Authors

1. Rasmussen, Birgit MHH
2. Uhrenfeldt, Lisbeth RN, MScN, PhD

Abstract

Review question/objective: The objective of this review is to synthesize the lived experiences of self-efficacy and well-being the first year after hip fracture.

Background: People sustaining a hip fracture are at risk of health impairment and mortality.1, 2 The peak age of people experiencing a hip fracture is between 75 and 80 years and most often hip fractures occur in women.1, 3 Eighty percent of hip fractures are associated with low-impact trauma.4 After hip fracture some experience short or long term disability; some never regain their former level of mobility.5, 6 Bertram et al.5 found that after one year, 35% were unable to walk independently and 29% experienced lifelong disability. The consequence of this can be new dependency in assistance with everyday functioning, e.g. getting in and out of a bath or going shopping. Some suffer a loss in quality of life6-8 and wellbeing8, and some move to nursing home facilities.3, 5, 9

For society, it is important to find ways to improve recovery after hip fracture. In 2000, the worldwide disability-adjusted life years lost associated with hip fracture were estimated to be at least 2.53 million.1 The lifetime cost for all hip fractures is estimated to exceed $20 billion in the United States alone.10 Interventions should take into consideration all factors that can affect function after hip fracture11 such as age and comorbidity,7, 12 pre-fracture function, gender, pain, muscle strength, early mobility level11, 13-15, 17 and cognitive14, 16, 17 and effective status.17, 18 Rehabilitation starts immediately after surgery and can take place in a variety of practices: during hospitalization, in an ambulatory setting and after discharge from hospital.19, 20 The effect of rehabilitation after hip fracture is suggested to be less effective if there are restrictions in function from a fear of falling (FOF).21, 22 Fear of falling is linked to self-efficacy. Self-efficacy is the belief persons have about their capability to do a certain task.23, 24

After hip fracture, older people reported that their lives were changed physically, personally and socially.25, 26 In a study by Jellemark et al25 the interviewees talked about feeling isolated which lead to loneliness and could result in frustration and helplessness. McMillan et al27, 28 conducted interviews three months after discharge from hospital and found that during hip fracture rehabilitation older people struggled to take control of their future life by trying to balance risk-taking and help-seeking.27, 28 The interviewees were aware that on one hand it could be risky to move around and they were afraid of falling but on the other hand they wanted to be active and were trying to do things. They were determined to regain independency. In order to make progress, some of the interviewees stressed the importance of receiving information and being included in talks regarding their progress.27, 28 Not understanding or not remembering the information received, resulted in feelings of being anxious about what they could or could not do.

The lived experience of own mobility after hip fracture may be linked to a fear of falling, and experiences of low self-confidence may affect the degree of mobility and activities carried out in daily life. A self-induced restriction in physical activity after hip fracture rehabilitation can lead to diminished physical function, increase the risk of future falls and affect experiences of wellbeing.21,29,30 It may be important to include strategies to increase confidence in individuals undergoing rehabilitation after hip fracture.21,30-32

In a mixed methods study, Jellesmark et al.25 explored the experienced relationship between a fear of falling and functional debility in older people three to six months after hip fracture. The people interviewed applied different strategies to avoid falling. For example, a walker could reduce their fear of falling but it could also be a barrier and make it impossible to take the bus;25 a woman chose to sit in a soft chair where she felt safe, while others chose an active life-style despite the risk of falling; and some were able to walk but had promised their relatives to be careful and this kept them from being active.25

An earlier study underlined the traumatic impact of a hip fracture on the lives of older people.33 They experienced fear of falling and dependency. Some perceived their hip fracture to be a chronic problem which affected the improvements they made during rehabilitation.33

It is possible to experience feelings of wellbeing after hip fracture. Todres and Galvin34 developed an existential theory of wellbeing where wellbeing is understood as a resource when it comes to eradicating ill health. People live in a world that is relational and full of meanings, where you sense, embody and experience. This intimate togetherness with the world is experienced before any reflection or attitude and is named the life-world. Within the life-world you just know and sense what wellbeing is.34

During illness, people experience the limitations of their existential possibilities. Galvin and Todres35 call this an experience of "homelessness".35^(p.3)Within homelessness lies the potential experience of striving for homecoming. Striving for homecoming is an energizing flow that holds the possibility of wellbeing. Paradoxically the homecoming holds a possibility of wellbeing in the feeling of acceptance and peace. Galvin and Todres call these dimensions of wellbeing "mobility" and "dwelling".35^(p.2) The intertwining unity of dwelling and mobility provides the possibility to experience the deepest form of wellbeing: the space where the rootedness and inner peace of dwelling embraces the energy and mobility of "adventurous horizons".36^(p.3)

Possible experiences of wellbeing can be considered with an emphasis on different existential qualities: temporality, spatiality, embodiment, intersubjectivity, mood and identity.36 The mobility-experience of personal identity emphasizes identity as "I can" encompassing a sense of "being able to".36^(p.8) To a person who has lost confidence in the ability to walk without falling after hip fracture, it can be relevant to ask, what the possibilities are for facilitating self-efficacy in the life of this specific person. To gradually rebuild "I can" successes may become a source of wellbeing.36

Well-being may change during rehabilitation after hip fracture. Taylor et al31 in semi-structured interviews investigating mobility levels after hip fracture found that during rehabilitation in hospital, participants reported feeling optimistic.31 However, after discharge from hospital, the picture changed: interviewees were concerned that they had difficulties walking, especially outdoors. One expressed that "[horizontal ellipsis]I get frustrated[horizontal ellipsis] I think if I'm going to be like this the rest of my life I don't want to live".31^(p.1288) They reported struggling to cope with daily activities and lack of confidence and resignation were common experiences.31

Wellbeing and self-efficacy are resources for both health and illness that can be taken into account when exploring ways to promote possibilities for recovery. The insight is sparse when it comes to understanding what matters to older people after a hip fracture. The findings of this review might provide evidence useful to both health care professionals in their clinical work and to future research. Drawing on the experiences of the elderly with hip fractures can enhance the understanding and awareness of issues that may be important when caring for and developing interventions to improve the functional level, self-efficacy and wellbeing of older people after hip fracture rehabilitation.