15.1 Introduction

The concept of patient-centred care has gained increasing prominence as a key goal of healthcare systems. However, despite growing recognition of the importance of patient-centred care and evidence of its effectiveness in contributing to other system goals such as efficiency and effectiveness, many national health systems are falling short in this area. Data from international studies show that patients often rate hospitals and healthcare providers highly, but report significant problems in accessing important information, understanding treatment options, getting explanations about medications, and receiving responsive, compassionate service from their care providers [1, 2].

The literature identifies the following as some of the key factors in achieving patient-centred care at the organisational level [3]:

  • Involvement of patients and families at multiple levels, not only in the care process, but as full participants in key committees of the organisation that cares for them.

  • A supportive work environment that involves staff in all aspects of process design and treats them with the same dignity and respect that is expected of patients and families.

  • Supportive technology that involves patients and families directly in the care process and facilitates access to information and communication with their carers.

A hip fracture is a sudden event that often requires immediate and increased support from carers (family, friends, neighbours). People with a hip fracture may need ongoing support due to deconditioning or reduced physical function. While people with a hip fracture are in hospital, carers continue to play an active role in helping the person to maintain their Activities of Daily Living (ADL), such as hygiene, dressing, and eating hygiene, as well as providing social interaction and emotional support. In particular, carers of people with hip fractures have expressed difficulties in adapting to their new role, managing stress and strain, navigating the unknown, accessing appropriate information, and understanding the discharge planning process [4].

In addition to patient and carer challenges, some studies identified a number of current gaps in the literature that need to be addressed to improve the care experience. The authors identified the importance of further understanding and unpacking the tensions associated with caregiving, as well as issues around changing identity and family dynamics. Further exploration of these areas from the perspectives of patients, carers and healthcare providers is essential to inform care planning and discharge processes. Therefore, studies are exploring how carers of older adults with hip fracture navigate their roles and responsibilities in a complex healthcare system [5, 6].

In this context, knowing how to support patients and carers, not only educationally but also emotionally, is crucial. First and foremost, health professionals need to be trained and empowered to empower others.

15.2 Learning Outcomes

At the end of this chapter, the practitioner will be able to:

  • Discuss the role of family and friends as carers and how healthcare professionals should facilitate family involvement in care

  • Describe how to empower patients and carers

  • Discuss the importance of education programmes for patients with hip fractures

  • Describe how caregiver support programmes can affect care-related burden

  • Define the term eHealth technology

15.3 The Value of Partnership Work and Empowerment

There has been a significant shift in the way healthcare professionals view care, from a medical-centred model to a patient-centred approach. It is now recognised that a key priority for patients is how their wishes and those of their families and carers are integrated into the care process. Healthcare professionals are expected to focus on working with patients and families of all ages, at all levels of care and in all healthcare settings [7].

The aim of patient-centred healthcare is to empower patients to become active participants in their own care, while also ensuring the empowerment of the family when they play an important role in patient care [6]. The philosophical concept of empowerment can be traced from Latin America and Paulo Freire and his ‘Pedagogy of the Oppressed’ [8] to other philosophers such as Sartre [9]. Although Freire’s theory of consciousness-raising among underprivileged groups was not related to illness, the idea is that encouraging people to reflect on their situation is a way of allowing power to come from the person and for change to happen, that empowerment highlights the person’s competencies and that there are many different solutions to a problem. The idea behind the concept of empowerment is that it is possible to help people cope and feel better through dialogue and reflection between the professional and the person in need, or between the family carer and the care provider. According to Freire, as part of an empowerment strategy, the professional should encourage the person to reveal their own vulnerability and resources in the face of illness and other limitations, in order to reflect together on the meaning of the illness and to promote the person’s choice to act and cope.

Research shows [10] that to empower a person, it is necessary to take a holistic approach, considering all aspects of the person’s needs, such as social, spiritual, emotional, and physical. Simply inviting a person to participate in their own care process will not lead to empowerment, so it is important that the person’s private experiences and thoughts are in harmony with what they are doing. The empowerment process is a continuous interaction of empowering practice and critical reflection. However, practitioners must first become empowered themselves before empowering others, as a person needs competence and motivation to empower others.

According to Adams [11], empowerment is the ability of individuals or groups to take control of the situation and achieve their own goals. It is the process by which individuals or groups can improve their quality of life and help themselves. The literature shows [12, 13] that educational support for patients and carers, and the provision of resources and methods that increase self-awareness, ensure an empowerment process, which is important during patients’ recovery, especially after traumatic events such as a fragility fracture.

Health professionals are vital in the empowerment process of family carers and patients. Only by considering the situations and experiences of family members will it be possible to define their needs [14].

Empowerment of family carers and patients can be achieved in several ways, such as providing comprehensive information about health conditions; involving them in care decisions; helping them to recognise their own needs; encouraging them to keep in touch with friends and others with similar experiences. Providing financial support, in countries where the social/health system allows, is also considered an important resource in the empowerment process. Feeling supported educationally and emotionally also prevents exhaustion and stress. In orthopaedic wards, patient and caregiver empowerment, managed by specially trained nurses and a specialised, tailor-made rehabilitation programme, can be instrumental in helping patients reduce their hospital stay and return to their previous life [15].

Carr [16] states that the levels of participation in decisions about one’s own health and the empowerment of people who use social/health services continue to be low, highlighting the fact that the lives of family carers and people who use services are often so pressurised that they are reluctant and/or unable to make decisions. This shows that the creation of health and emotional support and education programmes led by health professionals needs to become routine in all health services so that ‘making decisions about one’s health’ can become the norm for patients and carers.

15.4 Educational Support to the Patient

Patient education can be defined as ‘the process by which the patient comes to understand his or her physical condition and self-care through the use of various media and experiences’ [17]. The main aim of patient education is to enable patients to make appropriate decisions to improve their health. Therefore, patient education is much more than just understanding the health problem or disease [17]. Sometimes it requires changes in values, attitudes, and beliefs, which are not easy to achieve. Healthcare providers must create a friendly environment in which patients can share their perceptions and discuss the changes needed, which may include help from others and/or changes in habits and customs. The use of adapted (simple) language by health professionals to facilitate the understanding of health problems and to ensure the right shared decision-making [18] is also essential. Some of the theoretical models used by healthcare providers to design patient education programmes are:

  • cognitive dissonance theory [19]

  • self-efficacy theory [20]

  • health belief model [21]

  • adult learning theory [22]

All these models describe different concepts and offer tools for providing appropriate patient education. Some of the benefits of patient education described in the literature include [23]:

  • improved continuity of care

  • reduced complications

  • increased adherence to treatment

  • improved satisfaction

  • anxiety, empowerment of patients

  • improvement in their independence and quality of life

It has also been shown to reduce costs by reducing hospital stays and health centre visits [24].

Educating older adults with hip fracture about their injury and the best treatments is essential. However, age should be considered when designing specific patient education programmes to ensure an appropriate decision-making process, which should include family/carers. Some specific postoperative educational programmes conducted with older adults with hip fracture have been shown to be effective in:

  • improving chances of discharge to home [25]

  • health-related quality of life [26]

  • functional status [27,28,29]

  • satisfaction [30]

  • reducing functional urinary incontinence [31]

These educational programmes have been delivered face to face, but there are other blended programmes using written information and online resources, such as the FReSH Start toolkit (manual and online resources) [32, 33] and the ActiveHip+ educational programme for older adults with hip fracture and their carers [34]. Although each patient education programme must be designed considering the context and specific characteristics of each population, the FReSH Start toolkit [32, 33] and the ActiveHip+ programme [33, 34] can be used as examples of education programmes for older adults with hip fracture.

The basic content that should be included in this type of health education programme for patients includes:

  • An overview of the process from hospital admission to discharge to reduce anxiety for older adults and their carers. This overview could be provided using a friendly infographic with information about medical tests (e.g. X-rays, blood tests), healthcare providers who will see the patient (e.g. doctors, nurses, physiotherapists, occupational therapists, social workers), schedules of activities in the hospital (e.g. meals, Activities of Daily Living (ADL) training, medication intake, exercise training), and any other information of interest from each health centre.

  • Knowledge of hip anatomy and biomechanics, types of surgery and postoperative mobility prescription, including an overview of activities to avoid early after hemiarthroplasty (the main movements to avoid are hip flexion above 90° and hip adduction) as discussed in Chap. 7.

  • Common misconceptions about hip fracture. Sometimes older adults have misconceptions based on the experiences of other relatives, friends, or neighbours who have had a hip fracture. Healthcare professionals need to provide information about best practice based on the latest evidence. For example, explaining why early mobility (within 24 h after surgery) is important (see Chap. 8), or performing ADLs as soon as possible, including self-care and locomotion.

  • Pain management. Explanation of ‘typical’ pain patterns after hip fracture, and basic analgesic medication and its use specifically before ambulation (see Chap. 8). A clear message encouraging older adults to ask doctors and nurses if pain persists needs to be included, as does an emphasis on controlling pain while remaining active.

  • Post-surgery mobilisation. Healthcare professionals should provide a detailed description of exercises to be performed in the first days after surgery, the correct way to walk (using different walking aids), the safest way to perform transfers (e.g. bed-to-chair, chair-to-toilet), and other ADLs (24 h after surgery if indicated) [34]. The focus needs to be on supporting older adults to do as much as possible, even though tasks may take longer in the early days. Chapter 8 provides more detail about remobilisation and exercise.

  • Assistive devices for ADLs and mobility. Healthcare professionals can demonstrate and explain the use of some ADL aids (e.g. raised toilet seat, bath transfer bench, long shoe horn) and mobility aids (e.g. walker, crutch, cane, and crutches).

  • An overview of the recovery process after discharge from hospital. An infographic with information on the different care pathways available in each context, health and social resources, key contact details for social and health services, reminders for medical appointments, and home recommendations would help older adults cope with the new situation. Chapter 16 considers discharge and post hospital care in more detail.

  • Hydration and nutrition. It is essential to provide information on the importance of maintaining adequate hydration and optimal nutrition with a protein-rich, nutrient-dense diet, and dairy products to support the recovery process so that patients and their carers can engage actively in this aspect of their care (see Chap. 11).

  • Home environment recommendations. Healthcare providers need to emphasise the importance of a safe home environment that supports older adults to move around and reduces fall risk factors, such as adequate handrails, supportive lighting, and clear paths between rooms.

  • Post-discharge mobilisation. Examples of balance and strength exercises of varying levels of difficulty to be performed at home and outdoors, and suggestions for adapted ADLs to be performed at home to improve physical function and independence need to be provided (see Chap. 14). Healthcare providers need to encourage older adults to go out for shopping or leisure activities to increase social participation.

  • Routines and wellbeing. It is important to prevent older adults from taking on a passive role. Therefore, the moment of returning home will be very important for regaining roles, routines, and social interactions to avoid depression and isolation. Family carers and friends can support older adults to engage in some leisure activities, make phone calls, and meet other relatives and friends to improve their wellbeing.

  • Preventing falls and secondary fractures. Information about osteoporosis, medications to stimulate bone regeneration, dietary and physical activity recommendations should be discussed with patients to ensure proper understanding and to motivate them to adopt new habits. See Chaps. 1 and 5 for more information about osteoporosis treatment and Chap. 4 for falls prevention.

15.5 Family Involvement in the Care Process

The concept of family care has also evolved significantly and now reflects the changing nature of ‘family’ in society. Much informal care is provided by individuals who would not traditionally be considered family members, and such ‘informal care’ is recognised as an important facet of care provision. Informal caregivers are defined as ‘persons without formal health care training who are caring for or assisting a person with functional disabilities, prolonged psychiatric or physical illness, or age-related problems’ [35].

Families (defined in this chapter as anyone who has an important relationship with the patient, such as relatives, partners, friends, and neighbours) are an essential component of care, health, and wellbeing; quality and safety initiatives recognise their role in ensuring high standards of care [36]. Families often act as primary carers and advocates for patients who are unable to make decisions for themselves (see Chap. 17). They are an essential part of the patient care continuum, and a key feature of holistic care is that nurses need to collaborate with others to achieve best practice [36].

There are four key factors to consider in relation to patient and family involvement:

  • dignity and respect

  • information sharing

  • participation

  • collaboration

Communication is also a key factor in ensuring timely and appropriate information sharing between healthcare professionals and the patient and family. Any information shared should be unbiased and relevant; asking the patient or family what they need to know or understand better can help avoid frustration, miscommunication, upset, and anxiety. Practitioners also need to communicate the same message to the patient and family to avoid misunderstandings and ensure they can make the most appropriate decision about their care [37].

During the process of family involvement, it is important to gain and document a full holistic understanding of the family’s role in the patient’s care; without ever assuming that the family is willing or able to provide care, nor judging whether they would prefer not to be involved in direct care. It is important to establish how much support has been, and can be, provided by non-family members, the costs involved and its effectiveness. The family should be asked if they know of any voluntary or community support that can provide resources. Grants and financial support may be available to patients and family members from social work/care agencies or voluntary organisations [36].

Family involvement in post-discharge care requires careful planning and organisation during the discharge planning process, starting with an open discussion with the patient and family to ensure that everyone understands the implications of decisions. Arrangements need to be made for equipment and services at home. Family members may need to develop specific caring skills and arrangements need to be made to ensure that they understand issues such as the patient’s limitations and potential progress towards recovery. If the decision is made to discharge the patient to a residential facility, either permanently or temporarily, the implications for the family, such as social and financial aspects, need to be carefully considered with the help of social workers [38].

15.6 Caregiver Burden and Supporting Caregivers

Depending on the carer’s circumstances, caring can be a joy or a source of anxiety. A person who needs a lot of help and care can have a negative impact on the caregiver’s quality of life, which can also affect the relationship between caregiver and care recipient [39].

The rehabilitation task of caregiving in the context of hip fracture most often falls to a family member. Several studies have focused on the concept of burden, defined as ‘caregiving burden’, losing sight of the importance of assessing the positive aspects that characterise an individual’s health status. Informal carers are an important resource for older hip fracture patients, as they play a key role in their recovery. One important role is to motivate patients to adhere to their treatment programmes. Informal caregivers have to cope with physical, psychological, and social stressors that negatively affect their health status and quality of life [13, 40].

Many carers take on the role of carer with little or no preparation and have to learn to manage several aspects of care in a very short time. In most cases, they do not have any professional skills in caregiving. In fact, carers often do not know what to expect during hip fracture recovery. They are faced with situations where they must deal with various care-related tasks, such as arranging rehabilitation services and assistive devices. These situations become more stressful when caregivers have to balance their own work and family life with their caregiving activities. Informal caregivers have been repeatedly recognised as a model of chronic stress due to the high levels of daily stress they experience. The main stressors experienced by informal caregivers are related to the severity of the illness and the amount of time spent providing assistance [41, 42].

When caregivers are observed over a considerable period of time, it becomes clear that family caregiving responsibilities do not end when a disabled relative moves to institutional care. Instead, this important transition seems to influence the type and intensity of help provided. Some studies treat institutionalisation as an ‘endpoint’ in family caring, but recent research has highlighted the continuing involvement of relatives in care and the impact of institutionalisation on family members’ stress and mental health [43].

High levels of depressive symptoms and low levels of life satisfaction among caregivers may also be associated with poor quality of care provided to their frail care recipients and even with mistreatment of the older adult (see Chap. 17). Caregiver burden and related stress negatively affect caregivers’ perceived overall physical and mental health and have been negatively correlated with the functional status of older family members 1 month after discharge following hip fracture surgery [44].

Research shows that what family carers need most is support and information. The most frequently mentioned issues by family caregivers were the need for advice in complicated situations and the need for information about medication and onset of disorientation and mood changes. Carers also need both skills and knowledge to provide care and to reduce their own distress [45].

A literature review has shown that there are several ways to empower family carers through educational courses and information services. However, these initiatives should offer family carers the opportunity to express their needs and should include ways to help family carers better manage their emotions and increase coping/problem-solving skills. Knowledge about the rights of the family carer and the different support services available to them should be provided. It is essential that training courses and information services are well planned to increase family carers’ self-esteem by providing the right kind of skills and knowledge, for example, on medication management and depression. Family carers will be empowered through the improvement of their competence and self-esteem through meeting the psychological needs of their carers [46].

The needs of carers must be considered when designing educational content for them. Educational needs change according to the socio-economic and anthropological conditions in which the patients find themselves, and according to the characteristics of the carers themselves. It is common to find informal carers who are of a different nationality from the patient and who provide different types of care according to their own culture [47].

As the literature shows, the needs of caregivers range from the more technical to the more relational. Multidisciplinary educational initiatives that include this content have been shown to be effective in reducing stress and inappropriate hospitalisation. Carers participating in these support programmes have also reported feeling valued and empowered. In addition to the topics usually included patient education following fractures, the caregiver of a post-fracture patient needs appropriate attention to effective communication with the patient, support for the cognitively impaired patient, the role of the caregiver, consideration of anthropological differences, and stress management through the development of appropriate coping strategies [48].

15.7 Family Cares and Patient Education Using Technology

The COVID-19 pandemic has given digital educational pathways enormous visibility, as it was impossible to organise face-to-face support groups for patients and carers worldwide. The term ‘eHealth technology’ is used to refer to digital support (mobile applications, web-based platforms, virtual reality, etc.) that delivers digital interventions or relevant educational content. Studies have found many positive aspects of this approach and suggest that digital health tools can be an inexpensive, easily accessible and time-saving option for addressing caregiver burden and mental health. Further improvement and the development of commercialised digital health tools that are scientifically based but tailored to carers is needed [49].

Evidence suggests [50] that digital tools for caregivers (including web-based solutions, mobile applications, or virtual reality; through video, audio, text, and interactive content) that help to develop coping skills, emotional self-regulation, caregiver education, skill building, and training using a well-structured approach can be very effective in managing caregiver stress and burden. Due to their accessibility, adaptability, and the ability to provide structured and therapeutic interventions, digital health tools are an important means of support for informal carers.

Regarding the use of digital content among patients, it is important to consider that the digital format is not an option for all patient profiles (if they have cognitive deficits or are unfamiliar with devices such as smartphones, PCs, tablets) and healthcare providers need to explore the preferences and digital skills of each older adult before offering this type of educational programme [49].

Summary and Main Points for Learning

  • The aim of patient-centred healthcare is to empower patients to become active participants in their own care, while also ensuring the empowerment of the family when they play an important role in patient care. A key priority for patients is how their wishes and those of their families and carers are integrated into the care process. Healthcare professionals are expected to focus on working with patients and families of all ages, at all levels of care and in all healthcare settings.

  • Educating older adults with hip fracture about their injury and the best treatments is an essential aspect of healthcare. However, the age of this patient profile should be considered when designing specific patient education programmes to ensure an appropriate decision-making process, which should include their carers.

  • The needs of carers must be considered when designing educational content for them. Educational needs change according to the socio-economic and anthropological conditions in which the patients find themselves, and according to the characteristics of the carers themselves. It is common to find informal carers who are of a different nationality from the patient and who provide different types of care according to their own culture.

15.8 Suggested Further Study

Ariza-Vega P, Ortiz-Piña M, Kristensen MT, Castellote-Caballero Y, Jiménez-Moleón JJ (2019) High perceived caregiver burden for relatives of patients following hip fracture surgery. Disabil Rehabil. 41(3):311–318.

Batista de Lima ME, Falaschi P, Eleuteri S (2020) Supporting family caregivers of older adults with hip fracture: the role of educational courses. in Caregiving: Perspectives, experiences and challenges. Nova Science Publishers. ISBN: 978-1-53616-889-1.

Guilcher SJT, Maunula L, Cadel L, Everall AC, Li J, Kuluski K (2021) Caregiving for older adults with hip fractures: Exploring the perspectives of caregivers, providers and decision-makers in Ontario, Canada. Arch Gerontol Geriatr. 93:104321.