Dr Laura McMillan is a Lecturer at the University of the West of Scotland; Dr Jo Booth and Dr Kay Currie are Readers at Glasgow Caledonian University; Professor Tracey Howe is the Director of HealthQWest at Glasgow Caledonian University

ABSTRACT

This study sought to understand how older people manage life after hip fracture. Semi-structured interviews were carried out with older people after discharge home, in 2 health board areas in Scotland. Using grounded theory, a core category of ‘taking control’ emerged. The three stages that people moved through in the process of taking control after hip fracture were: ‘going under’, ‘keeping afloat’ and ‘gaining ground’. Nautical metaphors emphasise the precarious and unstable conditions of life after hip fracture, as well as conceptualising the physical and emotional struggles that people faced in ‘balancing’ help and risk. People took control to manage their concerns about losing control and independence in the future. This study highlights that older people are vulnerable to losing control after hip fracture and stresses that healthcare professionals have a vital role to play in facilitating restoration of control and increasing self efficacy.

INTRODUCTION

There are 6,000 hip fractures per year in Scotland, the majority of which are caused by accidental falls (SHFA, 2009). Hip fracture is the second leading cause of hospitalisation for older people (Beaupre et al., 2005) and research highlights that this traumatic injury remains one of the most significant causes of morbidity and mortality amongst this group. Mortality rates of around one third at one year are summarised from the literature (SIGN, 2009) and half of those who have experienced this injury do not regain their pre-fall abilities (Magaziner et al., 2003).
The goal of hip fracture care is to help people return to pre-fracture residence and function (SHFA, 2008), thus to enable them to regain independence and quality of life. Concerns and worries that older people experience after hip fracture are highlighted to be a ‘hurdle’ to successful rehabilitation (Olsson et al., 2007), and the current health care policy of early discharge potentially lessens the opportunities people have to communicate concerns with healthcare professionals (Jacobs, 2000). The aim of this study was to explore older people’s concerns following surgical intervention for fall-induced hip fracture, responding to the gap in the literature. The rationale was to enable healthcare professionals to anticipate potential difficulties for older people on their return home and to discuss concerns before discharge, as advised by SIGN (2009).

METHODS

This study used the grounded theory method, where the researcher starts with a general area of interest rather than any preconceived background knowledge or hypothesis (Glaser & Strauss, 1967), and this is to ensure that the theory emerges from the data (i.e., is grounded). Ethical approval was granted by the National Research Ethics Committee in July 2007.

This study included 19 participants aged between 67-89 years who had sustained fall-induced hip fracture, had been discharged home; and who were willing and able to provide informed consent to participate. The sample consisted of 15 women and 4 men; 10 lived alone and 9 lived with family/partner.

FINDINGS

‘Taking control’ emerged as the core category that linked each of the main categories in this theory; it explained both the process and the strategies that people used to resolve their main concern of losing control again in the future. As people started to recover following hip fracture, they started to take control of the help and support available to them and to take control of their future risk. This process is explained conceptually as ‘balancing’. This theory makes use of nautical metaphors; the process of taking control is compared to the navigation of rough seas, in order to conceptualise and emphasise the physical and emotional struggles that older people experience as they strive to take control. The 3 stages of the process are discussed below.

The first stage: Going under
Going under conceptualises the fall event and the immediate loss of control experienced as a consequence. The fall itself was conceptualised as ‘the downfall’; as it had the potential to be the individual’s downfall and to impact on future health, independence, wellbeing and personal control.

After the fall, people resurfaced to the experience of pain and immobility and floundered; attempting to move and assess their injury, and trying to make decisions about how to source help. The main concern of ‘going under anew’ emerged as people faced the immediate challenge of keeping afloat.

The second stage: Keeping afloat
Keeping afloat conceptualises the physical struggle to manage in the post operative and post discharge context. Keeping afloat was precarious and people were aware of the potential of going under anew, i.e., of losing control again. Keeping afloat was characterised by ‘enforced dependence’: people struggled to cope with being dependent on others, unable to actively take control. However, people made attempts to control or ‘balance’ help, in order to obtain preferred levels and types of help, including making refusals of help offered, for example refusing carers on discharge.

People also took control by balancing risk as they made efforts to rebuild their confidence. People balanced risk by ‘being on protective guard’ and ‘following orders’. People were acutely aware that their hip was extremely fragile and recognised that all of their expectations for recovery, resuming control and normality were linked to this, therefore, they instinctively made efforts to slow down and concentrate. Simultaneously, they ‘followed orders’ provided by healthcare professionals.

The provision of information helped people to pace their progress and to balance help and risk safely and appropriately. In situations where people were not provided with information, they were left grasping to understand and their ability to take control was inhibited.

The third stage: Gaining ground

Gaining ground was characterised by people taking control more consistently and proactively. It involved rebuilding confidence and reaching landmarks, meaning that people made tangible progress and were able to recognise this progress. One important landmark was returning home. However, as a consequence, people often had to relaunch their struggle to keep afloat, especially if they lived alone, before they could start to gain ground again.

People moved back and forward between the stages of keeping afloat and gaining ground depending on the context and conditions of the moment. For some people, gaining ground was limited and a return to pre fracture ‘normal’ function and routine was unlikely; therefore they maintained the struggle to keep afloat and attempted to take control how and when they could.

People continued to balance help and risk during this third stage. People started to look to the future, seeing either foggy horizons or hope on the horizon depending on how confident they felt about their future ability to take control.

The diagram below summarises the theory of taking control conceptually, demonstrating the 3 stages of going under, keeping afloat and gaining ground. This diagram highlights the main concern of going under anew and positions ‘balancing’ as significant within the stages of keeping afloat and gaining ground.

Diagram 1: The theory of taking control

 

DISCUSSION

This study highlights the significance of the process of taking control after hip fracture, in that it appears integral to the process of recovery. The findings of this research highlight that for older people after hip fracture, their predicament is particularly significant as a consequence of their older age. The literature highlights that older people are ‘particularly vulnerable’ to losing a sense of control (Toby Brown & Furstenberg, 1992; Wolinsky et al., 2003) and this study has reiterated the significance of this issue.
This study also re-iterates the significance of the provision of informational support in helping people balance help and risk safely and appropriately. Furthermore, it highlights that the concept of self efficacy is central to the process of taking control. The findings of this study demonstrate that older people want to take control however they can after hip fracture; therefore, it is fundamental that healthcare professionals have an awareness of why older people strive to take control, and under what conditions and contexts they do so, in order that they can help them to do this safely and appropriately.
The significance of the core category of taking control is reflected in the wider literature on perceived control, self efficacy, and stress and coping after a health trauma. This study therefore lends support to earlier research that highlights the importance of control within the specific hip fracture recovery context (Furstenberg, 1988), in wider recovery contexts (Pearson & Kiger, 2004), and specifically for older people in relation to their health (Wolinsky et al., 2003).

SUMMARY

Older people are concerned about losing control after hip fracture and healthcare professionals have a vital role in providing information to patients and their families, helping to restore control and increase self efficacy. For older people who are able to return to their own homes after hip fracture, the first 3 months post discharge are precarious and present many challenges as they strive to regain control over their lives. This theory conceptualises how older people balance multi-factorial stressors as they move precariously through a three stage process of ‘going under’, ‘keeping afloat’ and ‘gaining ground’. It provides understanding of the individual’s experience and as such, its relevance should enable healthcare professionals to enhance their care of older people who sustain this traumatic injury and help them to facilitate successful balancing and progression through this trajectory.

REFERENCES

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Furstenberg, A. L. (1988) Attributions of control by hip fracture patients, Health and Social Work, Winter, pp. 43-48.

Glaser, B. G. & Strauss, A. L. (1967) The discovery of grounded theory: Strategies for qualitative research, Sociology Press: Mill Valley, Ca.

Jacobs, V. (2000) Informational needs of surgical patients following discharge, Applied Nursing Research, Vol. 13, no. 1, pp. 12-18.

Magaziner, J., Fredman, L., Hawkes, W., Hebel, J. R., Zimmerman, S., Orwig, D. L.,

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Olsson, L. E., Nystrom, A., Karlsson, J. & Ekman, I. (2007) Admitted with a hip fracture: Patient perceptions of rehabilitation, Journal of Clinical Nursing, Vol. 16, no. 5, pp. 853-859

Pearson, E. & Kiger, A. (2004) How emergency patients cope with their unexpected surgical event: an exploratory study, Journal of Advanced Perioperative Care, Vol. 2, no. 1, 11-18.

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Scottish Hip Fracture Audit (2009) Rehabilitation Report. Information Services Division Scotland: Edinburgh.

Scottish Intercollegiate Guidelines Network (SIGN) (2009) Guideline 111 Management of hip fracture in older people: A national clinical guideline. SIGN: Edinburgh.

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Wolinsky, F. D., Wyrwich, K. W., Babu, A. N., Kroenke, K. &Tierney, W. M. (2003) Age, aging, and the sense of control among older adults: A longitudinal reconsideration. Journal of Gerontology, Vol. 58B, no. 4, pp. S212-S220.