Background
Many countries around the world are facing the aging of their population [1]. The population of older persons (OP) over the age of 65 is particularly at risk of falling, often for reasons related to physiological aging [2, 3]. Falls account for approximately 10–15% of the reasons for emergency department visits by OP [4, 5]. In such cases, more than half of patients have a hip fracture [6, 7]. Globally, the number of hip fractures following a fall is increasing at the same rate as the ageing population [8]. The presence of co-morbidities decreased physical and cognitive resources, and their diminished ability to recover make OP a high-risk population regarding complications during hospitalisation [9, 10]. A thorough understanding of the stressors experienced by OP hospitalised for hip surgery following a fall can help improve healthcare and prevent complications, including delirium.
The main postoperative complications following hip surgery, are urinary tract infections [11], cardiovascular problems [12], delirium [13], pressure ulcers and dislocations [14]. These are reinforced by the presence of three or more comorbidities (e.g., cardiovascular disease, cancer, renal failure, cirrhosis of the liver, depression), frailty (e.g., dependence on activities of daily living, lack of physical activity, walking difficulties), and neurocognitive disorders [15‐23]. The main consequences are functional and cognitive decline, transfer to a long-term care facility, and death [24‐31], but also an increase in both the length of hospital stays and the costs of the care facilities [32, 33]. Depending on age, gender and postoperative complications, longitudinal studies suggest a mortality rate of between 20% and 30% of these OP within 30 days of surgery [34, 35].
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Furthermore, OP in hospital often relate negative experiences arising from a lack of consideration for their specific needs [36]. They report a shortage of time for professionals to respond to their needs, environmental difficulties (e.g. difficulty sleeping due to noise), lack of communication and information about their care (e.g. mobilization management), and the need for more support [37]. Findings from several qualitative studies aimed at exploring the experience of OP who have undergone hip fracture surgery highlight their physical and psychological distress, fear of falling, pain, worry about the future, vulnerability, and loss of autonomy [38, 39]. Finally, the diminishing presence of relatives—particularly informal caregivers (IC)—can induce feelings of sadness and loneliness in hospitalized OP, which are perceived as stressors by OP [40].
The presence of IC at the bedside of hospitalized OP and their involvement in care has been shown to have positive repercussions for both the OP and the IC [41]. However, communication between nurses, patients and IC is often inadequate, which limits the involvement of relatives in decision-making and care [42‐44].
Currently, knowledge about the consequences of surgery and the factors that can precipitate post-operative complications focuses mainly on physiological and psychological aspects, with less attention given to social and environmental factors. OP hospitalized for hip surgery encounter numerous internal and environmental stimuli, often described as stressors. In response to these stressors, they develop strategies to adapt with varying degrees of efficiency. To the best of our knowledge, the stressors and coping strategies developed by both OP and IC remain unexplored. Nonethless, in studies by Jensen et al. [45] and Ko et al. [39], researchers report that people who have undergone such surgery declare not being well prepared for discharge and that better support in the planning of the discharge would be beneficial. It is therefore important to gain a deeper understanding of the stimuli experienced, so that nurses can prevent the negative consequences of these stressors for the OP.
The present study is based on the Neuman System Model (2011) which takes a holistic, wellness-oriented perspective. In this model, human beings are seen as open systems with physiological (e.g., metabolism), psychological (e.g., cognition), socio-cultural (e.g., support), developmental (e.g., life transitions) and spiritual (e.g., the meaning of life, values) dimensions. They are constantly exposed to intra-personal (related to their internal physical or psychological environment), inter-personal (related to their proximal external environment) or extra-personal (related to their distal external environment) stressors. Neuman defines stressors as “tension-producing stimuli that have the potential to cause system instability” [46]. These stressors are considered neutral and their assessment (positive or negative) depends on individuals’ perceptions and coping skills. However, Neuman indicates that each individual (each system) has resources that enable it to maintain, attain or sustain stability and integrity aimed at its well-being, considered by Neuman as the manifestation of health [46]. These resources are located in what is called the “flexible line of defence” in the model. In some situations, the frontline health resources are insufficient to allow the system to protect its integrity and remain healthy, and the system is therefore destabilised.
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OP are particularly vulnerable to stressful events and, during hospitalisation for hip surgery following a fall, they are confronted with various stressors that can lead to complications with consequences for themselves, their IC and healthcare services. While intra-personal stressors are relatively well identified, there is a lack of data on the inter- and extra-personal stressors to which OP are exposed and the strategies used by OP, their IC and health professionals to mobilise health resources. Therefore, the present study aimed to explore the intra, inter- and extra-personal stressors arising from hip surgery following a fall of an OP hospitalised in orthopaedic inpatient unit, as well as the coping strategies used by the OP, IC and professionals to deal with them, and the outcomes of these strategies.
Methods
Study design and objectives
A qualitative multiple case study was used in order to meet the following objectives: [1] to explore the perceptions of OP, their IC and healthcare professionals about the intra-, inter- and extra-personal stressors faced by OP hospitalised for hip surgery following a fall; [2] to explore the coping strategies used by OP, IC and healthcare professionals to adjust to the different stressors they face; and [3] to explore the outcomes arising from the coping strategies used by OP, IC and healthcare professionals.
The Consolidated Criteria for Reporting Qualitative studies (COREQ) guidelines were followed throughout the manuscript [47].
Setting and participants
A non-probability convenience sampling method was used to select participants relevant to the phenomenon under study and its in-depth understanding [48, 49]. The target populations were OP, their IC, nurses, orthopaedic surgeons, and physiotherapists. All patients admitted to the orthopedic surgery unit and accompanied by a IC were invited to take part in the study. Selection criteria (inclusion and exclusion) were determined to recruit participants and are presented in Table 1.
Table 1
Inclusion and exclusion criteria for participants
Inclusion criteria | Exclusion criteria | |
|---|---|---|
Older person | − 65 years and older − Hospitalised in a surgical unit − Hip surgery following a fall − Capable of discernment − Speaks and understands French | − Absence of an informal caregiver − Refusal of the informal caregiver to participate in the study |
Informal Caregiver | − Designated by the older person − Capable of discernment − Speaks and understands French | |
Nurse | − Working in the orthopaedic surgery unit for more than six months − Having cared for the OP for at least two days | − Temporary nurse − Student |
Physiotherapist | − Working in the orthopaedic department for more than six months − Having cared for the older person for at least two days | − Temporary physiotherapist − Student |
Orthopaedic Surgeon | − Working in the department for more than six months − Having performed surgery for a total hip replacement following the fall of the older person |
The head nurse of the orthopedic surgery care unit carried out the recruitment of the OP and their IC. She informed the OP who met the selection criteria about the possibility of participating in a study. Those who wished to participate in the study were given complete information on the modalities of participation. Those who agreed to participate were asked to appoint an IC willing to participate in the study. The research assistant then contacted the IC by telephone. After obtaining the informed consent forms from the OP and the IC, the head nurse of the care unit was informed about the inclusion of each dyad (OP-IC). She identified the referral nurses who had been caring for the OP, as well as the physiotherapist and the orthopaedic surgeon. The latter were recruited directly by the research assistant. One OP was excluded from the study because the caregiver who had initially agreed to participate was ultimately unable to do so. All the invited nurses, physiotherapists and surgeons accepted the invitation to participate. The total sample consisted of 32 participants: eight OP hospitalised for hip surgery after a fall and their ICs (n = 8), as well as nurses (n = 6), physiotherapists (n = 5) and orthopaedic surgeons (n = 5) from an orthopaedic unit of a public hospital in Switzerland. The participants were grouped into eight analysis units. Each unit consisted of an OP, an IC, a nurse, an orthopaedic surgeon and a physiotherapist involved in the OP care. Nurses, physiotherapists and orthopaedic surgeons caring for several OP participating in the study were included in more than one unit of analysis.
Data collection
Data collection was conducted at the end of the hospitalisation of the OP using several data sources [48]. Due to the small number of IC, nurses, physiotherapists, and surgeons participating in this study, socio-demographic data for these participants are not developed, in order to maintain confidentiality. The interviews conducted by one of the study authors (MT, CC) took place between August 2018 and February 2019. During the face-to-face interviews, each participant completed a questionnaire gathering socio-demographic data. For the OP, clinical data were also collected, including hospital admission and discharge dates, primary reason for hospitalization, main diagnosis, comorbidities, prescribed medications, details of surgical interventions (including type and location), anesthesia type, durations of stay in intensive care, continuous care, and surgical unit, as well as complications experienced during hospitalization (e.g., infections, anemia, delirium).
The audiorecorded interviews were then conducted using a semi-structured interview guide, inspired by the Neuman System Model (2011) and adapted to each type of participant (Additional file 1: Interview guides). The duration of the interviews varied between 15 and 45 min depending on the tolerance and availability of the participants. During the interviews, the interviewers kept a logbook to record observations on the context of the interviews that may have influenced how they were conducted, as well as to note any relevant details about the participants’ responses and behaviors.
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Data collection was conducted until data saturation was reached, ensuring no new themes or information emerged from additional data.
Data analysis
An Excel 2010® database was created to process the questionnaire data and perform descriptive statistics for the respective participant types. The digital audio data from the interviews was transformed into verbatim. The verbatim and interviewer’s logbook data were grouped for an intra-case analysis using the QSR Nvivo®11 textual data analysis software. Three of the authors coded the data (CC, MT, FP). Each case underwent thematic content analysis, enabling a comprehensive investigation of the phenomenon within each unit of analysis [48]. Subsequently, an inter-case analysis was carried out. For this purpose, the themes identified in the analyses of the eight cases were grouped in a Table [50]. Table 2 concerns both inter- and extra-personal stressors. As a result of the inter-case analysis, new themes emerged from the connections established by comparing the similarities and differences among the case themes [48].
Table 2
Condensation of cross-case analysis results
Cross-case subtopics | Cross-case topics |
|---|---|
Interpersonal stressors - Decreased social contact - Feeling of loneliness - Discomfort in asking for help, mainly for hygiene care - Care varies between professionals - Lack of information Extrapersonal stressors - Preparation for discharge from the hospital for a rehabilitation stay (+/-) - Standardised care (loss of reference with the environment and delay in responding to requests for care) - Characteristics of the environment (about perceived comfort) | Loss of relational, environmental and way of life markers |
Several strategies were used to ensure scientific rigour at different stages of the study [48]. The full transcript of the interviews with the participants ensured the reliability of the recording. Triangulation between the socio-demographic data, the interviews with the various participants, and the interviewers’ logbook helped guarantee the study’s internal validity. Regarding construct validity, the concepts were defined based on a theoretical model in nursing, the steps of the study were documented in the logbook and integrated into the data analysis. Finally, to ensure construct validity, the thematic analysis of the interviews was carried out during regular meetings between the research assistant and two researchers also involved in the research. Subsequently, meetings were planned with a fourth independent researcher in order to ensure the reliability of the results.
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Results
Characteristics of the participants
Nine OP were recruited, but one could not participate in the interview. The eight remaining OP were primarily men. Their ages ranged from 67 to 92 years old and six out of eight were married. The majority had more than three comorbidities and were operated on within one day of the fall. Five had postoperative complications such as anaemia, diarrhea, anxiety and confusion. The duration of hospitalisation varied between 5 and 11 days. Before the accident, all OPs lived at home. Due to the small number of OP, socio-demographic data are not developed, in order to maintain confidentiality.
Most of the IC were married, retired people who lived with the OP. Their ages ranged from 33 to 79, including four spouses over 75. Among the caregivers, six mentioned having a very good to excellent relationship with the OP they visit daily.
The six nurses recruited were mainly women, of Swiss nationality, aged between 29 and 55. Regarding training, three nurses had a Bachelor’s degree, two had a diploma in general care (DGC) and one nurse had a postgraduate training (Diploma of Advanced Studies; DAS). Professional experience varied between four and 30 years and the presence in the care unit varied between four and 16 years. Most nurses worked full-time and alternate day and night shifts.
The five physiotherapists recruited were mainly men, aged between 23 and 43. Regarding education, two physiotherapists had a Bachelor’s degree, two had a degree considered equivalent to a Bachelor’s degree, and one had a Master’s degree. The years of professional experience varied between two and 18 years and the years in the department of physiotherapy of the hospital varied between one and 18 years. The physiotherapists worked full-time (100%), mainly during the day.
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The five surgeons recruited were men, aged between 31 and 53 years. Four of them had a specialisation in orthopaedic surgery. The years of professional experience ranged from seven to 20 years and the years in the department of surgery of the hospital varied from one to 14 years. They all worked full-time (100%), day and night.
Themes and sub themes
Five themes emerged from the data analysis. Two of these themes relate to the stressors faced by OPs, two other themes highlight the strategies used by OP, IC or various professionals providing care and, finally, a fifth theme highlights the outcomes of these strategies on OP. These themes are described in more detail below.
Physical and psychological consequences of the fall and hospitalisation
For OP, a fall is a stressful event with both physical and psychological implications. OP describes the various sensations experienced during a fall, sometimes with humor. These include the sudden nature of the fall. Some see themselves falling without being able to catch themselves. Another stressful situation was reported by being on the ground and unable to get up. OP quickly becomes aware of the severity of their fall. Here is how one OP described his fall:
The most stressful thing is […] to realise that there is something wrong, because you can’t feel your leg, you can’t move it, your foot is twisted in a strange position and then […] there are all these people who come running, looking worried, wanting to help and so on, so that’s the first, the first stressful moment. (OP 1)
The OP also talk about their fall and fears with their informal caregivers. One OP said to her relative several times: “I can still see myself falling, I can still see myself falling”. (IC 8)
During hospitalisation, OP, their IC and health care professionals report that the fall generates fear that can hinder the performance of specific activities. Physiotherapists report that many OP are apprehensive about mobilization and walking. For example, one physiotherapist explained that while the patient was in bed, he was calm and smiling, but
[…] as soon as we started to mobilize him, he would scream with pain in the room. Not only of pain when he was being moved, but also yelling his fear of falling, his insecurity despite the fact that we had properly secured him. As soon as it was time to move, he was not the same person. Even when he was in the armchair, all he asked was to go back to bed as soon as possible. (Physiotherapist 5)
Although some patients are perfectly capable of walking, the fear of falling is an obstacle to their rehabilitation. This is what one physiotherapist has to say about an OP:
It’s a fear, an irrational fear of falling, of losing her balance and falling, which makes her tense up a bit, she stiffens up and, as a result, she’s all the more at risk of falling when she’s perfectly capable of walking much better (Physiotherapist 4).
Besides the pain associated with hip surgery, the fear of falling also manifests itself during nurse care. A nurse explained that when a patient got up, she always “[…] remained very tense. Well, I think also because of the pain. But also because she was afraid of falling.” (Nurse 6).
Concerning surgery, the majority of OP were operated on within the first 24 h. However, one OP had to wait several days, and the surgeon thought this was an additional stressor for her. The aftermath of the operation is also often made more complicated because of pain, disorientation, and elimination problems, which can also cause stress. One OP said that before her fall, she already had after-effects of a previous stroke, but that with the fall “[…] at some point, it was a bit as a fog. There was the accident and everything got mixed up”. (OP 4)
In addition, OP sometimes had pre-existing chronic conditions that made hospital care more complex. Hospitalisation and drug treatments can also destabilise a pre-existing chronic pathology. One OP explained that he managed his antibiotic treatment for his diverticulitis problems at home independently. In the hospital, he said that it was also a little stressful, because “if on top of that [the surgery], I’m going to be bothered by my intestines, well it’s not going to be enjoyable. Well, let’s say, that [the intestinal problem] bothered me the most”. (OP 9)
In the case of OP with neurocognitive disorders, they have difficulty understanding their environment and what is required of them. This was the case for one older participant for whom the nurse noted that “the fact […] that she sees different people also stressed her a little bit”. (Nurse 4)
Loss of relational, environmental and way of life markers
Several OP mentioned that the lack of contact with their IC and friends during hospitalisation led to feeling isolated and lonely. As one OP put it:
Not being at home, as I told you before, [not being with] the wife, the pets, guests. Who visits me here? My wife, that’s all. (OP 5)
Hospitalisation is also a challenging time for OP living with a partner. Regarding separation, a relative said: “[…] I think that, in the end, he must suffer from being in the hospital, and then from being away from me, that’s for sure. I’m convinced of that, and it’s the same for me. The separation is very hard” (IC 7). Moreover, there is not necessarily much contact and exchange with the roommates, as one OP reported: “This man doesn’t even say hello to you. […] Not a word. […] two people in the same room. And then, you don’t say a word to each other all day long, for days and days”. (OP 5)
The hospital environment was mentioned as a stressor for the OP. On arrival at the hospital, OP are moved quickly through several departments as described by a surgeon:
First, she goes through the emergency room. Then to the operating theatre. Then she returns or arrives in the hospital room. All these factors are a bit annoying, especially as the lady suffered a fracture. And a bit stressful for people of that age. (Surgeon 6)
In addition, the OPs are hesitant to disturb the staff and often delay requesting assistance. Occasionally, they even forget how to use the bell. This is what one OP said:
But I’m the stupid one. I don’t know how to ring the bell. […] I was afraid to disturb them and that’s it. Which is not normal, in a way. […] I said to myself “no, I’m not going to call for that, it’s not possible”. Afterwards, I regretted it because when he attended to me, I was fine. (OP 6)
Another stressor reported by OP concerned being dependent for hygiene care. Care is sometimes experienced as moments when OP have no influence. They are caught in a spiral and do not know what they will have to endure. Moreover, their specific needs are not always considered, and they feel embarrassed by their situation of dependance. As reported by one OP, in some situations, “[…] the stress is more that one feels embarrassed, it’s more a kind of embarrassment, because one says to oneself, yes, but it’s not normal that at seventy-seven years old I pee myself” (OP 1). The IC also reported that her husband “[…] was ashamed that he had wet the bed” (IC 1). As for the nurse, she spoke of the patient’s fear of urinating in bed and his shyness to “[…] have the nurses wash him […]”. (Nurse 1)
Also, the OP pointed out that there was no longer any room for their habits, that they had to adapt to the organisation of nursing care, to the continual staff changes and to a lack of information. As one OP pointed out: “Um, you have to fit in and then, when you have understood that, you have understood everything” (OP 7). However, this can have consequences for more anxious OP who find themselves in an unfamiliar environment. In this regard, one nurse noted that in the hospital environment, OPs feel more anxious and distrustful during care and in relation to things that are not usual for them (Nurse 4).
Furthermore, many OP mentioned that they often had to wait. As the physiotherapist’s visits were not scheduled, this caused stress, especially when the OP saw the physiotherapist arrive after an already eventful morning.
In most cases, when the OP lived at home before the fall, they were concerned about the possibility of returning home even though they already had difficulties or falls repeatedly. (Surgeon 5). The majority of OP and their IC were worried about hospitalisation after surgery. They did not always agree which could cause stress. One OP said: “[…] No, I hope they don’t put me in a [rehabilitation] center. Because then I would really lose the will to live” (OP 5), while the IC worried that he was not walking well enough to go home. Transfers to rehabilitation centers are most often organised without taking into account the preferences of the OP, which leads to additional stress for them.
Being resilient and involved in one’s care
In order to cope with the stressors inherent to the physical and psychological consequences of a fall and of surgery as well as the loss of relational, environmental and way of life markers, the OP implemented passive and active coping strategies during their hospitalisation. Regarding the passive strategies, the OP tried to accept their situation and be resilient. One of the first steps was recognising the reality of being hospitalised and losing one’s standard bearings in a new environment. As one OP said: “It always feels strange to leave home. However, that’s a fact, but otherwise no, no, I’ve got to go and that’s it. (OP 6) Another FC mentions the impossibility of maintaining her habits in the hospital:
You have to take it when it has to be done and that’s it. […] You can’t, you can’t. You have to take it as it comes. […] Oh, I’d like that [smoking]. But I know that I can’t here. So I don’t insist, I don’t even try. I’m in a place where I can’t do everything, that’s it (OP 5).
Acceptance and resilience are coping strategies that OP use and are necessary for relationships with health professionals.
An OP said: “You have to accept that the person in front of you, who may be very young, is a professional who knows what he or she is doing […].” (OP 1) Nevertheless, one of the OP stressed that acceptance sometimes requires work on oneself:
You’re hit by stress over which you have no influence, it’s external, and then there is stress that you can control. At least, you can react to it, decide to accept it as stress or to let it. So when it’s something you can’t influence, it’s another form of stress than the one you do to yourself”. (OP 1)
The OP interviewed also used more active strategies. They expressed their needs, got involved in their own care and tried to entertain themselves during their hospital stay. For example, one OP took an interest in her blood pressure and made links with her medication. Others invested in their rehabilitation exercises and made efforts to regain their independence, especially with regard to their mobility and hygiene care. Here are two verbatims illustrating these strategies:
Ah! Yes, so, he was always very motivated. I mean, every time I went into the room… um, he was already… he would get up straightaway, he would take his walking sticks and then… um, he would start off, so… um, there you go, he was always well motivated to… to move, to mobilise himself. (Physiotherapist 9)(…) I saw, there was another patient who had to learn to put on his socks, or his shoes and everything. I was able to watch how they did it, how he did it. Then the physiotherapist came this morning, I wasn’t there. She left the equipment, I was able to put on my socks, I was able to put on my shoes. (OP 7)
Partially meeting the needs of the OP
Informal caregivers and health professionals developed strategies to meet the needs of the OP in hospital and to provide them with information to help them manage the various stressors they faced. For example, here are the strategies used by a relative to meet her husband’s needs and try to entertain him:
[…] I brought him ice so that he could cool down […] I massaged his legs with arnica […] He can’t move, so he needs to be massaged a bit […] I talk to him, I phone him, that’s the good thing with cell phones today, and WhatsApp in the morning. […] I brought him some fruit because he’s a big fruit eater. […] Then I brought the IPAD, like that, that’s how happy he is. I bought him a book, if he ever wants to read, and then I bought, he loves doing the crossword. (IC 1)
Like IC, nurses sought to respond to the needs expressed by the OP, particularly about daily living activities and pain management. They also contributed to developing the OP’s autonomy in preparation for their return home. Here is how one nurse described her intervention:
[…] it’s mainly to encourage him, well, to do things by himself. Um, meals… for example, in the evening, breakfast, he eats in bed, the evening meal, he eats in bed. So… um, getting him used to going back to everyday life. (Nurse 9)
As for the other professionals involved in the rehabilitation of OP, their interventions were adapted according to individual specificities. In practice, surgeons adapted their surgical technique and physiotherapists adapted their walking rehabilitation strategies. Physiotherapists also tried to reassure, motivate and encourage the OP during their rehabilitation exercises. Here is what a physiotherapist had to say about this:
I get physically closer to her. I support her firmly so that she feels that I am there and that I am holding her and that she is safe, so we walk with her walking frame […] this attitude is at the same time very reassuring and at the same time very motivating and… and with a mixture of… authority, humor, that’s what makes the system work. (Physiotherapist 4)
Some health professionals said that they only gave a little information about the organisation of treatments to avoid stressing the OP. Here is how one physiotherapist explains his strategy: “I never make appointments with patients, otherwise I’m sure I’ll forget them and not come at the correct time, so I tell them: either I come in the morning, or I come in the afternoon, that’s it”. (Physiotherapist 1)
Despite the interventions by IC and health professionals to meet the needs of the elderly, there were some discrepancies in the latter’s expectations. For example, one nurse explained the difficulties in convincing the OP of the need for a stay in rehabilitation before returning home:
So we tried to make him understand: “There, you see that you can’t get up on your own. How are you going to manage at home and so on?” We explained it to him, but… we could see it wasn’t working. He didn’t want to understand. (Nurse 5)
Reassurance through consideration of some of the OP’s needs
Surgery can be a very frightening experience for OP. They were reassured when the surgeon explained the operation and the post-operative care. One surgeon emphasised that when he told an OP “that she would be able to walk again and regain her independence and that she would be back on her feet fairly quickly, as they say. That was something that reassured her”. (Surgeon 6)
In fact, during care, explanations help to calm and reassure OP. For example, the information received is useful for OP to adapt their movements. In this respect, one OP said that “from the answers, I was thinking: be careful with this, be careful with that, etc., don’t force it, etc. Here they are… they are really good. […] I don’t stay in the room because I like to walk around, […] I have to move. […] But at my own pace”. (IC 7)
For physiotherapy, adapting mobility training strategies and auxiliary means can calm patients. Here is what a physiotherapist had to say:
[…] we were able to see that we were going further in amplitude. […] That, I think, reassured him a little bit because he could see progress at that level, in terms of amplitude. […] I think it reduced the stress […] It’s the fact of seeing this change that perhaps reduced the stress he was feeling. Not necessarily the fact that I put the machine on, but in any case, seeing the results. […] I think he was quite happy. (Physiotherapist 1)
Visits from IC and friends were appreciated as long as there were not too many at once.
About transfers to a rehabilitation centre, these were often more complicated. The health professionals’ arguments did not always help to calm the situation, as this surgeon pointed out: “[…] this is a person who was not very open to our arguments, […] and she was not at all open to, to understanding the message”. (Surgeon 5) This was often the case when the OP wanted to go straight home, as in a situation where an OP wanted to go back home immediately and was not at all open to listen to the professionals’ arguments and the relative indicated that this was not possible. For this person, the nurse underlined that “[…] it stressed her a lot”. (Nurse 5)
Discussion
This study explored the intra-, inter- and extra-personal stressors arising from hip surgery following a fall in elderly orthopaedic inpatients and the coping strategies used by the OP, IC, and professionals and the outcomes of these strategies. The five themes presented provide essential information related to the research questions.
The results highlight, and add to current knowledge, that OP hospitalised for hip surgery following a fall are exposed to various stressors that can contribute to the development of complications. The physical and psychological consequences of the fall and of the surgery and the loss of relational, environmental and way of life references represent the intra-, inter- and extra-personal stressors that can have consequences for the hospitalised OP. Thus, our results show that psychological, socio-cultural, developmental (life transition) and spiritual (meaning of life, values) dimensions should be considered in the same way as the physiological dimension in order to improve the quality and the safety of care [51]. Despite the large number of stressors experienced by hospitalised OP, these are only partially assessed and taken into consideration by the members of the healthcare team. In this respect, it seems particularly relevant that professionals carry out a holistic assessment. To do so, they can draw on Neuman’s systems model [46], the theoretical model of this study and of person-centred care and family carers [52]. In orthopaedics, certain authors have also suggested multidisciplinary approaches to address the complexity of the needs of OP with hip fractures [53‐55]. Neuman’s systems model encourages a comprehensive evaluation of physical, psychological, social, and spiritual stressors, enabling tailored interventions that address the OP’s overall well-being. This systematic approach not only helps in understanding the interconnected nature of stressors but also supports proactive management strategies that promote resilience and recovery. By integrating Neuman’s systems model into daily practice, nurses and the multidisciplinary team can improve patient outcomes, enhance patient satisfaction, and ensure a more holistic and effective approach to care for orthopaedic OP with hip fractures. By applying this model, which emphasizes a holistic approach to patient assessment, healthcare professionals can systematically identify and address the stressors OP face.
The results also highlight the different coping strategies used by OP, their IC and health professionals and the results obtained. These strategies, which to our knowledge have not been explored in previous studies, represent protective factors for withstanding stressors and maintaining a balance that promotes health. Moreover, they are a partial response to the recommendations of the Jensen et al. [45] and the Ko et al. [39] studies regarding preparation for discharge. Notably, IC and health professionals can help OP implement their coping strategies and provide feedback on their observations and suggestions for shifting from emotional coping strategies (e.g., avoidance) to problem-focused coping strategies and resolution. These findings are consistent with those of the Mackie, Marshall, & Mitchell’s study [42] concerning the involvement of family carers, which is manifested in different ways, such as emotional support, information sharing, direct contributions to care and decisions about the care plan. Discussions between OP, IC and health professionals are seen as a co-regulation process to find a dynamic stability, aimed at well-being. Depending on the co-regulation quality, this will generate a “positive” (e.g. security, harmony, openness) or “negative” (e.g. discomfort, loneliness, fear) environment [46].
Furthermore, the results of the present study show that IC play an important role in preventing undesirable health consequences of stressors in the OP. Ambrosi et al. [56] have also highlighted the role of IC in the care of OP in hospital. They have essential information to pass on to the nurses, and their integration into care can help to manage the stresses encountered by the OP in the best possible way [57]. Thus, they are privileged partners in personalising care. Moreover, they want to take part in decision-making and contribute to personalised care. As such, health professionals could integrate them more into the decision-making and intervention implementation, particularly those aimed at preventing the consequences of stressors [43, 58, 59]. However, Mackie et al. (2019) note that nurses lack strategies for working in partnership with family caregivers [42]. Previous studies have shown that communication is a key element that influences positively or negatively the involvement of IC in care [42, 44, 60].
Finally, healthcare professionals do not always have effective intervention strategies to identify and support older people who are experiencing stressors of various kinds. In acute care settings, the complexity of the needs and care requirements of OP in hospital means that nurses must have the skills, but also the work conditions and the time to design care centred on the OP and their IC [61, 62]. To address this complexity, a programme to improve the care of hospitalised OP and their IC would be required [63, 64].
Based on the views of the various actors involved, the results of this study offer interesting avenues for developing personalised, multidimensional and multi-professional care interventions addressing all the stressors involved in the occurrence of complications in hospitalised elderly people. These preventive interventions should meet the needs of the OP, reinforce their efficient coping strategies or support them in developing them in order to reduce the occurrence of possible complications.
Conclusion
The study identified intra-, inter-, and extra-personal stressors from total hip replacement surgery after a fall, emphasizing the need for improved care quality and safety. OP and their IC often have to find coping strategies, while healthcare professionals lack effective interventions for these stressors. Nurses play a crucial role in addressing OP needs in collaboration with other professionals. The findings highlight the complexity of stressors and the necessity for innovative nursing and multi-professional interventions to prevent complications and promote recovery. Adopting a person- and family-centered approach is essential, as it anticipates and addresses stressors, ensuring high-quality, safe interventions. This knowledge enhances holistic care and reduces OP exposure to stressors.
Acknowledgements
The authors would like to thank the older person and their informal caregivers for their availability during the interviews. We would also like to express our sincere thanks to the nursing staff, nurses, medical doctors and physiotherapists for their participation in the study.
Declarations
Ethics approval and consent to participate
The Human Research Ethics Committee of the Canton of Vaud (CER-VD) approved the research protocol on July 31, 2018 (N°2018 − 00732). We confirm that all study methods were performed in accordance with the relevant guidelines and regulations. All the individuals approached during recruitment were given verbal and written explanations. They were given an information document detailing the study’s objectives, procedures, and data confidentiality assurance. All study participants gave their written informed consent to the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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