Table II.

Summary of qualitative studies investigating performance indicators in hip fracture care of older patients.

Study ID, country, Study period	Study aim	Population	Study design	Analyses method (theory/framework/model used)	Themes/subthemes	Categories/subcategories
Haslam-Larmer et al (Canada) Study period: 201924	To identify factors influencing participation in early mobility activities after hip fracture surgery	Hip fracture Patients: 19 Family members: NR Healthcare professionals: 10 (Physiotherapists, occupational therapists, therapy assistants, and registered nurses)	Part of mixed method study. Qualitative method: Face to face semi structured interviews The Healthcare professionals interview questions based on Theoretical Domains Framework The patient & family member questions were grounded in the COM behaviour change model	Theoretical Domains Framework Capability, Opportunity, Motivation, Behaviour (COM-B) change model	Patients Patient’s pre-fracture functional status Patients’ cognitive status Medical unpredictability Healthcare professionals Healthcare provider perceptions Healthcare providers attitudes and behaviours Preconceived notions held by healthcare providers and patients Patients and Healthcare professionals Environment factors Psychological and physiological factors Mismatch of expectations	Patients and Healthcare professionals Factors affecting early mobility: external to patient unique to person
Jensen et al (Denmark) Study period: 201530	To describe experiences of the hip fracture pathway.	Hip fracture Patients:10 Relatives: 4 (daughter, husband, wife) Health professionals*:15 (*physiotherapists, nurses, geriatrician, physicians, healthcare workers and PhD student)	Qualitative – semi structured interviews and field observations to gain a broader and richer description and to clarify if the patients feel empowered and able to perform selfcare after short time stay in hospital.	Phenomenological and Reflective Lifeworld Research approach Phenomenon: 'hip fracture pathway with short time stay in hospital (STSH)'	NR	Patient Pre-conceived notions Importance of autonomy 'Master in my own house' Will and zest for life Health professional Self-care and empowerment Cross sectional collaboration Preparing for discharge
Mow et al (Australia) Study period: unclear, sometime between 2013 to 201523	To identify processes that could be clarified and streamlined, with the agreement of relevant stakeholders, in the creation of a new hip fracture pathway	Clinical staff: NR (Anaesthetists, radiographer, ortho surgeon, ortho registrar, medical registrar, physician, allied HP, theatre nurse)	Part of mixed method study. Qualitative method: Unclear	Smart simplicity model (to drive progress toward the common goal by cooperative process restructuring, allowing staff involved in the processes to explore jointly the approaches that were best supported by evidence)	Clinical staff Cultural issues causing delay to hip fracture patient progress through the pathway	NR
Rath et al (India) Study period: 2014 to 201522	To document current practices, barriers and facilitators to adopting best practice guidelines and consequently make recommendations for improving the management of older adults with hip fracture	Healthcare professionals*: NR (*Involved in pre to postop hip fracture care and included clinical leads, residents, and nurses from orthopaedics, anaesthesia, geriatrics, medicine, and physiotherapy depts)	Part of mixed method study. Qualitative method: open ended question interviews and focus group discussions to obtain information on existing care pathways within their hospital setting and potential barriers and facilitators to adopting best practices	Behaviour change wheel framework COM model	Healthcare professionals Persuasion in hip fracture patients’ care pathways Modelling Enablement Education & training Environmental restructuring	Healthcare professionals COM behaviour change Communication/marketing Guidelines Service provision Environmental/social planning Regulation
Gunningberg et al (Sweden) Study period: 200025	To investigate possible changes in nursing and treatment routines in pressure ulcer risk	Multiprofessional group*: 6 (*Ortho surgeon, nurses & technicians from ED, operation theatre, and ortho ward)	Part of mixed method study. Qualitative method: focus group interviews to investigate possible changes in nursing and treatment routines	Framework of the Plan-Do-Study-Act model & VIPS model based on four key concepts (wellbeing, respect for integrity, prevention, and safety)	Multiprofessional staff Intervention functions Service provision Enablement Modelling Environmental restructuring Education and training	Multiprofessional staff Audit nursing and treatment routines Fast track care of hip fracture patients Identify risk factors Develop pressure prevention programme in orthopaedic wards
Volkmer et al (UK) Study period: NR29	To explore physiotherapists’ perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit.	Physiotherapists: 21	Qualitative – one-to-one and semi-structured telephone interview. Open-ended questions about their experiences working with hip fracture patients; their views on potential reasons for reported variation in physiotherapy after hip fracture; the types of patients they treat, the structure of their service, the role of other healthcare professionals, patients and informal/formal carers in early recovery after hip fracture	Normalization Process Theory	Physiotherapists Achieving protocolised and personalized care Patient and carer engagement Multidisciplinary team engagement across the care continuum Strategies for service improvement	NR
Jensen et al (Denmark) Study period: 201630	To use a Habermasian lens to illuminate health professionals' perspective of the gap between what the system provides, and patients’ needs and wishes, with a view to supporting patient empowerment.	Mixed group of health professionals*: 16 (*doctor in chief, leading orthopaedic doctor, nurses, endocrinologist, geriatricians, researchers, external observers, social and healthcare assistants, physiotherapists)	Qualitative – three focus groups Open-ended questions which allowed participants to freely discuss their thoughts, perceptions and ideas on hip fracture care and generated follow-up questions	Habermas' theoretical framework	Health professionals Systematized pathways and clinical guidelines are inevitable How to counteract patients' lack of information	Health professionals Objective world (e.g. knowledge) Social world (rules/norms of social interactions, patient expectations, health related decisions) Subjective world (intentions, thoughts, emotions and wishes)
Christie et al (UK) Study period: NR36	To explore a multidisciplinary collaborative approach to implementing evidence-based, person-centred hip fracture care.	Clinical leaders*: 16 (*From different disciplines and were knowledgeable in the field of hip fracture care and were in a position to influence others)	Qualitative – data collected during eight two-hour action meetings	Collaborative inquiry approach (underpinned by the combination of critical theory and Habermas’ concept of lifeworld, Mezirow’ action orientated approach to learning from experience and Rogers’ humanistic psychology of person-centred practice)	Clinical leaders What it was like Overcoming the risks together Thinking differently Enhanced experience	NR
Schroeder et al (Israel) Study period: 202126	To understand the perspective of the patient’s experience of rehabilitation following hip fracture	Hip fracture Patients: 15	Qualitative method: Open-ended questions semi-structured interviews and focus groups via video conference and telephone Questions were about the physical, emotional, personal goals of rehabilitation as well as the participant’s view of optimal timing for administration of the SF36 questionnaire.	SF-36 model (used SF-36 questionnaire for patient reported outcome measurements) The Lincoln and Guba Framework	Patients Uniqueness Physical needs Roles (physical, social, emotional)	Patients Identify needs post hip fracture Ageism, old age, falls & fractures Physical functioning Independence Therapy Rehabilitation/training Physical role Bodily pain Vitality Social role Emotional role (fear of falls, uncertain future, moods, guilt and sadness)
Southwell et al (UK) UK Study period: NR27	To explore older adult’s perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture.	Hip fracture patients: 15	Qualitative – In-depth semi-structured interviews with three open-ended questions on starting rehabilitation, rehabilitation activities and benefits, and challenges of rehabilitation for recovery).	Bury’s biographical disruption theoretical framework.	Patients Importance of self-determination Reliance on professional support Importance of meaningful feedback Anxiety about the future Reliance on social capital	NR
Asplin et al (Sweden) Study period: 201628	To explore patients’ experiences during inpatient rehabilitation after hip fracture surgery and the use of Traffic Light System -Basic ADL in their rehabilitation process	Hip fracture patients:19	Qualitative – semi-structured interviews with questions on experiences of recovery and participation in their rehabilitation process including the use of TLS-BasicADL	Content analysis using Graneheim and Lundman method	Patients Being seen as a person Striving for Independence	Patients Interaction gives trust and security Information is key to understanding Encouragement is essential to promote activity Accepting the situation while trying to remain positive The greener the better, but it’s up to me Ask me, I have goals Uncertainties concerning future
Segevall et al (Sweden) Study period: 2016 to 201731	To describe rural older people’s experiences of recovering after hip fracture surgery	Hip fracture patients: 13	Qualitative –individual semi-structured interviews, according to Kvale and Brinkman method. 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.	Phenomenological content analysis using Catanzaro procedure.	Patients An unexpected life-altering event Preparing to return home Needing adjustment and support at home Struggling to manage at home.	NR
Bruun-Olsen et al (Norway) Study period: NR32	To explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process	Hip fracture patients: 8	Qualitative – semi-structured interviews with open-ended questions on the issues related to their experiences of barriers and facilitators of the different stages in the recovery process	Phenomenological approach	Patients Feeling vulnerable A span between self-reliance and dependency Disruption from normal life	Patients Feeling of subservience Feeling of gloominess and hopelessness The gap between expectations and reality Recovery as self-reliance Recovery as dependent on actions from others Less independence and mobility The impact of age
Ivarsson et al (Sweden) Study period: NR33	To elucidate perceived situations of significance experienced by patients with hip fracture during the prehospital- and in-hospital care.	Hip fracture patients: 8	Qualitative – semi- structured interviews with open-ended questions on their experiences as hip fracture patients	Critical incident technique approach	Patients Oscillating between being satisfied and enduring a new demanding situation	Patients Pain and pain management Feeling fear and satisfaction in perioperative care Experiencing continuity in care Considering information Feeling encouragement and assistance
Gesar et al (Sweden) Study period: 201334	To explore healthy older patients’ perception of their own capacity to regain pre-fracture function in the acute phase (the first two to five days) after hip fracture surgery	Hip fracture patients: 30	Qualitative - Semi-structured interviews with open-ended questions to describe their hip fracture experiences and the possibilities of regaining functions and recovery after hip surgery.	Explorative inductive qualitative design. Data analyzed using manifest inductive content analysis	Patients To end up in a new situation with or without control	Patients Belief in recovery, nothing will be altered No problem, I will manage this unexpected event, determination will be needed Adapting to a new situation in hospital Need for appraisal Context as a negative influence An unpredictable future When and how to recover Uncertainty
Griffiths et al (UK) Study period: 201237	To explore what patients consider important when evaluating their recovery from hip fracture and to consider how these priorities could be used in the evaluation of the quality of hip fracture services.	Hip fracture Patients: 31	Qualitative – semi- structured interviews to explore with patients and, where appropriate, their carers, what they consider to be important outcomes and to explore variation across this patient group.	NR	Patients Mobility (within 24 hrs post surgery) Valued day-to-day activities Self-care Pain Mental wellbeing Fear of falling Leg shortening.	NR
Olsson et al (Sweden) Study period: NR38	The aim of this study was to describe the hip fracture patients’ own perceptions of their situation and views of their responsibility in the rehabilitation process.	Hip fracture Patients: 13	Qualitative – semi-structured interview questions, related to the informants’ perception of the transitional properties,	Phenomenographic analysis	Patients Common patient traits Variations in need for information	Patients Lacked awareness Were shocked by the hip fracture accident/event Had a strong desire to recuperate The Autonomous (who knew what they wanted after discharge) The Modest (who gave the impression of being vulnerable and dependent on others and they expressed themselves cautiously) The Heedless (who appeared to view their situation with some detachment, almost as if it did not really concern them)
Archibald et al (UK) Study period: 200139	This study was conducted to explore the experiences of individuals who had suffered a hip fracture to inform nursing practice.	Hip fracture Patients: 5	In-depth, open-ended, unstructured interviews	Phenomenological methodology, grounded theory approach	Patients The injury experience, The pain experience, The recovery experience The disability experience	Patients Storytelling, recalling the experience of the injury itself Coping with the pain Involved the operation, beginning the struggle of recovery, and regaining independence. The disability itself, depending on others, and being housebound

^*Study number as per Supplementary Tables iv and v.

ADLs, activities of daily living; COM, capability, opportunity, and motivation; HP, healthcare professional; N/R, not reported; RCT, randomized controlled trial; TLS, traffic light system.