the recovery process. Because recovery begins at the hospital, this study highlight patients' need to participate in recovery planning, as well as the need to have information about what it means to be affected by a hip fracture and how to prevent it from happening again. This study emphasizes that nurses' awareness of patients' need to participate in planning the recovery process is crucial for enabling patients' return to a daily life that is similar to their prefracture life.

Cecilia Segevall, MSc, RN, Research Student, Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden.

Siv Söderberg, PhD, RNT, Professor, Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden.

Kerstin Björkman Randström, PhD, RN, Senior Lecturer, Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden.

Correspondence: Cecilia Segevall, MSc, RN, Department of Nursing Sciences, Mid Sweden University, SE-83125 Östersund, Sweden (cecilia.segevall@miun.se).

All authors contributed to study design, data analysis, and manuscript preparation.

The authors have disclosed no conflicts of interest.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Introduction

A hip fracture is an unexpected, traumatic experience that affects the person in both physical and emotional ways (Archibald, 2003); his or her dependence on family, friends, and neighbors is often significant due to physical impairments related to the fracture. Feelings of pain, fear, and a sense of losing control over one's life are commonly reported (McMillan, Booth, Currie, & Howe, 2012), as well as guilt and remorse stemming from the idea that the fall may have been avoided had they been just a little more cautious (Forsberg, Söderberg, & Engström, 2014). The recovery for people after a hip fracture starts at the hospital (Chou, Chien, Lee, Bai, & Hung, 2014). But in the last few years, the length of hospital stays has been shortened, and now, most of an individual's recovery from hip fracture surgery will take place in the home (Rikshöft, 2016).

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Background

Independence and autonomy are important to older people, and it is difficult for them to imagine a life in which they are unable to get by on their own and where they depend on others for simple daily activities (King & Farmer, 2009). For people who have suffered a hip fracture, it is important to return to living an independent, mobile, and pain-free life after the fracture (Griffiths et al., 2015). People who have undergone hip fracture surgery are aware that it will take time and energy to recover, but they are not necessarily prepared for the extent of help they will need for even the simplest things—things that they took for granted before, such as bathing, dressing, or walking (Forsberg et al., 2014; Wu et al., 2013). As the older person grows more able to do things on his or her own, and when help is less needed, confidence begins to be rebuilt (McMillan et al., 2012). When recovery is perceived as slow, the opposite occurs: The older person can start to lose faith in his or her own capacity (Gesar, Bååth, Hedin, & Hommel, 2017). Furthermore, although they find it difficult, older people who have suffered a hip fracture discover that it is crucial to ask for help and support to maintain and/or increase their level of independence (Schiller et al., 2015). They expect help and support to come primarily from their immediate family members, while not wanting to be a burden, recognizing that family members have their own lives (Healee, McCallin, & Jones, 2017).

Every year, a substantial number of people suffer a hip fracture due to a fall. Because advanced age is one of many well-known risk factors, the incidence of hip fractures is likely to rise worldwide as the number of adults living to older ages increases (Marks, 2010). The term “hip fracture” includes different types of fractures of the proximal femur region. Each type of fracture has its own surgical procedure (Parker, 2010), but the goal is the same: to enable the affected person to regain his or her previous level of activity and to live as independently and as pain-free as possible (Bruyère et al., 2008; Rikshöft, 2016).

Recovery can be described as the process of learning to live in a new way after an acute, life-altering event or a chronic illness. It does not require living a life without symptoms or limitations, but rather finding new ways of perceiving, interacting, and coping with one's surroundings (Anthony, 1993; Godfrey & Townsend, 2008). Older women who experienced a fracture describe recovery in terms of getting back to normal, which involves assessing and reflecting on one's physical and emotional needs as well as engaging in rehabilitation (Bergeron, Friedman, Messias, Spencer, & Miller, 2016). The recovery process is understood as being influenced by a number of factors, such as surgery and treatment interventions (Mouzopoulos et al., 2008), and the individual's level of outdoor walking ability prior to the hip fracture (Lin & Chang, 2004), as well as nursing factors including pain management, nutritional support, and monitoring for signs of anemia (Kristensen, 2011).

In many countries worldwide, migration patterns have shifted, leading to the phenomenon of rural, relatively remote, and sparsely populated areas typically having the highest proportions of older people (Burholt & Dobbs, 2012). Living in a rural area has been described as problematic due to long distances to healthcare facilities and a lack of public transportation. This can be especially problematic for older people because they often have more complex health issues than younger people (Scharf, Walsh, & O'Shea, 2016).

The phenomenon of hip fractures is a well-researched area. Research focuses mainly on the risk factors for suffering a hip fracture (Enseki & Read, 2013; Marks, 2010), regaining mobility and function, postoperative pain (Shyu, Chen, Chen, Wu, & Su, 2009), and health-related quality of life (Ekström, Németh, Samnegård, Dalen, & Tidermark, 2009; Orive et al., 2015). Less attention has been paid to describing older people's experiences of falls and the consequences of suffering a hip fracture (Archibald, 2003; Griffiths et al., 2015; McMillan et al., 2012; Zidén, Scherman, & Wenestam, 2010). To the best of our knowledge, little to no attention has been given to describing older people's experiences of recovery after hip fracture surgery in the rural context. Because many older people live in rural areas, sometimes with long distances to healthcare services and limited access to rehabilitation services, it is possible that they experience recovery differently from those who live in urban areas. The purpose of this study was to describe rural older people's experiences of recovering after hip fracture surgery.

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Methods

Design

Because the aim was to describe older people's experiences of recovery after a hip fracture, a descriptive, qualitative method was chosen. A qualitative design has the ability to provide in-depth knowledge of the phenomenon of interest (Patton, 2015). Data were collected with individual semistructured interviews, according to the method of Kvale and Brinkman (2014), and analyzed with qualitative content analysis, in line with Catanzaro's (1988) procedure.

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Context

The study was conducted in a region of mid-Sweden at a hospital that provides healthcare to the entire county, which is rural, sparsely populated, and with a population density of 2.7 habitants per km2 (Statistics Sweden, 2018). Every year, approximately 18,000 people in Sweden, most of them older than 65 years (M = 81.4), suffer a hip fracture. At the orthopaedic unit investigated, nearly 300 patients undergo hip fracture surgery every year. The Swedish hip fracture care program involves a short amount of time between admission to the hospital and surgery (preferably within 24 hours), early mobilization, and continuing rehabilitation in the home, with or without the help of a physiotherapist. This expedited protocol shortens the length of hospital stay. The average length of stay after hip fracture surgery at the hospital investigated was 9.3 days, which is slightly more than the Swedish national average of 8.3 days (Rikshöft, 2016).

Providing patients with information during their hospital stay, both orally and in writing, is a joint effort between the physician, physiotherapist, occupational therapist, and nurses. The nurses are responsible for providing the patient with information regarding, for instance, the importance of eating properly, staying hydrated, and pain management, as well as how and when to take medications. At discharge, they also inform patients about the possibility of receiving help from municipal social services and what to monitor in terms of signs of wound infection, as well as when and where to go for removing sutures. The physiotherapist and the occupational therapist are responsible for informing patients about mobility and for prescribing walking aids and other types of aids that could be useful at home during the recovery period. The physician provides medical information, such as information about the surgical procedure. Information is usually provided solely to the patient, but in some cases where the patient requires or requests it, family members are included.

In Sweden, discharge planning involves a collaboration of various members of the healthcare team, including physicians, nurses, physiotherapists, and occupational therapists, as well as patients and their relatives. If the patient will require help from social services at discharge, a social worker from the municipality also participates (National Board of Health and Welfare, 2005). At the hospital investigated, it is not just a social worker from the municipality who participates at the discharge planning meeting held at the unit but rather a whole team, referred to as the “municipal discharge planning team,” consisting of a district nurse as well as a physiotherapist and an occupational therapist from the municipality.

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Participants

Study participants included a purposive sample of 13 older people (seven women and six men) who lived in a rural area and who had been discharged home from an orthopaedic unit following hip fracture surgery within the last 3–5 weeks. The participants were between 66 and 98 years of age (median = 74); eight lived alone, and five lived with a partner or spouse. They had been admitted to the unit for approximately 6–21 days before discharge. To be included in the study, the participant had to be a Swedish-speaking person 65 years or older who had undergone hip fracture surgery. Furthermore, participants had to be oriented cognitively to their person, time, space, and situation, and they had to be willing to talk about their experience. Finally, they had to have been discharged from the hospital to their own home in a rural area. The sample size was guided by the concept of information power developed by Malterud, Siersma, and Guassora (2016), which means that the more information the sample holds, the fewer participants are required. Thus, sample suitability and data quality are more important than the number of participants.

The recruitment of participants took place at an orthopaedic unit at a hospital in the middle of Sweden, a region that is mostly rural. The head of the orthopaedic unit gave his consent to allow the nurses at the unit to take part in recruitment. The first author, who is a PhD-prepared nurse researcher with experience in orthopaedic nursing, informed the nurses about the study. Patients who met the inclusion criteria received oral and written information about the study from the nurses at the orthopaedic unit on the day of discharge to give their consent for the research team to contact them at home for further information. The first author collected the contact information at the hospital and, a few weeks later, contacted by telephone those who had shown an interest in participating to find out whether they were still interested and, if so, to set a date and time for the interview. Of the 18 people who agreed to be contacted for further information, 13 chose to participate in the study.

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Data Collection

Individual semistructured interviews were conducted, using an interview guide to ensure that the topics of interest were covered (Kvale & Brinkmann, 2014). The first author conducted the interviews between October 2016 and June 2017. The interviews took place in participants' homes 3–5 weeks after discharge and lasted between 32 and 128 minutes (median = 59). The spouses of two participants were present during the interviews. The interview guide comprised questions about the older person's experience of the fracture-related fall as well as his or her health, well-being, and recovery. Participants were asked to talk about the fall, how they perceived their hospital stay, and how their life now compares with how it was prior to the fall. Probing questions, such as “Can you tell me more about that?” “How did that make you feel?” and “Can you explain this a little bit further?” were asked when clarification was needed. The interviews were digitally recorded and transcribed verbatim by the first author.

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Data Analysis

The text of the interview was analyzed using qualitative content analysis, according to Catanzaro (1988). Qualitative content analysis aims to reduce data by making sense of a volume of qualitative material by identifying patterns and themes within the data (Patton, 2015). At first, the text of the interviews was read repeatedly to get a sense of the content. The text was then divided into meaning units, which were condensed, abstracted, and labeled with a code. Finally, the meaning units were compared and sorted into four themes based on similarities and differences in content (Catanzaro, 1988). All authors were involved in the analysis; interpretations were discussed until consensus was reached.

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Ethical Considerations

The study was approved by the Regional Ethical Review Board in Umeå, Sweden (DNR No. 2016-154-31). All participants were provided with oral and written information about the study before giving their informed consent to participate. The information included the aim of the study, as well as the participant's right to withdraw from the study at any time without giving a reason. Furthermore, the participants were guaranteed confidentiality and assured that the findings would be presented without any mention of names or other identifying information.

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Results

The analysis resulted in the following four themes: an unexpected life-altering event, preparing to return home, needing adjustment and support at home, and struggling to manage at home. The themes are presented in the following text and are illustrated with referenced quotes from the interviews.

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An Unexpected Life-Altering Event

Participants described falling and breaking their hip under different circumstances. They described the fall as something that had happened so fast that they did not have time to react or to try to prevent it. Participants described the fall as unnecessary, clumsy, and something that could have been prevented had they just been a little more careful. Afterward, they felt guilt and remorse.

I had put sand on almost the entire courtyard not to slip on the ice, but I had been careless with the corners. And where do you think I walked? In the corner of course—so stupid of me. (P12)

Some participants explained that they knew right away that they had broken their hip because the pain was excruciating, and they were unable to get up when they tried. Some participants said that they knew because one of their feet was pointing in another direction than it usually did. They immediately got help to call for an ambulance. Others described not understanding that they had broken their hip, although they had difficulties getting up and needed help to be able to go home. At home, these participants somehow managed to get around for a couple of days while waiting for it to improve, but when it did not, they realized that they had to go to the hospital.

But I didn't think like that—no, I just thought that if I got home, things would be alright. I thought that I had just pulled a muscle and that it would get better, but it didn't. (P8)

Participants who had fallen when no one else was around and who could not reach their telephone felt insecure, and they worried about how long it would take before someone would miss them and come to search for them.

You just lay there and try to get up to get help, but there aren't that many people running around out here. It was lucky that she [his wife] was home to help me. (P11)

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Preparing to Return Home

Participants described that the work toward regaining independence started after surgery, with early mobilization, training with the physiotherapist, and preparing to return home. Pain was a salient feature in the first couple of days, especially when moving. They said that the nurses asked them about pain and that they received painkillers regularly. The participants described finding themselves in a new situation where they were dependent on others for simple things they normally could do for themselves. They were not happy about it, but they accepted that they needed help. Participants said that it felt strange to need help getting out of bed, showering, and walking to the toilet. At the same time, they felt safe knowing that help was close by.

Well, I'll tell you something. It wasn't fun to need help, but I couldn't do it on my own. That's the fact. (P2)

Participants said that the staff wanted them to start walking the day after surgery. Some participants trusted the staff to know what was best, even though they found it difficult and painful to move. Others did it only because they realized that they had to try if they were going to regain their mobility and independence. Some described refusing to try to walk because they thought that it was too soon and they chose to start a couple of days later when they felt ready. Participants mentioned meeting with the physiotherapist during the hospital stay, who taught them how to walk with walking aids and how to climb stairs. Some felt that they did not get the amount of training that they would have preferred during their hospital stay and said that they did not have a say regarding the activities that were practiced.

Some participants described being asked by the nurses at the unit whether they thought they needed help from municipal social services after discharge. Some felt that they could manage by themselves and declined but said that it could have been different if they felt that they needed help or if they lived alone. Others said that they could not recall being asked and concluded that the nurses had assumed they would manage; however, they wished that they had been asked. Participants who did have a discharge planning meeting with a discharge planning team from the municipality found it difficult to know what help they needed and what help was available to them. Having relatives present at the meeting was comforting.

You see, it was difficult for me to know what kind of help I could need when I came home. I guess that's why they decided that they [staff from municipal social services] would come check up on me four times a day to begin with, and that was fine by me. (P4)

Participants said that the support they received from the staff in the unit was valuable to them when they were preparing to return home and described that they were satisfied with the hospital stay. Staff members were perceived as doing their very best to support and assist the participants, and participants felt well taken care of. Some participants said that, as they started to be more able to do things by themselves and, when the day for discharge came, they longed to go home. Others thought that they were being discharged too early and refused to go home, and after discussions with the doctor, they were able to stay another day.

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Needing Adjustment and Support at Home

Participants described feeling grateful that they had been able to come home, particularly when their house needed only minor adaptations and modifications to ensure accessibility. Coming home was not possible without support. Participants said that moving furniture and removing rugs made their house look dreary, but it made things easier because these changes accommodated their recovery. Some participants had to make more significant adjustments for at-home recovery; an example would be making a second shower in the laundry room because the shower was upstairs, and they could not walk up the stairs. Participants also described receiving aids or assistance, including the walking aids that they needed. Some participants said that they were initially reluctant, but when they realized these aids were useful, they changed their opinion.

I didn't want the walking aid in the beginning, but now I think I will keep it in case of future needs. (P7)

Participants said that they were grateful for the support they received from family, friends, neighbors, and social services and that the support was invaluable. Although they felt sad that they could not manage by themselves and sometimes found it difficult to ask for help, they realized that they had no other option.

Around here, people say “hi” to each other, and if you haven't seen someone in a while, you go over there, knock on the door, and ask if everything is all right. (P2)

Participants who received help from social services in the form of food delivery and housework such as cleaning and laundry appreciated that this help was available to them. Although they would have preferred not to need it, they were not ashamed to have it. Those who were later able to reduce the assistance they received from municipal social services said that it felt great to be able to become more independent.

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Struggling to Manage at Home

Participants described the first days and weeks at home as somewhat difficult, as they struggled with immobility and pain while attempting to perform everyday chores. They felt that they had made progress after they had come home and that things had become easier. Some were surprised that recovery took less time than they had anticipated and felt that they were already back to the way they were prior to the fracture. Others were impatient and started to worry that something was wrong because they thought that they would have recovered by now.

Participants described that they had received both oral and written information at discharge. The information included, for instance, how to take the prescribed medicines, how to check the surgical wound for signs of infection, and where to go to get sutures removed. Some said that they wanted more information and felt that they were sent home with unanswered questions (such as whether a follow-up visit to the doctor was planned). Others said they did not have the strength to read the extensive information at the hospital but found it useful later. Still, others described feeling disappointed with the information when they found it to be contradictory and said they were not given a phone number to call to get their questions answered.

I think that they have failed with the information. It is difficult to be a patient under such circumstances. (P4)

Participants described having become anxious after the fall and that as a result, they now thoroughly planned activities to avoid unnecessary risks. Some did not dare to walk outside anymore and especially not on their own; walking without their walking aid was unthinkable because the walking aid made them feel safer. Some feared that being anxious could slow down their recovery.

Well, I have never been afraid of anything before, but now I have become a bit fussy. I mean, I wouldn't like to fall again. (P6)

Participants described that they had adopted a humbler approach to life after the hip fracture. They now valued things they used to take for granted, such as dressing and walking outdoors by themselves. Participants looked toward the future with confidence while admitting to not knowing what tomorrow would bring and realizing that they were getting older. They were convinced that it was important to think positively during recovery, and they believed that the hip fracture would not stop them from getting back to living their previously active lives. The things that they feared could be a hindrance were their age and other health issues.

Now you have become aware that life quickly can change, and you didn't think like that before, no. You can't take things for granted anymore; you'll just have to wait and see what tomorrow brings. (P8)

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Discussion

The aim of this study was to describe rural older people's experiences of recovery after hip fracture surgery. The participants described the hip fracture as an unexpected life-altering event. It led to a disruption in daily life and a new experience of being dependent on others to do things they had previously done by themselves. During the hospital stay, they started to plan and prepare for coming home. Participants described the need for adaptations and modifications in their home to facilitate daily life. At home, participants struggled with being immobilized; for some, pain also had an impact on their recovery. Participants highlighted the importance of receiving information and support as something that supported the process of recovering.

This study shows that participants began to plan for their recovery immediately after surgery, while they were still in hospital and were dependent on the healthcare staff. For participants, regaining independence was central to their recovery, and perhaps more central than for others, as these participants were living in rural areas. Gesar, Hommel, Hedin, and Bååth (2017) showed that, although patients expected a hip fracture to cause problems with mobility in the first weeks, they had a strong inner drive to recover. In addition to their own inner drive, patients needed to feel supported by healthcare personnel. Feeling supported could include being able to participate in the recovery planning. According to Eldh, Ekman, and Ehnfors (2006), patients feel supported when they are regarded as individuals, when they have received sufficient information to make adequate decisions, and when they can take an active part in the planning of their care. Doyle, Lennox, and Bell (2013) showed that when patients participate in their own care, they are generally more satisfied with the hospital stay, which, in turn, is strongly associated with a greater chance of recovery. Considering that the time they spend in the hospital is short, it is important to use it wisely and give patients the opportunity to participate in their care, as the recovery process starts there.

The findings show that some participants said they were asked whether they would need help from municipal social services after discharge whereas others said they were not asked. This suggests that the nurses involved in discharge planning made a decision for the patient about such assistance instead of together with the patient. This could lead to older people being discharged without the right support they need to manage at home. Alharbi, Carlström, Ekman, Jarneborn, and Olsson (2014) showed that when decisions about discharge planning were made without the patient's knowledge, it could lead to a worsening health status because the patient was not given the opportunity to assess his or her own ability to manage at home. It is reasonable to believe that this could increase the risk of otherwise avoidable readmission. What nurses assume is in the patient's best interest does not always coincide with what the patient believes. Hence, it would seem pivotal in nursing care that nurses see their patients as partners in their own care and give them the opportunity to participate in decisions regarding their care.

Our findings show that participants found it difficult to participate in decision making regarding postdischarge care because they did not know what they would need help with; they simply accepted what healthcare personnel decided for them. Several studies (Dyrstad, Laugaland, & Storm, 2015; Ekdahl, Andersson, & Friedrichsen, 2010; Malmgren, Törnvall, & Jansson, 2014) show that patients do not always feel involved in their own discharge planning, nor do they feel they can influence decisions. When patients do not feel involved in discharge planning, they can feel diminished and excluded (Rydeman, Törnkvist, Agreus, & Dahlberg, 2012). The patient needs to have sufficient information to be able to participate in the decision-making process. This is in line with Larsson, Sahlsten, Segesten, and Plos (2011), who showed that patients found it difficult to understand, cooperate, and make decisions regarding their care due to a lack of knowledge about the situation. Participating in decision making during a hospital stay is important because it can strengthen the older person's ability to manage daily life after discharge (Lyttle & Ryan, 2010).

The rural setting did not seem to affect older people's experiences of recovering from hip fracture surgery. These findings are in line with those of other studies (Archibald, 2003; McMillan et al., 2012) in different contexts. The participants discussed the effects of the rural setting only in terms of close relationships between neighbors, although they lived somewhat apart from each other. Because hip fracture surgery results in temporary or permanent physical impairment, regardless of where the affected people's homes are located, it is reasonable to assume that it would be just as difficult for a person who lives in a city to do things that require mobility, for instance, to go to the pharmacy, as for people living in rural areas. Another possible explanation for the rural setting not being a significant contextual factor is that the current way of planning discharge for patients who live in rural areas is functioning well and that patients receive the support they need; municipal social services in Sweden are state subsidized so that everyone who needs and wants help can afford it.

What seemed to be most important to participants in this study was their ability to return to their own home, regardless of its location. They were grateful that they were able to return to their own home and were willing to make adjustments to make it safer and more manageable. Randström, Asplund, Svedlund, and Paulson (2013) and Gabrielsson-Järhult and Nilsen (2016) have shown that older people prefer to be discharged from the hospital to the home as long as they perceive it to be safe. According to Fänge and Ivanoff (2009), during the aging process, the home becomes increasingly important, as it is considered a safe and stable place to return to for rest and recovery.

Some participants in this study expressed that they did not receive enough information before discharge and left the hospital with unanswered questions. Schiller et al. (2015) reported that older people who experienced a hip fracture wanted to know more, especially about the recovery process. Other studies (Dyrstad et al., 2015; Malmgren et al., 2014) showed that patients received oral information at the hospital, but they often struggled to understand and remember it. This suggests the need for well-designed patient information materials that the patient can read at home. Tsui et al. (2015) found that, after hip fracture surgery, older adults noticed that it was useful to have a manual containing practical information about what to expect in regard to a recovery timeline and milestones, as well as psychological adjustments needed during the recovery process. Moreover, the older adults felt that such a manual could assuage their anxiety surrounding the uncertainty that develops after the unexpected and overwhelming event of a hip fracture. Such a manual would be particularly useful for participants in this study who thought recovery was too slow and who started to worry that something was wrong because that can lead to doubt about the total recovery and regaining independence (cf. Gesar, Bååth, et al., 2017). Such patient information can also improve patient outcomes by describing how to prevent pneumonia and dehydration, as well as the importance of mobility, because these are the most common reasons for readmission to the hospital after hip fracture surgery (Gardner, 2015).

The findings also showed that participants had become anxious after their fall and consequent hip fracture and that they tended to avoid activities they perceived as unnecessary, such as walking outdoors alone or without their walking aid. A review by Kristensen (2011) found that fear of falling is common among older people who have suffered a fall-related hip fracture and that this fear can negatively affect recovery in terms of mobility and social activities. Jellesmark, Herling, Egerod, and Beyer (2012) found that fear of falling was twofold: On the one hand, it can lead to a reduced quality of life; on the other hand, it can also function as a form of protection because the avoidance of certain activities leads to older people taking fewer risks. Our findings suggest that people who have undergone hip fracture surgery need support concerning how they can overcome or decrease their fear of falling again. Visschedijk, Achterberg, Van Balen, and Hertogh (2010) found that this fear of falling may be decreased by home-based rehabilitation programs that aim to strengthen relevant muscle groups and enhance balance.

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Study Limitations

This study has limitations that must be considered when interpreting the results. The number of participants was relatively small. However, the participants willingly spoke about their experiences and the interviews were rich in content and contained variation, similarities, and differences within the older people's experiences of recovering from hip fracture surgery. Another possible limitation is the fact that two participants had their spouses present during the interview, which could have influenced these participants' answers. However, the spouses did not interrupt or interfere during our conversation and these interviews did not contrast with the other interviews.

To ensure trustworthiness in data analysis, every step of the analysis has been systematically documented. The analysis is furthermore described so that the reader can follow the process. Quotations from the interviews help the reader judge whether our interpretations are credible.

The findings from this study cannot be generalized, as it was not the purpose of this qualitative research. Nevertheless, the findings can be transferred to similar situations if they are decontextualized from the current context (Polit & Beck, 2016).

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Conclusion

This study shows the importance of older people recovering from hip fracture surgery receiving the support they need to be able to once again become independent and take the day for granted. The fear of falling again affected participants' daily lives, and information about how to prevent this should facilitate recovery at home. Older people have faith in their own ability to recover, but they need support and sufficient information while doing so. Living in a rural area while recovering from hip fracture surgery seems to be of minimal importance, but this should be explored further. Knowledge about older people's experiences of recovering from a hip fracture has the potential to improve recovery outcomes for older adults. Because recovery begins in the hospital, nurses need to be aware of these needs to inform and prepare patients before they are discharged home. Further studies should also focus on increasing patients' participation in their own nursing care.

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Acknowledgments

The authors thank all the study participants for sharing their experiences of recovering from hip fracture surgery, as well as the nurses at the orthopaedic unit for their recruitment efforts.

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