BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available.
When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to.
The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript.
BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com).
If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on October 1, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Developing an individualised activity-based cross-sectoral programme to support rehabilitation of elderly people with hip fracture: a qualitative study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-044539
Article Type: Original research
Date Submitted by the 09-Sep-2020 Author:
Complete List of Authors: Ropke, Alice; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences Lund, Karina; Herlev Hospital, Department of Physiotherapy and Occupational Therapy Thrane, Camilla ; Herlev Municipality, Health Promotion and Rehabilitation Juhl, Carsten; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences
Morville, Anne-Le; Jönköping University, Department of Rehabilitation http://bmjopen.bmj.com/ School of Health and Welfare
Hip < ORTHOPAEDIC & TRAUMA SURGERY, QUALITATIVE RESEARCH, Keywords: REHABILITATION MEDICINE
on October 1, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 45 BMJ Open
1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 45
1 2 3 4 Title page BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Title: Developing an individualised activity-based cross-sectoral programme to support 8 rehabilitation of elderly people with hip fracture: a qualitative study 9 10 Authors: 11 1,2Alice Røpke 12 1Karina Lund 13 3 14 Camilla Thrane 1,2 15 Carsten Bogh Juhl 16 4Anne-Le Morville 17 18 Corresponding author:For peer review only 19 Alice Røpke 20 Herlev and Gentofte Hospital 21 22 Department of Physiotherapy and Occupational therapy 23 Borgmester Ib Juuls Vej 29 24 Opgang 8, 3. sal, O1 25 2730 Herlev 26 Denmark 27 Email (work): [email protected] 28 29 Email: (private): [email protected] 30 https://orcid.org/0000-0001-7793-5558 31 Phone: +45 (0) 26882002 (mobile) 32 33 1Department of Physiotherapy and Occupational Therapy 34 Copenhagen University Hospital, Herlev and Gentofte 35 Department of Physiotherapy and Occupational therapy 36 Borgmester Ib Juuls Vej 29
37 http://bmjopen.bmj.com/ 38 Opgang 8, 3. sal, O1 39 2730 Herlev 40 Denmark 41 Name: Alice Røpke 42 Email: [email protected] 43 Phone: +45 (0) 26882002 (mobile) 44 https://orcid.org/0000-0001-7793-5558
45 on October 1, 2021 by guest. Protected copyright. 46 Name: Karina Lund 47 Email: [email protected] 48 Name: Carsten Bogh Juhl 49 Email: [email protected] 50 https://orcid.org/0000-0001-8456-5364 51 Phone: +45 (0) 2139 5639 (mobile) 52 53 2 54 Department of Sports Science and Clinical Biomechanics 55 University of Southern Denmark 56 Campusvej 55 57 5230 Odense M 58 Denmark 59 60
1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 45 BMJ Open
1 2 3 4 Name: Alice Røpke BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Email: [email protected] 7 https://orcid.org/0000-0001-7793-5558 8 Phone: +45 (0) 26882002 (mobile) 9 Name: Carsten Bogh Juhl 10 Email: [email protected] 11 https://orcid.org/0000-0001-8456-5364 12 Phone: +45 (0) 2139 5639 (mobile) 13 14 3 15 Health Promotion and Rehabilitation 16 Tvedvangen 196 17 2730 Herlev 18 Denmark For peer review only 19 Name: Camilla Thrane 20 [email protected] 21 Phone: +45 (0) 4452 6308 22 23 4 24 Department of Rehabilitation 25 School of Health and Welfare 26 Jönköping University 27 Box 1026 28 551 11 Jönköping 29 Name: Anne-Le Morville 30 31 Email: [email protected] 32 http://orcid.org/0000-0003-1338-9644 33 Phone: +45 (0) 793101899 34 35 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 36
37 Word count: 4000 – excluding title page, references, figures and tables. http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 45
1 2 3 4 5 Developing an individualised activity-based cross-sectoral programme to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 6 7 support rehabilitation of elderly people with hip fracture: a qualitative study 8 9 10 ABSTRACT 11 12 13 Purpose: To develop an individualised rehabilitation programme for personal and instrumental 14 15 activities of daily living (ADLs), enabling elderly people with hip fractures to perform them safely 16 17 18 and independently. For peer review only 19 20 Methods: This study explores the experiences, needs and wishes related to a transitional 21 22 rehabilitation programme focusing on ADLs for elderly people with hip fractures using a 23 24 25 participatory design. Two research circles, each comprising four meetings, were conducted, 26 27 including a group of seven elderly people with hip fracture and a group of seven healthcare 28 29 professionals. 30 31 32 Results: Three key themes were identified (1) ‘Challenge the elderly with goal-oriented ADL 33 34 tasks’, (2) ‘Implement strategies to enhance independent and safe performance of ADLs’ and (3) 35 36 ‘Communicate the important information to the target group and across sectors. A programme
37 http://bmjopen.bmj.com/ 38 theory was developed and an intervention to enhance usual rehabilitation was designed comprising: 39 40 41 an individualised intervention component consisting of five additional therapy sessions; one during 42 43 hospitalisation, four in the municipality and a follow-up phone call. 44
45 on October 1, 2021 by guest. Protected copyright. 46 Conclusions: Engaging and integrating occupations into rehabilitation treatment may support 47 48 meaningful occupations during rehabilitation of the elderly with hip fractures. Recommendations 49 50 51 for challenging the elderly in performing daily activities, implementing strategies and 52 53 communicating information are proposed in transitional rehabilitation. 54 55 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 56 57 58 59 60
3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 45 BMJ Open
1 2 3 4 Strengths and limitations of this study BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 This study highlights that a participatory design is suitable when developing a hip fracture 8 9 10 rehabilitation programme 11 12 The credibility and trustworthiness of our findings were enhanced by using peer and 13 14 member checking 15 16 17 A comprehensive process and feasibility evaluation of the hip fracture rehabilitation 18 For peer review only 19 programme is needed to test adherence and compliance of the intervention 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 45
1 2 3 4 DECLARATIONS BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 8 Acknowledgements 9 10 The authors thank the participants for sharing their insights and time with the research team. 11 12 Furthermore, we want to thank the two rehabilitation centres and the University Hospital for their 13 14 15 collaboration and for making their facilities available for researchers while conducting the research 16 17 circles, and Senior Researcher Morten Tange Kristensen for his input and feedback on the first HIP- 18 For peer review only 19 REP draft. 20 21 22 Funding 23 24 25 This study was funded by the Region’s Research and Development fund (R26-1121); the 26 27 Intersectoral Research Unit (P-2017-1-11; P-2019-2-16); University College Copenhagen, 28 29 Department of Physiotherapy and Occupational Therapy (Internal funding), University Hospital 30 31 32 Copenhagen, Herlev and Gentofte (Internal funding) and Occupational Therapists Association (FF2 33 34 - R104-A2093). 35 36
37 Declaration of interest statement http://bmjopen.bmj.com/ 38 39 40 The authors report no conflicts of interest. The authors alone are responsible for the content and 41 42 writing of the paper. 43 44
45 Ethics approval on October 1, 2021 by guest. Protected copyright. 46 47 The study followed the Danish legislation regarding ethics in scientific studies and was approved by 48 49 50 Ethics Committees [H-18000881] and the Danish Data Protection Agency [Jnr no.: 2012-58-0004]. 51 52 53 54 55 56 57 58 59 60
5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 45 BMJ Open
1 2 3 4 INTRODUCTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Despite positive surgical outcomes, elderly people with hip fractures (HF) need rehabilitation to 8 9 optimise their performance in Activities of Daily Living (ADLs). Just one-third regain their pre- 10 11 fracture level of physical function and capacity to perform ADLs.1 2 For the remaining two-thirds, 12 13 3-7 14 there is an increased risk of social isolation, depression and reduced Quality of Life (QoL). 15 16 Studies have reported poor post-fracture outcomes8 9 and the sharing of knowledge and coordination 17 18 across the healthcare sectorsFor does peer not always review meet frail patients’ only needs.10 Close, continuous and 19 20 efficient collaboration between different professions and healthcare sectors is essential to provide 21 22 11 23 patient-centred rehabilitation, based on the individual’s needs, wishes and competences. Several 24 25 studies support the effect of multidisciplinary rehabilitation of patients with HF, combining nursing 26 27 care, physiotherapy, occupational therapy and/or social work.11-14 Few studies focus on occupation- 28 29 15 7 16 17 30 based and focused interventions improving ADL outcomes, and how to support the elderly 31 32 with HF to safely and independently performing ADL activities is therefore not described in detail. 33 34 Thus, the aim of this study was to gather knowledge on the experiences, needs and expectations of 35 36 rehabilitation from elderly people with HF in order to develop an intervention programme focusing 37 http://bmjopen.bmj.com/ 38 39 on their ability to safely and independently perform ADLs of a personal (PADL) and instrumental 40 41 (IADL) nature. To develop a sustainable intervention, multiple perspectives from elderly people 42 43 with HF, their families, and the healthcare professionals (HCP) - specifically physiotherapists and 44
45 on October 1, 2021 by guest. Protected copyright. 46 occupational therapists - are needed. This study is the first step of a forthcoming trial of developing 47 48 and evaluating a complex intervention for the rehabilitation of elderly people with HF with a focus 49 50 on enabling ADL performance. 51 52 53 54 55 56 57 58 59 60
6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 45
1 2 3 4 MATERIAL AND METHODS BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Patient and public involvement 8 9 A participatory design was adopted, emphasising engagement and collaborative action between 10 11 elderly participants with HF, HCPs and researchers.18 19 To achieve this, the research circle method 12 13 20 21 14 was applied. The research circle process is characterised by mutual reflection and engagement 15 16 between participants contributing with equal authority to co-create collective knowledge. Research 17 18 circles are based on a commonFor themepeer that is reviewdiscussed to generate only new in-depth knowledge among 19 20 the included participants.22-24 Two research circles were formed: one with elderly participants with 21 22 23 HF and another with HCPs- occupational therapists and physiotherapists - working in hospital 24 25 settings and municipalities. 26 27 The overarching theme for each meeting was determined in advance by the first author and inspired 28 29 25 30 by the rehabilitation phases in practice developed by Borg ; 1) Rehabilitation during 31 32 hospitalisation, 2) Rehabilitation in transition to the municipality, 3) Rehabilitation in the 33 34 municipality, and 4) The resultant collective proposal for a hip rehabilitation programme. At each 35 36 meeting, an interview guide26 was developed based on the respective themes (figure 1). 37 http://bmjopen.bmj.com/ 38 39 40 41 42 Sampling and recruitment 43 44 Purposeful sampling was performed to recruit elderly participants with HF from a range of post-
45 on October 1, 2021 by guest. Protected copyright. 46 acute settings and demographics e.g. type of housing, geographical district, age and sex.27 The 47 48 49 HCPs were recruited from February to March 2018, from Herlev and Gentofte municipality 50 51 rehabilitation centres and from Copenhagen University Hospital, Herlev and Gentofte (table 1). 52 53 54 55 56 Insert table 1 here 57 58 59 60
7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 45 BMJ Open
1 2 3 4 HCPs at the two municipalities identified potential participants and scheduled dates and times for BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 the research circle meetings for both the elderly and the HCP participants. 8 9 To create a relaxed and trusting atmosphere, the research circles were conducted at the 10 11 rehabilitation facilities, known to the participants. Prior to the meetings, an email with information 12 13 14 about the overall topic for the meetings, time, place and provision of transportation were sent to the 15 16 participants. 17 18 For peer review only 19 20 21 Data collection 22 23 All research circle meetings were conducted between April and June 2018. Two pilot interviews to 24 25 test the preliminary interview guide were carried out prior to the research circles: one interview 26 27 28 with an experienced HCP and a group interview with five elderly patients who had sustained hip 29 30 fractures and experienced hip fracture rehabilitation. Testing the interview guide, firstly within the 31 32 research team and subsequently with potential study participants28 resulted in a reduced number of 33 34 questions and revision of the interview guide. 35 36
37 http://bmjopen.bmj.com/ 38 39 Insert figure 1 here 40 41 42 43 44 Each meeting of the research circle was prepared and facilitated by the first author (AR) and second
45 on October 1, 2021 by guest. Protected copyright. 46 author (KL) (figure 1). Led by the interview guide, open-ended questions were asked about the 47 48 participants’ needs, wishes and expectations for individualised activity-based rehabilitation for 49 50 51 elderly people with hip fractures. The meetings were conducted every third week with the elderly 52 53 and HCPs separately for the first three meetings and in the last meeting, the elderly participants and 54 55 HCPs met together in order to share their knowledge and ideas gathered from the previous 56 57 meetings. Each meeting lasted for approximately 2 hours. Between the meetings, the participants 58 59 60
8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 45
1 2 3 4 were encouraged to reflect and take notes in a booklet as a resource for discussion at the following BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 meeting. At the end of each meeting, the participants were asked to highlight one idea or statement 8 9 that they thought important to include in further developing the intervention programme. Summary 10 11 notes from each meeting were subsequently presented at the next meeting to sustain the continuity 12 13 14 of innovations across meetings. Further, the participants were asked to verify the summaries and 15 16 thereby be actively involved in the initial analysis. Scenarios concerning rehabilitation of elderly 17 18 people with HF were discussedFor peerand important review points impacting only an individualised rehabilitation 19 20 programme across healthcare sectors were clarified. 21 22 23 24 25 Data analysis 26 27 The analysis procedure included two levels and was performed by two authors (AR and KL). Level 28 29 30 one began after the first meeting of each research circle. The summary of notes taken during the 31 32 meetings formed the basis of an emerging categorisation of data, confirmed by participants at the 33 34 end of every meeting. Level two of the analysis process involved inductive content analysis 35 36 performed at a manifest level in three phases as described by Elo and Kyngäs.29 During level two, 37 http://bmjopen.bmj.com/ 38 39 the last author (AM) joined the analysis process. In the preparation phase, each of the transcripts 40 41 was read thoroughly several times to verify its accuracy. The organising phase included open 42 43 coding, whereby the first and second author independently highlighted key lines of text in the 44
45 on October 1, 2021 by guest. Protected copyright. 46 transcripts related to the topics in the interview guides. Using an iterative style, all marked meaning 47 48 units were then organised and condensed by the two authors using Nvivo 11 Pro.30 The analysis 49 50 moved from lower to higher levels of abstraction, identifying an initial interpretation of patterns, 51 52 53 grouping, and comparing data in subcategories and categories. In the reporting phase, a description 54 55 of the subcategories and categories was then articulated. The authors explored similarities and 56 57 differences in the analysis during meetings, which facilitated the development of categories and 58 59 60
9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 45 BMJ Open
1 2 3 4 31 patterns that best illustrated the needs, expectations and experiences of the participants. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Subcategories emerged and finally the abstraction to generic categories was performed. The process 8 9 is shown in figure 2. 10 11 Theoretical considerations 12 13 14 The Framework for Development and Evaluation of Complex interventions (MRC Framework) 15 16 from the Medical Research Council in the United Kingdom32 33 guided the development of the 17 18 intervention alongside Forthe Template peer for Intervention review Description only and Replication and the 19 20 34 35 21 Consolidated Criteria for Reporting Qualitative Research guidelines. In addition, a transactional 22 23 perspective on occupation36-38 has inspired the development phase from the very beginning, 24 25 highlighting the importance of considering constructs (e.g., person, occupation, and context) as co- 26 27 36 28 constitutive. The relationship between constructs was included in the development of a 29 30 theoretically grounded logic model, including six components: the situation, inputs, outputs, 31 32 outcomes, assumptions and external factors.39-42 The various interacting components of the 33 34 intervention are illustrated in a logic model and used to support intervention planning, 35 36
37 implementation and evaluation of the HIP fracture REhabilitation Programme for the elderly with http://bmjopen.bmj.com/ 38 39 hip fractures (HIP-REP). Furthermore, the HIP-REP programme is based on the Occupational 40 41 Therapy Intervention Process Model (OTIPM), which frames activities to situational elements. The 42 43 44 intervention process is depicted as occurring over three global phases: evaluation and goal setting,
45 on October 1, 2021 by guest. Protected copyright. 46 intervention, and re-evaluation, and each step in the process may be occupation-based, occupation- 47 48 focused, or both.15 43 44 49 50 51 The authors discussed the results and agreed upon identification of important components to be 52 53 included in the rehabilitation programme. Following the development of a draft of the manual for 54 55 the HIP-REP programme, it was assessed and commented on by an impartial rehabilitation expert 56 57 with knowledge of elderly people with HFs and development of complex interventions. 58 59 60
10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 45
1 2 3 4 Furthermore, participants from the research circles all agreed to read and comment on the draft of BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 the manual for the HIP-REP programme to verify the content, and thus verify the relevance and 8 9 expected feasibility of its implementation. 10 11 12 RESULTS 13 14 15 In total 14 participants were included in the research circles: four occupational therapists, three 16 17 physiotherapists and seven elderly people with HF (six females and one male). Table 2 summarises 18 For peer review only 19 the elderly and HCP participant demographic data. 20 21 22 23 24 Insert table 2 here 25 26 27 28 Even though the two groups faced their own unique challenges, the elderly and the HCP 29 30 31 participants shared experiences, needs and ideas for a transitional rehabilitation programme, which 32 33 led to the identification of three core categories: 1) Challenge the elderly with goal-oriented ADLs, 34 35 2) Implement strategies to enhance an independent, safe performance of ADLs, and 3) 36
37 http://bmjopen.bmj.com/ 38 Communicate the information to the target group and across sectors (to elderly people with HF and 39 40 healthcare sectors) (figure 2). 41 42 43 44 Insert figure 2 here
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 Each generic category extracted from the data is summarised and supported with quotes. The 50 51 supporting quotes in Table 3 will indicate which of the research circle meetings the quote was 52 53 54 extracted from, the research circle, group, and number e.g. (RCEHF01). 55 56 57 58 59 60
11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 45 BMJ Open
1 2 3 4 Challenge the elderly with goal-oriented ADLs BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 All participants emphasised the importance of elderly people with HF being challenged to perform 8 9 PADL and IADL tasks in their own accommodation i.e. early independence and safety in walking 10 11 to the bathroom and managing toileting and bathing to gain previous levels of function: 12 13 14 “We want to learn to be ourselves again. As quickly as possible! 15 16 (W4, female participant, RC0402) 17 18 Due to the influence ofFor medication, peer pain, and review lack of sleep and only food during the hospital stay, several 19 20 of the elderly participants with HF lacked confidence in ambulation and ADL abilities. They 21 22 23 expressed concerns about what to expect regarding their physical abilities when discharged to home 24 25 or to rehabilitation centre. At the same time, the elderly expressed the importance of the HCPs and 26 27 other care providers to challenge them in performing ADLs from day one after surgery: 28 29 30 “And it is possible if you start during the 8 days (at the Hospital), before 31 32 going to the Rehabilitation Centre, and you were activated all you were 33 34 able to do, to show what you are capable of…but they forget that the patient has to be 35 36 challenged…they should activate us as much as possible”. (L1, female patient, RCEHF01) 37 http://bmjopen.bmj.com/ 38 39 40 41 They suggested individual ADL tasks (e.g. preparing and eating fresh fruit, washing hands and 42 43 face, brushing teeth by the sink) matching the elderly participant’s capacity and wanted a focus on 44
45 on October 1, 2021 by guest. Protected copyright. 46 personal ADL goals while in the hospital. After discharge from hospital, more complex domestic 47 48 and social ADL tasks was asked for by the elderly. 49 50 51 52 53 Implement strategies to enhance independent and safe performance of ADLs 54 55 All participants emphasised “implement strategies to enhance independent and safe performance of 56 57 ADLs”. The elderly raised the issue of their reliance on mobility devices from day one and in the 58 59 60
12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 45
1 2 3 4 following weeks or even months, as it limited their ability to perform ADL tasks. They emphasised BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 the importance of the timing of introduction and graduation of the use of a walking trolley, walker 8 9 and/or crutches. Strategies and ideas for carrying objects over short distances were discussed, e.g. 10 11 using an apron with pockets or crossbody bag for carrying a mobile phone and/or snacks/beverage: 12 13 14 “…I used a crutch indoors. So, if I want to carry anything I must run back and forth 15 16 17 times you know, because I can only carry one thing at a time right, but then you can 17 18 use an apron toFor put things peer in the front review pocket” (LI, female only patient, RCEHF03). 19 20 Additionally, being presented with small assistive devices, e.g. sock aid, long handled reacher etc. 21 22 23 several times was indicated as necessary both during hospital stay/admission and at follow up in the 24 25 municipality: 26 27 I was able to arrange a visit where they (occupational therapist) brought a 28 29 30 stocking aid, that was great. It was fabulous…she gave me this and 31 32 one, two, three, I could use it myself”. (W4, female patient, RC0402) 33 34 35 36
37 Communicate the important information to the target group and across sectors http://bmjopen.bmj.com/ 38 39 The final category that emerged was the lack of information and communication across healthcare 40 41 sectors. Organisational changes in workflow are not always passed on to healthcare professionals 42 43 44 across sectors, i.e. new procedures regarding instructions in movement restrictions or new
45 on October 1, 2021 by guest. Protected copyright. 46 guidelines regarding rehabilitation services in the municipalities. 47 48 “… we can’t promise the elderly with HF at the hospital anything regarding 49 50 51 the future rehabilitation in the municipality before we are sure of their opportunities”. 52 53 (P02, clinical specialist occupational therapist, RCHCP02) 54 55 56 57 58 59 60
13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 45 BMJ Open
1 2 3 4 Furthermore, the elderly participants with HF sought general knowledge, e.g. a booklet with BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 information about the procedure and contact details for the rehabilitation centre in the municipality. 8 9 This included information about what to expect during and after the operation and rehabilitation 10 11 phases, e.g. information concerning the operation method, normal physical reactions after HF 12 13 14 surgery, restrictions and how these could influence a person’s performance of ADL. 15 16 The importance and dependence of the elderly participants’ social network was clear when 17 18 gathering information andFor planning peer the rehabilitation. review Several only of the elderly with HF emphasised 19 20 that they were dependent on family and friends to support basic ADLs, both at home and at the 21 22 23 rehabilitation centre. 24 25 “I think it is important that the HCP at the hospital pays attention to whether there is 26 27 any network no matter how old you are…”” 28 29 30 (S4, clinical specialist physiotherapist, RC0401) 31 32 The elderly participants with experience in staying at the rehabilitation centre emphasised the 33 34 importance of a home visit prior to discharge, to identify potential barriers and minimise the fear of 35 36 returning home. Furthermore, both the elderly and HCP participants expressed the need for a home 37 http://bmjopen.bmj.com/ 38 39 visit within 1 to 3 working days post discharge directly from the hospital or the rehabilitation centre 40 41 to their home to resolve any issues associated with their new home environment and plan their 42 43 individual rehabilitation by increasing the complexity of ADL tasks. 44
45 on October 1, 2021 by guest. Protected copyright. 46 “A visit to the home provides valuable information about how the elderly person functions 47 48 outside the rehabilitation setting. Maybe the elderly person needs a rail in the bathroom, or 49 50 the carpet needs to be removed or nightlights need to be set up. So, whatever caused the fall, 51 52 53 you go through the environment, removing obstacles so they will feel safer at home” 54 55 (ML1, clinical specialist, occupational therapist, RCHCP01). 56 57 58 59 60
14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 45
1 2 3 4 The development of the HIP-REP programme BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 The qualitative data were used to develop an overarching working theory: ‘The following will lead 8 9 to safer and more independent performance of ADL tasks: (i) challenging elderly people with HF 10 11 with goal-specific ADL tasks through an individually tailored goal-oriented programme that 12 13 14 increased the complexity of ADL tasks in addition to usual rehabilitation, and (ii) increasing the co- 15 16 ordination and information of services between sectors delivering rehabilitation across sectors’. 17 18 For peer review only 19 The HIP-REP programme focuses on individual adaptation of the programme and increases the 20 21 complexity of ADL tasks with the goal to return to a more independent and safer performance of 22 23 ADL tasks. A detailed logic model of the intervention activities presents the structure and content of 24 25 26 the HIP-REP programme with the key element (inputs), ADL intervention (outputs) and proposed 27 28 intervention outcomes guiding the intervention delivery (outcomes). (See online supplementary file 29 30 6, figure 3). 31 32 33 34 35 Programme Structure 36
37 The HIP-REP programme consists of three phases over a total of 8 weeks (table 3) with preliminary http://bmjopen.bmj.com/ 38 39 interviews, baseline tests, five activity-based interventions that each lasting a minimum of 1 hour 40 41 and a maximum of 2 hours (including transport and registration for the HCP), and a follow-up 42 43 44 phone call at 10 weeks post-operatively. Due to the different structures in the municipalities, the
45 on October 1, 2021 by guest. Protected copyright. 46 HIP-REP programme was divided into a ‘two-way track’ after discharge from hospital. Both tracks 47 48 applied four interventions in the municipality undertaken in agreement with the elderly participant. 49 50 51 Track one involved the elderly participant being transferred directly to their own home. Track two 52 53 involved the elderly participant staying at a rehabilitation centre before discharge to their home. In 54 55 both tracks, the intervention was expected to be offered on the scheduled day or week, in 56 57 58 collaboration with the elderly participant as shown in table 3. When discharged from either hospital 59 60
15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 45 BMJ Open
1 2 3 4 or rehabilitation centre, visits to the elderly participant’s own home were designed to be carried out BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 between the first and third working day after returning home. 8 9 10 11 Programme Content 12 13 14 The content of the HIP-REP programme is standardised and guided by a manual (table 3) but 15 16 individually tailored to the elderly, and the intervention thus varies in the content and complexity of 17 18 ADL tasks, based on theFor elderly peer participant’s review priorities, type ofonly hip fracture and surgical fixation. 19 20 45 46 21 The OTIPM guides the HIP-REP programme, with focus on occupational performance for both 22 23 intervention and evaluation as described in the manual (full version in Danish available from 24 25 authors on request). In general, for each intervention, the following elements appear: 1) Interview, 26 27 28 assessment and identification of problems and/or change in the execution of ADL tasks; 2) The 29 30 intervention phase with implementation of customised, purposeful activities for performing ADL 31 32 tasks; 3) The re-assessment phase with an initial interview to identify the elderly participant’s 33 34 meaningful pre-hip fracture activities. Worksheets for the HCP were prepared for each session with 35 36
37 the elderly participant, e.g. the goal-setting and ADL tasks chosen for each intervention. http://bmjopen.bmj.com/ 38 39 40 41 Insert table 3 here 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 DISCUSSION 48 49 The main result of our study was the identification of additional components for the rehabilitation 50 51 52 of elderly people with HF. It revealed tangible strategies to facilitate the transitional rehabilitation 53 54 process across sectors. Three core categories emerged. 55 56 57 58 59 60
16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 45
1 2 3 4 Challenge with goal-oriented ADLs BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 The results showed that challenges must fit the individual’s expectations, wishes and foremost their 8 9 capabilities off performing ADL tasks. A previous study showed that such a fit resulted in better 10 11 outcomes when tailoring the rehabilitation.47 Our findings emphasise the importance of involving 12 13 14 the elderly in the process as soon as possible after their operation, to set relevant goals and promote 15 16 the experience of confidence and active participation in their rehabilitation. Participants provided 17 18 insights into what typeFor of ADLs peer they prioritised review during the first only months after hip fracture, i.e. 19 20 activities performed within their own residence, including social activities. Our findings extend 21 22 23 previous research, recognising that identification of individual goals supports the participants 24 25 regaining independence and facilitates their recovery process.48 In addition, the participants in our 26 27 study showed an interest in facilitating individualised goals by using a booklet to document and 28 29 30 encourage achievement of goals during the different steps of transition between care settings and 31 32 home. 33 34 35 36
37 Implement strategies to enhance independent and safe performance of ADLs http://bmjopen.bmj.com/ 38 39 Our study showed that the elderly often developed their own strategies to enhance independent and 40 41 safe ADL performance. They used work simplification and energy-saving techniques during the 42 43 44 first post-operative weeks including prioritisation of activities due to lack of energy, adaptation of
45 on October 1, 2021 by guest. Protected copyright. 46 their environment, use of assistive devices for mobility, bathing and dressing. Their strategies show 47 48 that relatively simple solutions, such as an apron or a cross-over bag for transport of devices, 49 50 51 enabled them to move safely, independently and perform manageable activities. As previous 52 53 literature reported, the elderly can generate individual strategies to overcome the temporary loss of 54 55 independence and thus manage being at home after discharge. By recognising their challenges, they 56 57 adjusted and/or adapted their expectations e.g. simplifying ADL task complexity, context and 58 59 60
17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 45 BMJ Open
1 2 3 4 49 duration. This highlights that the elderly participants with HF considered a transactional BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 36 39 7 perspective on their use of strategies taking into account constructs such as person, occupation, 8 9 and context as discrete entities that function dependently as co-constitutive. 10 11 12 13 14 Communicate the important information to the target group and across sectors 15 16 There is a trend towards reduction in length of stay at hospital due to a higher rate of early operative 17 18 treatment within the firstFor 24 hours. peer 48 50 This reviewleaves only a few only days to accomplish complex aspects 19 20 21 of rehabilitation during the post-operative phase. In our study, the elderly participants reported the 22 23 rapid transition as daunting. The assessment, advice and strategies regarding ADLs at the hospital 24 25 become a challenge to achieve before discharge e.g. education in hip precautions, introducing and 26 27 28 providing the elderly with small aids during their stay to become more independent. As described 29 30 by Langford et al49, becoming dependent on others for several ADLs causes distress to some elderly 31 32 people, usual routines is disrupted, or as another study reports, a feeling of not being equipped or 33 34 prepared for the transition51. More ADL practice could reduce this distress.49 Our study highlights 35 36
37 the importance of knowing what to expect regarding the rehabilitation and also the need focusing on http://bmjopen.bmj.com/ 38 39 ADLs during the hospital stay, at the rehabilitation centre and at home. This applies especially to 40 41 elderly people with HF living alone, a point that was emphasised both by HCPs and the elderly, as 42 43 44 those people are more vulnerable with even more need for information prior to discharge. Social
45 on October 1, 2021 by guest. Protected copyright. 46 support from family and friends has been reiterated in other studies as important46 48 not only to 47 48 assist with practical arrangements, but also to motivate, encourage and give emotional support. 49 50 51 Providing patients with a ‘recovery map’ including information, forthcoming appointments and 52 53 other resources could be beneficial, suggesting that written patient-centred information enhances 54 55 knowledge and facilitates decision-making and recovery.52 53 In addition, the participants in our 56 57 study suggested including a booklet containing information about the hip fracture operation and 58 59 60
18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 45
1 2 3 4 which symptoms to expect, e.g. pain and discoloration around the site of the operation. This stresses BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 the importance of the HCP’s role in supporting more effective communication, involving and 8 9 informing elderly people with HF and their relatives across professions and settings.53-55 10 11 Participants in our study found the transition from hospital or rehabilitation centre to own home as 12 13 14 critical. They found that home visits prior to and post discharge, to assess and/or modify 15 16 environmental barriers in the home, improved ADL performance and reduced the risk of falling. 17 18 This is consistent with Forresults from peer other studies review involving older only people with functional limitations 19 20 in hospital discharge planning. Furthermore, by including home visits has been shown to result in 21 22 56 57 23 reduced re-admission, risk of falls and improved functional performance. 24 25 Gathering information using a participatory method from multiple perspectives ensures that a 26 27 delivery of a transitional individualised ADL intervention supports a patient-centred approach. 28 29 30 31 32 Methodological considerations 33 34 Our study has some limitations as it only includes two professions in the research circles out of a 35 36
37 broader interdisciplinary team. However, the HCPs were experienced and conscious of this and http://bmjopen.bmj.com/ 38 39 responded from the perspective of the broader team. The use of research circles did not aim for a 40 41 deeper analysis of feelings and emotions, but provided a participatory focus, making it possible to 42 43 44 collaborate with the elderly and HCP participants throughout the research process supporting the
45 on October 1, 2021 by guest. Protected copyright. 46 development and gaining new knowledge together through reflection. 18-20 24 47 48 The study excluded elderly people with severe cognitive impairments or difficulty in 49 50 51 communicating in Danish, which may limit the generalisability of the results and the intervention 52 53 may therefore need to be adapted to other patient groups. 54 55 The credibility and trustworthiness of our findings were enhanced by using peer and member 56 57 checking26, independent coding and experts’ views on the draft of the HIP-REP programme. This 58 59 60
19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 45 BMJ Open
1 2 3 4 was enabled by ensuring that all participants would feel comfortable sharing ideas and information BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 during the meetings in an open supportive environment. To ensure credibility, transparency in the 8 9 analysis phase using steps recommend by Elo et. al (2014) was followed as well as using quotes to 10 11 emphasise the similarities and differences in the categories.29 12 13 14 15 CONCLUSIONS 16 17 Our study highlighted the importance of setting individual goals and challenging the elderly with 18 For peer review only 19 hip fracture by providing guidance in strategies to enhance safe and independent performance of 20 21 activities of daily living. Furthermore, the need for written and oral information for the elderly with 22 23 24 hip fractures and healthcare practitioners about goal-setting during the transitional rehabilitation 25 26 phase was emphasised. Including the perspectives of the elderly participants and healthcare 27 28 practitioners added value to the HIP-REP programme, and thus ensured an adequate, tangible, and 29 30 31 implementable rehabilitation programme. 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 45
1 2 3 4 REFERENCER BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 1. Giannoulis D, Calori G, Giannoudis P. Thirty-day mortality after hip fractures: has anything 8 9 changed? European Journal of Orthopaedic Surgery & Traumatology 2016;26(4):365-70. doi: 10 11 10.1007/s00590-016-1744-4 12 13 14 2. Le Manach Y, Collins G, Bhandari M, et al Outcomes After Hip Fracture Surgery Compared 15 16 With Elective Total Hip Replacement. JAMA, 2015:7. 17 18 3. González-ZabaletaFor J, Pita-Fernandez peer S, Seoane-Pilladoreview T, only et al. Dependence for basic and 19 20 instrumental activities of daily living after hip fractures. Arch Gerontol Geriatr 2015;60(1):66- 21 22 23 70. doi: 10.1016/j.archger.2014.10.020 [published Online First: 2014/11/06] 24 25 4. Alarcón T, González-Montalvo JI, Gotor P, et al. Activities of daily living after hip fracture: 26 27 profile and rate of recovery during 2 years of follow-up. Osteoporos Int 2011;22(5):1609-13. 28 29 30 doi: 10.1007/s00198-010-1314-2 [published Online First: 2010/06/03] 31 32 5. Orive M, Aguirre U, García-Gutiérrez S, et al. Changes in health-related quality of life and 33 34 activities of daily living after hip fracture because of a fall in elderly patients: a prospective 35 36 cohort study. Int J Clin Pract 2015;69(4):491-500. doi: 10.1111/ijcp.12527 [published Online 37 http://bmjopen.bmj.com/ 38 39 First: 2015/02/27] 40 41 6. Sirkka A, Bränholm I. Consequences of a hip fracture in Activity Performance and Life 42 43 Satisfaction in an Elderly Swedish Clientele. 2003; 10(1). 44
45 on October 1, 2021 by guest. Protected copyright. 46 7. Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy 47 48 training in 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand 49 50 2004;75(2):177-83. doi: 10.1080/00016470412331294435 51 52 53 8. Beaupre LA, Binder EF, Cameron ID, et al. Maximising functional recovery following hip 54 55 fracture in frail seniors. Best Pract Res Clin Rheumatol 2013;27(6):771-88. doi: 56 57 10.1016/j.berh.2014.01.001 58 59 60
21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 45 BMJ Open
1 2 3 4 9. Valentiner LS, Steen R. Genoptræningsforløbsbeskrivelse for hoftenært brud. Tværsektoriel BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 genoptræningsforløbsbeskrivelse. Region Hovedstaden: Den Administrative Styregruppe i 8 9 Region Hovedstaden, 2014. 10 11 10. Retsinformation. Lov om ændring af sundhedsloven, lægemiddelloven og lov om kliniske 12 13 14 forsøg med lægemidler Viborg: Civilstyrelsen; 2018 [Available from: 15 16 https://www.retsinformation.dk/Forms/R0710.aspx?id=201512 accessed 08/08 2018. 17 18 11. Ziden L, Frandin K,For Kreuter peer M. Home rehabilitation review after onlyhip fracture. A randomized controlled 19 20 study on balance confidence, physical function and everyday activities. Clin Rehabil 21 22 23 2008;22(12):1019-33. doi: 10.1177/0269215508096183 [published Online First: 2008/12/05] 24 25 12. Crotty M, Killington M, Liu E, et al. Should we provide outreach rehabilitation to very old 26 27 people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial. Age 28 29 30 and Ageing 2019;48(3):373-80. doi: 10.1093/ageing/afz005 31 32 13. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip 33 34 fractures: a prospective, randomised, controlled trial. Lancet 2015;385 North American 35 36 Edition(9978):1623-33. doi: 10.1016/S0140-6736(14)62409-0 37 http://bmjopen.bmj.com/ 38 39 14. Lahtinen A, Leppilahti J, Harmainen S, et al. Geriatric and physically oriented rehabilitation 40 41 improves the ability of independent living and physical rehabilitation reduces mortality: a 42 43 randomised comparison of 538 patients. Clinical rehabilitation 2015;29(9):892‐906. doi: 44
45 on October 1, 2021 by guest. Protected copyright. 46 10.1177/0269215514559423 47 48 15. Fisher AG. Occupation-centred, occupation-based, occupation-focused: Same, same or 49 50 different? Scandinavian Journal of Occupational Therapy 2013;20:162–73. 51 52 53 16. Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability 54 55 concerning ADL and IADL after hip fracture: a randomized trial. Acta orthopaedica 56 57 2006;77(1):114-9. doi: 10.1080/17453670610045786 [published Online First: 2006/03/15] 58 59 60
22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 45
1 2 3 4 17. Martin-Martin LM, Valenza-Demet G, Ariza-Vega P, et al. Effectiveness of an occupational BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 therapy intervention in reducing emotional distress in informal caregivers of hip fracture 8 9 patients: a randomized controlled trial [with consumer summary]. Clinical Rehabilitation 2014 10 11 Feb 17;28(8):772-783 2014 12 13 14 18. Iwarsson S, Edberg A-K, Ivanoff SD, et al. Understanding User Involvement in Research in 15 16 Aging and Health. Gerontology and Geriatric Medicine 2019;5:2333721419897781. doi: 17 18 10.1177/2333721419897781For peer review only 19 20 19. Reed J, Weiner R, Cook G. Partnership research with older people – moving towards making 21 22 23 the rhetoric a reality. Journal of Clinical Nursing 2004;13(s1):3-10. doi: 10.1111/j.1365- 24 25 2702.2004.00920.x 26 27 20. Härnstein G. The Research Circle: Building Knowledge in Equal Terms. 1994. 28 29 30 21. Haak M, Slaug B, Oswald F, et al. Cross-national user priorities for housing provision and 31 32 accessibility-findings from the European innovAge Project. Int J Environ Res Public Health 33 34 2015;12(3):2670-86. doi: 10.3390/ijerph120302670 [published Online First: 2015/03/02] 35 36 22. Högdin S KC. Research Circles: A Method for the development of knowlegde and the creatoin 37 http://bmjopen.bmj.com/ 38 39 of change in practice. Sabar & Educar 2014;19 40 41 23. Östlund B. The revival of research circles: meeting the needs of modern aging and the third age. 42 43 2008; 04(34 (4)). 44
45 on October 1, 2021 by guest. Protected copyright. 46 24. Persson S. Forskningscirklar - en vägledning. Malmö: Malmö stad, 2008. 47 48 25. Borg T. Livsførelse i hverdagen under rehabilitering. Et socialpsykologisk studie. Aalborg 49 50 Universitet, 2002. 51 52 53 26. DePoy. E G, L.N. Introduction to Research - Understanding and Applying Multiple Strategies. 54 55 4th ed. St. Louis (USA): Elsevier Mosby 2011. 56 57 27. Coyne IT. Sampling in qualitative research; merging or clear boundaries? Journal of Advanced 58 59 60
23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 45 BMJ Open
1 2 3 4 Nursing 1997;26(3):7. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 28. Kallio H, Pietila AM, Johnson M, et al. Systematic methodological review: developing a 8 9 framework for a qualitative semi-structured interview guide. J Adv Nurs 2016;72(12):2954-65. 10 11 doi: 10.1111/jan.13031 [published Online First: 2016/05/26] 12 13 14 29. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-15. doi: 15 16 10.1111/j.1365-2648.2007.04569.x 17 18 30. Nvivo 11 Pro for WindowsFor [program].peer 11.4review version: QSR onlyInternational, 2017. 19 20 31. Richards L. Handling Qualitative Data. A Practical Guide. Third ed. Australia: Sage Publication 21 22 23 2014. 24 25 32. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the 26 27 new Medical Research Council guidance. BMJ 2008;337 28 29 30 33. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the 31 32 new Medical Research Council guidance. Int J Nurs Stud 2013;50(5):587-92. doi: 33 34 10.1016/j.ijnurstu.2012.09.010 [published Online First: 2012/11/15] 35 36 34. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for 37 http://bmjopen.bmj.com/ 38 39 intervention description and replication (TIDieR) checklist and guide. BMJ : British Medical 40 41 Journal 2014;348:g1687. doi: 10.1136/bmj.g1687 42 43 35. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): 44
45 on October 1, 2021 by guest. Protected copyright. 46 32-item checklist for interviews and focus groups. Int Journal Qual Helath Care 47 48 2007;19:349-57. 49 50 36. Aldrich RM. From complexity theory to transactionalism: Moving occupational science forward 51 52 53 in theorizing the complexities of behavior. Journal of Occupational Science 2008;15(3):147-56. 54 55 doi: 10.1080/14427591.2008.9686624 56 57 37. Aldrich RM, Cutchin, M. P. Dewey's concepts of embodiment, growth, and occupations: 58 59 60
24 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 45
1 2 3 4 Extended bases for a transactional perspectives. In M. P. Cutchin & V. A. Dickie (Eds.) ed: BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 New York: Springer 2013. 8 9 38. Cutchin MP, Aldrich RM, Bailliard AL, et al. Action theories for occupational science: The 10 11 contributions of Dewey and Bourdieu. Journal of Occupational Science 2008;15(3):157-65. 12 13 14 doi: 10.1080/14427591.2008.9686625 15 16 39. Lee Bunting K. A transactional perspective on occupation: a critical reflection. Scandinavian 17 18 Journal of OccupationalFor Therapy peer 2016;23(5):327-36. review doi: only 10.3109/11038128.2016.1174294 19 20 40. Wight D, Wimbush E, Jepson R, et al. Six steps in quality intervention development (6SQuID). 21 22 23 Journal of epidemiology and community health 2016;70(5):520-5. doi: 10.1136/jech-2015- 24 25 205952 [published Online First: 2015/11/18] 26 27 41. Rogers PJ. Using Programme Theory to Evaluate Complicated and Complex Aspects of 28 29 30 Interventions. Evaluation 2008;14(1):29-48. doi: 10.1177/1356389007084674 31 32 42. Ball L, Ball D, Leveritt M, et al. Using logic models to enhance the methodological quality of 33 34 primary health-care interventions: guidance from an intervention to promote nutrition care by 35 36 general practitioners and practice nurses. Australian Journal of Primary Health 2017;23(1):53- 37 http://bmjopen.bmj.com/ 38 39 60. doi: http://dx.doi.org/10.1071/PY16038 40 41 43. Fisher AG, Marterella, A. Powerful Practice - A Model for Authentic Occupational Therapy. 42 43 Colorado, USA: Center for Innovative OT Solutions, Inc. 2019. 44
45 on October 1, 2021 by guest. Protected copyright. 46 44. Fisher AG, Jones, K B. Occupational Therapy Intervention Process Model. In: Hinojosa J, 47 48 Kramer, P., Royeen C. B., ed. Perspectives on Human Occupation - Theories Underlying 49 50 Practice. Secon edition ed. United States of America: F. A. Davis Company 2017:237-86. 51 52 53 45. Fisher AG. OTIPM. København: Munkgaard 2013. 54 55 46. Taylor NF, Harding KE, Dowling J, et al. Discharge planning for patients receiving 56 57 rehabilitation after hip fracture: A qualitative analysis of physiotherapists' perceptions. 58 59 60
25 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 45 BMJ Open
1 2 3 4 Disability and Rehabilitation 2010;32(6):492-99. doi: 10.3109/09638280903171568 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 47. Young Y RB. Don't worry, Be Positive: Improving functional recovery 1 year after hip fracture. 8 9 Rehabilitation Nursing 2009;34:110-17. 10 11 48. Saul D, Riekenberg J, Ammon JC, et al. Hip Fractures: Therapy, Timing, and Complication 12 13 14 Spectrum. Orthopaedic Surgery 2019;11(6):994-1002. doi: 10.1111/os.12524 15 16 49. Langford D, Edwards N, Gray SM, et al. “Life Goes On.” Everyday Tasks, Coping Self- 17 18 Efficacy, and Independence:For peer Exploring Olderreview Adults’ Recovery only From Hip Fracture. Qualitative 19 20 Health Research 2018;28(8):1255-66. doi: 10.1177/1049732318755675 21 22 23 50. Pablos-Hernández C, González-Ramírez A, da Casa C, et al. Time to Surgery Reduction in Hip 24 25 Fracture Patients on an Integrated Orthogeriatric Unit: A Comparative Study of Three 26 27 Healthcare Models. Orthopaedic Surgery;n/a(n/a) doi: 10.1111/os.12633 28 29 30 51. Tuscan J MB, Santi SM, Stolee P. "Just another fish in the pond": the transitional care 31 32 experience of a hip fracture patient. International journal of integrated care 2013;13(2) 33 34 52. Schiller C, Franke T, Belle J, et al. Words of wisdom - patient perspectives to guide recovery 35 36 for older adults after hip fracture: a qualitative study. Patient preference and adherence 37 http://bmjopen.bmj.com/ 38 39 2015;9:57-64. doi: 10.2147/ppa.S75657 [published Online First: 2015/01/23] 40 41 53. Jensen CM, Smith AC, Overgaard S, et al. “If only had I known”: a qualitative study 42 43 investigating a treatment of patients with a hip fracture with short time stay in hospital. 44
45 on October 1, 2021 by guest. Protected copyright. 46 International Journal of Qualitative Studies on Health and Well-being 2017;12(1):1307061. 47 48 doi: 10.1080/17482631.2017.1307061 49 50 54. Asif M, Cadel L, Kuluski K, et al. Patient and caregiver experiences on care transitions for 51 52 53 adults with a hip fracture: a scoping review. Disability and Rehabilitation 2019:1-10. doi: 54 55 10.1080/09638288.2019.1595181 56 57 55. Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving 58 59 60
26 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 45
1 2 3 4 Transitional Care for Persons with Continuous Complex Care Needs. Journal of the American BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Geriatrics Society 2003;51(4):549-55. doi: 10.1046/j.1532-5415.2003.51185.x 8 9 56. Lockwood KJ, Harding KE, Boyd JN, et al. Predischarge home visits after hip fracture: a 10 11 randomized controlled trial. Clin Rehabil 2019;33(4):681-92. doi: 10.1177/0269215518823256 12 13 14 [published Online First: 2019/01/16] 15 16 57. Stark S, Keglovits M, Arbesman M, et al. Effect of Home Modification Interventions on the 17 18 For peer review only 19 Participation of Community-Dwelling Adults With Health Conditions: A Systematic 20 21 22 Review. The American Journal of Occupational Therapy 2017;71(2):1-11A. doi: 23 24 25 http://dx.doi.org/10.5014/ajot.2017.018887 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
27 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 45 BMJ Open
1 2 3 4 Table 1 Inclusion and exclusion criteria for elderly people with hip fracture BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Inclusion criteria Exclusion criteria 7 8 Aged 55 years or older Not expected to be discharged to home or rehabilitation 9 10 centres in the municipality 11 12 Recent proximal hip fracture (S 72.0 Medial femur Not able to speak and/or understand Danish 13 14 fracture, S 72.1, Pertrochanteric femur fracture, S 72.2, 15 16 Subtrochanteric femur fracture) 17 18 Living at home prior to hipFor fracture inpeer Herlev or reviewSevere physical only and /or mental disabilities prior to the 19 20 Gentofte municipalities hip fracture 21 22 Ability to give informed consent 23 24 Discharged from hospital and receiving or having 25 26 received rehabilitation from the municipalities within the 27 28 last 3 months from onset 29 30 Inclusion criteria in research circles for health care professionals. 31 32 At least 2 years of experience with rehabilitation of elderly with hip fracture in the included municipalities or 33 34 Hospital. 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
28 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 45
1 2 3 4 Table 2 Demographic data of the participants in research circles (n=14) BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Sex Age Living Dwelling Transition 7 situation 8 9 1 Female 93 Living alone 2-family house, Acute care – Inpatient 10 1st floor rehab – Home 11 12 13 14 2 Female 83 Living alone Flat, 2nd floor Acute care – Inpatient 15 rehab – Home care 16 17 18 For peer review only 19 3 Female 71 With others Flat, ground Acute care – Home 20 floor 21 4 Female 78 Living alone Flat Acute care – Home care 22 23 24 5 Male 58 Living alone Flat, 2nd floor Acute care – Home 25 26 6 Female 64 Living alone Flat, 2nd floor Acute care – Home 27 28 29 7 Female 63 With others Flat, 2nd floor Acute care – Home 30 31 32 33 Health care Profession Years of experience 34 Professionals (range) 35 (n=7) 36
37 3 Physiotherapist 10-25 years http://bmjopen.bmj.com/ 38 39 4 Occupational therapist 2-25 years 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
29 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 45 BMJ Open
1 2 3 4
Table 3 HIP-REP programme for elderly people with hip fracture from first post-operative day to Week 12 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 including five activity-focused and/or activity-based interventions: One intervention during hospital stay, and 6 four at the rehabilitation centre and/or at home. Home visits must be carried out in both tracks 1 and 2 7 8 9 10 The Progress at the hospital 11 12 Day Post Session Intervention Activities Operative 13 Day 1 1st Inform and identify Welcome to the ward 14 Day 1-2 15 2nd Inform and identify Initial interview Interview – prioritize two ADL-tasks for AMPS 16 Day 3 3rd Inform and identify Observation: AMPS, as well as clarifying and interpreting 17 Objectives, planning and implementation cause and discussing objectives 18 For peer reviewGeneric hand-out”only Operation for hip fractures” Day 3-4 4th 1st ADL intervention PADL and IADL tasks at the ward prioritized by the elderly 19 Inform and identify, goalsetting, plan, engage 20 and assess results 21 Day 4-5 5th Evaluate and end course Clarify and order assistive devices 22 The Progress in the municipality 23 24 Track 1 Track 2 Discharge from Hospital to in-patient Direct discharge from hospital to own dwelling 25 Rehabilitation Centre to own dwelling 26 Week post- Session Intervention Activities Intervention Activities 27 operative 28 Week 2 6th 2nd ADL Welcome/ Initial 2nd ADL intervention at The accessibility of the intervention conversation home housing is reviewed 29 Inform and identify, PADL and IADL tasks Weekday 1-3 after Review of ADL tasks in 30 goalsetting, plan, as the elderly has discharge own residence 31 engage and assess prioritized Inform and identify, results goalsetting, plan, engage and 32 assess results 33 Week 3 7th 3rd ADL PADL and IADL tasks 3rd ADL intervention at PADL and IADL tasks as 34 intervention at home as the elderly participant home the elderly participant has if possible. has prioritized Inform and identify, prioritized 35 Inform and identify, goalsetting, plan, engage and 36 goalsetting, plan, assess results
37 engage and assess http://bmjopen.bmj.com/ 38 results Week 5 8th 4th ADL The accessibility of the 4th ADL intervention at PADL and IADL tasks as 39 intervention housing is reviewed home the elderly participant has 40 Home visit in Review of ADL tasks in Inform and identify, prioritized 41 connection with own residence goalsetting, plan, engage and discharge from in- assess results 42 patient 43 Rehabilitation 44 Centre Inform and identify, 45 goalsetting, plan, on October 1, 2021 by guest. Protected copyright. 46 engage and assess 47 results Week 8 9th 5th ADL PADL and IADL tasks 5th ADL intervention at PADL and IADL tasks as 48 intervention as the elderly participant home the elderly participant has 49 In own residence has prioritized Inform and identify, prioritized 50 Inform and identify, goalsetting, plan, engage, 51 goalsetting, plan, End course and evaluate assess results, and end course End course and evaluate engage, assess 52 results, and end 53 course 54 Week 10 Phone- Assess results and Phone the elderly Assess results and evaluate Phone the elderly call evaluate participant and follow-up participant and follow-up 55 on the HIP-REP on the HIP-REP 56 intervention intervention 57 Week 12 10th Evaluate Evaluate Evaluate Evaluate 58 59 60
30 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 45
1 2 3 4 Figure legends BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Figure 1 Research circle process with overall topics discussed. 7 8 Figure 2 Analysis process: abstraction of subcategory to generic category 9 10 Figure 3 Logic model of the HIP-REP intervention, and steps used to develop the HIP-REP manual 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
31 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 45 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 Research circle process with overall topics discussed 46 47 209x297mm (300 x 300 DPI) 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 45 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 Figure 2 Analysis process: abstraction of subcategory to generic category 30 31 297x209mm (300 x 300 DPI) 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 35 of 45 BMJ Open
1 2 3 4 5 6 7 8 9 10 11 12 For peer review only 13 14 15 16 17 http://bmjopen.bmj.com/ 18 19 20 21 22 23 24 25 on October 1, 2021 by guest. Protected copyright. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open Page 36 of 45
International Journal for Quality in Health Care; Volume 19, Number 6: pp. 349–357 10.1093/intqhc/mzm042
Advance Access Publication: 14 September 2007 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 Consolidated criteria for reporting 4 5 qualitative research (COREQ): a 32-item 6 7 8 checklist for interviews and focus groups 9 1,2 1,3 1,2 10 ALLISON TONG , PETER SAINSBURY AND JONATHAN CRAIG Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 11 1School of Public Health, University of Sydney, NSW 2006, Australia, 2Centre for Kidney Research, The Children’s Hospital at Westmead, 12 3 NSW 2145, Australia, and Population Health, Sydney South West Area Health Service, NSW 2170, Australia 13 14 Abstract 15 16 Background. Qualitative researchFor explores peer complex phenomena review encountered by only clinicians, health care providers, policy 17 makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of 18 qualitative design. 19 Objective. 20 To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups). 21 22 Methods. We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews 23 of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for 24 existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive 25 list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and 26 reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. 27 Results. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data 28 collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of 29 supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data 30 analysis and reporting. 31 Conclusions. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the 32 research team, study methods, context of the study, findings, analysis and interpretations. 33 http://bmjopen.bmj.com/ 34 Keywords: focus groups, interviews, qualitative research, research design 35 36 37 Qualitative research explores complex phenomena encountered randomized controlled trials [5]. Systematic reviews of qualitat- 38 by clinicians, health care providers, policy makers and consu- ive research almost always show that key aspects of study 39 mers in health care. Poorly designed studies and inadequate design are not reported, and so there is a clear need for a 40 reporting can lead to inappropriate application of qualitative CONSORT-equivalent for qualitative research [6].
41 research in decision-making, health care, health policy and The Uniform Requirements for Manuscripts Submitted to on October 1, 2021 by guest. Protected copyright. 42 future research. Biomedical Journals published by the International Committee Formal reporting guidelines have been developed for ran- of Medical Journal Editors (ICMJE) do not provide reporting 43 domized controlled trials (CONSORT) [1], diagnostic test guidelines for qualitative studies. Of all the mainstream biome- 44 studies (STARD), meta-analysis of RCTs (QUOROM) [2], dical journals (Fig. 1), only the British Medical Journal (BMJ) 45 observational studies (STROBE) [3] and meta-analyses of has criteria for reviewing qualitative research. However, the 46 observational studies (MOOSE) [4]. These aim to improve guidelines for authors specifically record that the checklist is 47 the quality of reporting these study types and allow readers to not routinely used. In addition, the checklist is not compre- 48 better understand the design, conduct, analysis and findings of hensive and does not provide specific guidance to assess some 49 published studies. This process allows users of published of the criteria. Although checklists for critical appraisal are 50 research to be more fuller informed when they critically available for qualitative research, there is no widely endorsed 51 appraise studies relevant to each checklist and decide upon reporting framework for any type of qualitative research [7]. 52 applicability of research findings to their local settings. Empiric We have developed a formal reporting checklist for 53 studies have shown that the use of the CONSORT statement in-depth interviews and focus groups, the most common 54 is associated with improvements in the quality of reports of methods for data collection in qualitative health research. 55 Address reprint requests to: Allison Tong, Centre for Kidney Research, The Children’s Hospital at Westmead, NSW 2145, 56 Australia. Tel: þ61-2-9845-1482; Fax: þ61-2-9845-1491; E-mail: [email protected], [email protected] 57 58 59 International Journal for Quality in Health Care vol. 19 no. 6 # 60 The Author 2007. Published byFor Oxford peer University review Pressonly on- http://bmjopen.bmj.com/site/about/guidelines.xhtml behalf of International Society for Quality in Health Care; all rights reserved 349 Page 37 of 45 BMJ Open
A. Tong et al. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 4 5 6 7 8 9
10 Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 Figure 1 Development of the COREQ Checklist. *References [26, 27], †References [6, 28–32], ‡Author and reviewer 50 guidelines provided by BMJ, JAMA, Lancet, Annals of Internal Medicine, NEJM. 51 52 These two methods are particularly useful for eliciting Basic definitions 53 patient and consumer priorities and needs to improve the quality of health care [8]. The checklist aims to promote 54 Qualitative studies use non-quantitative methods to contrib- complete and transparent reporting among researchers and 55 ute new knowledge and to provide new perspectives in indirectly improve the rigor, comprehensiveness and credi- 56 health care. Although qualitative research encompasses a bility of interview and focus-group studies. broad range of study methods, most qualitative research 57 58 59 60 350 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 45
Consolidated criteria for reporting qualitative research BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 publications in health care describe the use of interviews and validation of findings, method of recording data, description 3 focus groups [8]. of the derivation of themes and inclusion of supporting 4 quotations. We grouped all items into three domains: (i) 5 research team and reflexivity, (ii) study design and (iii) data Interviews 6 analysis and reporting. (see Tables 2–4) 7 In-depth and semi-structured interviews explore the experi- Within each domain we simplified all relevant items by 8 ences of participants and the meanings they attribute to removing duplicates and those that were ambiguous, too 9 them. Researchers encourage participants to talk about issues broadly defined, not specific to qualitative research, or pertinent to the research question by asking open-ended impractical to assess. Where necessary, the remaining items 10 Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 were rephrased for clarity. Based upon consensus among the 11 questions, usually in one-to-one interviews. The interviewer authors, two new items that were considered relevant for 12 might re-word, re-order or clarify the questions to further reporting qualitative research were added. The two new items 13 investigate topics introduced by the respondent. In qualitative health research, in-depth interviews are often used to study were identifying the authors who conducted the interview or 14 the experiences and meanings of disease, and to explore per- focus group and reporting the presence of non-participants 15 sonal and sensitive themes. They can also help to identify during the interview or focus group. The COREQ checklist 16 potentially modifiable factors forFor improving healthpeer care [9]. reviewfor explicit and comprehensiveonly reporting of qualitative 17 studies consists of 32 criteria, with a descriptor to sup- 18 plement each item (Table 1). 19 Focus groups 20 Focus groups are semi-structured discussions with groups of 21 4–12 people that aim to explore a specific set of issues [10]. COREQ: content and rationale 22 Moderators often commence the focus group by asking (see Tables 1) 23 broad questions about the topic of interest, before asking the 24 focal questions. Although participants individually answer the Domain 1: research team and reflexivity 25 facilitator’s questions, they are encouraged to talk and interact 26 with each other [11]. This technique is built on the notion (i) Personal characteristics: Qualitative researchers closely 27 that the group interaction encourages respondents to explore engage with the research process and participants and are 28 and clarify individual and shared perspectives [12]. Focus therefore unable to completely avoid personal bias. Instead 29 groups are used to explore views on health issues, programs, researchers should recognize and clarify for readers their 30 interventions and research. identity, credentials, occupation, gender, experience and train- ing. Subsequently this improves the credibility of the findings 31 by giving readers the ability to assess how these factors 32 might have influenced the researchers’ observations and 33 Methods http://bmjopen.bmj.com/ interpretations [13–15]. 34 (ii) Relationship with participants: The relationship and Development of a checklist 35 extent of interaction between the researcher and their partici- 36 Search strategy. We performed a comprehensive search for pants should be described as it can have an effect on the 37 published checklists used to assess or review qualitative participants’ responses and also on the researchers’ under- 38 studies, and guidelines for reporting qualitative studies in: standing of the phenomena [16]. For example, a clinician– 39 Medline (1966—Week 1 April 2006), CINAHL (1982— researcher may have a deep understanding of patients’ issues 40 Week 3 April 2006), Cochrane and Campbell protocols, but their involvement in patient care may inhibit frank dis- 41 systematic reviews of qualitative studies, author or reviewer cussion with patient–participants when patients believe that on October 1, 2021 by guest. Protected copyright. 42 guidelines of major medical journals and reference lists of their responses will affect their treatment. For transparency, 43 relevant publications. We identified the terms used to index the investigator should identify and state their assumptions 44 the relevant articles already in our possession and performed and personal interests in the research topic. 45 a broad search using those search terms. The electronic 46 databases were searched using terms and text words for Domain 2: study design 47 research (standards), health services research (standards) and 48 qualitative studies (evaluation). Duplicate checklists and (i) Theoretical framework: Researchers should clarify the 49 detailed instructions for conducting and analysing qualitative theoretical frameworks underpinning their study so readers 50 studies were excluded. can understand how the researchers explored their research 51 Data extraction. From each of the included publications, we questions and aims. Theoretical frameworks in qualitative 52 extracted all criteria for assessing or reporting qualitative research include: grounded theory, to build theories from the 53 studies. Seventy-six items from 22 checklists were compiled data; ethnography, to understand the culture of groups with 54 into a comprehensive list. We recorded the frequency of each shared characteristics; phenomenology, to describe the 55 item across all the publications. Items most frequently meaning and significance of experiences; discourse analysis, 56 included in the checklists related to sampling method, setting to analyse linguistic expression; and content analysis, to sys- for data collection, method of data collection, respondent tematically organize data into a structured format [10]. 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 351 Page 39 of 45 BMJ Open
A. Tong et al. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 Table 1 Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist 3 4 No Item Guide questions/description 5 ...... 6 Domain 1: Research team and reflexivity 7 Personal Characteristics 8 1. Interviewer/facilitator Which author/s conducted the interview or focus group? 9 2. Credentials What were the researcher’s credentials? E.g. PhD, MD
10 3. Occupation What was their occupation at the time of the study? Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 11 4. Gender Was the researcher male or female? 12 5. Experience and training What experience or training did the researcher have? 13 Relationship with participants 14 6. Relationship established Was a relationship established prior to study commencement? 7. Participant knowledge of the What did the participants know about the researcher? e.g. personal goals, reasons for doing the 15 interviewer research 16 8. Interviewer characteristicsFor peer What characteristics review were reported aboutonly the interviewer/facilitator? e.g. Bias, assumptions, 17 reasons and interests in the research topic 18 Domain 2: study design 19 Theoretical framework 20 9. Methodological orientation and What methodological orientation was stated to underpin the study? e.g. grounded theory, 21 Theory discourse analysis, ethnography, phenomenology, content analysis 22 Participant selection 23 10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball 24 11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email 25 12. Sample size How many participants were in the study? 26 13. Non-participation How many people refused to participate or dropped out? Reasons? 27 Setting 28 14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace 29 15. Presence of non-participants Was anyone else present besides the participants and researchers? 30 16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date 31 Data collection 32 17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?
33 18. Repeat interviews Were repeat interviews carried out? If yes, how many? http://bmjopen.bmj.com/ 34 19. Audio/visual recording Did the research use audio or visual recording to collect the data? 35 20. Field notes Were field notes made during and/or after the interview or focus group? 36 21. Duration What was the duration of the interviews or focus group? 37 22. Data saturation Was data saturation discussed? 23. Transcripts returned Were transcripts returned to participants for comment and/or correction? 38 Domain 3: analysis and findingsz 39 Data analysis 40 24. Number of data coders How many data coders coded the data? on October 1, 2021 by guest. Protected copyright. 41 25. Description of the coding tree Did authors provide a description of the coding tree? 42 26. Derivation of themes Were themes identified in advance or derived from the data? 43 27. Software What software, if applicable, was used to manage the data? 44 28. Participant checking Did participants provide feedback on the findings? 45 Reporting 46 29. Quotations presented Were participant quotations presented to illustrate the themes / findings? Was each 47 quotation identified? e.g. participant number 48 30. Data and findings consistent Was there consistency between the data presented and the findings? 49 31. Clarity of major themes Were major themes clearly presented in the findings? 50 32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes? 51 52 53 (ii) Participant selection: Researchers should report how [13, 17]. Convenience sampling is less optimal because it 54 participants were selected. Usually purposive sampling is may fail to capture important perspectives from difficult- 55 used which involves selecting participants who share particu- to-reach people [16]. Rigorous attempts to recruit participants 56 lar characteristics and have the potential to provide rich, rele- and reasons for non-participation should be stated to reduce vant and diverse data pertinent to the research question the likelihood of making unsupported statements [18]. 57 58 59 60 352 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 Consolidated criteria for reporting qualitative research BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from Page 40 of 45 † † † , item included in the checklist. † † † † †† † † † † BMJ Open [13] [15] [14] [17] [33] [34] [35] [16] [19] [36] [7] [37] [23] [38] [39] [22] BMJ b http://bmjopen.bmj.com/ [32] b [28] b †† [6] a †††††††† ††† † ††††† † ††† ††† †††† ††† †† †† † † ††† †† †† [27] a on October 1, 2021 by guest. Protected copyright. † †† † † ††† ††† † † References [26] ...... For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml facilitator / Systematic review of qualitative studies; BMJ, British Medical Journal—editor’s checklist for appraising qualitative research); b Items included in 22 published checklists: Research team and reflexivity domain Other publications, Table 2 Item a ...... Distance between researcher and participants Background Familiarity with setting Too close to participants Empathy Research team and reflexivity Nature of relationship between the researcher and participants Examination of role, bias, influenceDescription of role Identity of the interviewer Continued and prolonged engagement Response to events Prior assumptions and experience Professional status Journal, record of personalEffects experience of research onQualifications researcher Training of the interviewer Perception of research at inception Age Gender Social class Reasons for conducting study Sufficient contact Expertise demonstrated
353 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 A. Tong et al. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from † , item included in the checklist. † † [13] [15] [14] [17] [33] [34] [35] [16] [19] [36] [7] [37] [23] [38] [39] [22] BMJ b BMJ Open [32] b http://bmjopen.bmj.com/ †† † † [28] b †† †† ††† †† † † † † † † [6] a † ††††††††††† †††† † †††††††† † † † † ††† † †† †††† †† † † † [27] a † ††††† † ††††††††† † † † †††† † ††† †† †† † † ††††† †† † †††† ††††††† †††† † † †† † ††† † † † † † † †† † † † †† †† † †† † † †† † † References [26] ...... on October 1, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Systematic review of qualitative studies; BMJ, British Medical Journal—editor’s checklist for appraising qualitative research; b Items included in 22 published checklists: Study design Other publications, Table 3 Item a ...... Study design Methodological orientation, ontological or epistemological basis Sampling—convenience, purposive Setting Characteristics and description ofReasons sample for participant selection Non-participation Inclusion and exclusion, criteria Identity of the personSample responsible size for recruitment Method of approach Description of explanation ofLevel research and to type participants ofMethod participation of data collection,in-depth e.g. focus interview group, Audio and visual recording Transcripts Setting and location Saturation of data Use of a topicField guide, notes tools, questions Changes and modifications Duration of interview, focus group Sensitive to participant languageNumber and of views interviews, focusTime groups span Time and resources available to the study
354 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 41 of 45 Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 Consolidated criteria for reporting qualitative research BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from Page 42 of 45 ...... , item included in the checklist. † † † †† †† † † † [13] [15] [14] [17] [33] [34] [35] [16] [19] [36] [7] [37] [23] [38] [39] [22] BMJ BMJ Open b [32] http://bmjopen.bmj.com/ b [28] b [6] a ††† † †† ††††††††† † † †† ††† † †††††† †††† †††† † †† †† †† †† †† [27] a †††† †† † ††††††††††† † † † † †††††† † † † †††††† ††††††††† †† ††† ††††††† † † †† †† †† † ††† † †††† † † † † † † †† † † † † †† †† References [26] ...... on October 1, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml perceptions / Systematic review of qualitative studies; BMJ, British Medical Journal—editor’s checklist for appraising qualitative research, b Items included in 22 published checklists: Analysis and reporting Other publications, Table 4 Item a Respondent validation Limitations and generalizability Triangulation Original data, quotation Derivation of themes explicit Contradictory, diverse, negative cases Number of data analysts In-depth description of analysis Sufficient supporting data presented Data, interpretation and conclusions linked and integrated Retain context of data Explicit findings, presented clearly Outside checks Software used Range of views of participants Discussion both for andresearchers’ against arguments the Development of theories, explanations Numerical data Coding tree or coding system Inter-observer reliability Sufficient insight into meaning Reasons for selection ofNew data insight to support findings Results interpreted in credible, innovative way Eliminate other theories Distinguish between researcher and participant voices Proportion of data taken into account ......
355 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 43 of 45 BMJ Open
A. Tong et al. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 Researchers should report the sample size of their study to participants to add transparency and trustworthiness to their 3 enable readers to assess the diversity of perspectives included. findings and interpretations of the data [17]. Readers should 4 (iii) Setting: Researchers should describe the context in be able to assess the consistency between the data presented 5 which the data were collected because it illuminates why par- and the study findings, including the both major and minor 6 ticipants responded in a particular way. For instance, partici- themes. Summary findings, interpretations and theories gen- 7 pants might be more reserved and feel disempowered talking erated should be clearly presented in qualitative research 8 in a hospital setting. The presence of non-participants during publications. 9 interviews or focus groups should be reported as this can also affect the opinions expressed by participants. For 10 Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 example, parent interviewees might be reluctant to talk on 11 sensitive topics if their children are present. Participant Discussion 12 characteristics, such as basic demographic data, should be 13 reported so readers can consider the relevance of the find- The COREQ checklist was developed to promote explicit 14 ings and interpretations to their own situation. This also and comprehensive reporting of qualitative studies (inter- 15 allows readers to assess whether perspectives from different views and focus groups). The checklist consists of items 16 groups were exploredFor and compared, peer such as patientsreview and specific toonly reporting qualitative studies and precludes generic 17 health care providers [13, 19]. criteria that are applicable to all types of research reports. COREQ is a comprehensive checklist that covers necessary 18 (iv) Data collection: The questions and prompts used in 19 data collection should be provided to enhance the readers’ components of study design, which should be reported. The 20 understanding of the researcher’s focus and to give readers the criteria included in the checklist can help researchers to 21 ability to assess whether participants were encouraged to report important aspects of the research team, study 22 openly convey their viewpoints. Researchers should also report methods, context of the study, findings, analysis and 23 whether repeat interviews were conducted as this can influence interpretations. At present, we acknowledge there is no empiric basis that 24 the rapport developed between the researcher and participants shows that the introduction of COREQ will improve the 25 and affect the richness of data obtained. The method of quality of reporting of qualitative research. However this is 26 recording the participants’ words should be reported. no different than when CONSORT, QUOROM and other 27 Generally, audio recording and transcription more accurately reflect the participants’ views than contemporaneous reporting checklists were introduced. Subsequent research 28 has shown that these checklists have improved the quality of 29 researcher notes, more so if participants checked their own transcript for accuracy [19–21]. Reasons for not audio record- reporting of study types relevant to each checklist [5, 25], 30 and we believe that the effect of COREQ is likely to be 31 ing should be provided. In addition, field notes maintain con- textual details and non-verbal expressions for data analysis and similar. Despite differences in the objectives and methods of 32 quantitative and qualitative methods, the underlying aim of 33 interpretation [19, 22]. Duration of the interview or focus http://bmjopen.bmj.com/ group should be reported as this affects the amount of data transparency in research methods and, at the least, the theor- 34 obtained. Researchers should also clarify whether participants etical possibility of the reader being able to duplicate the 35 were recruited until no new relevant knowledge was being study methods should be the aims of both methodological 36 approaches. There is a perception among research funding obtained from new participants (data saturation) [23, 24]. 37 agencies, clinicians and policy makers, that qualitative 38 research is ‘second class’ research. Initiatives like COREQ 39 Domain 3: analysis and findings are designed to encourage improvement in the quality of 40 (i) Data analysis: Specifying the use of multiple coders or reporting of qualitative studies, which will indirectly lead to 41 other methods of researcher triangulation can indicate a improved conduct, and greater recognition of qualitative on October 1, 2021 by guest. Protected copyright. 42 broader and more complex understanding of the pheno- research as inherently equal scientific endeavor compared with quantitative research that is used to assess the quality 43 menon. The credibility of the findings can be assessed if the 44 process of coding (selecting significant sections from partici- and safety of health care. We invite readers to comment on 45 pant statements), and the derivation and identification of COREQ to improve the checklist. 46 themes are made explicit. Descriptions of coding and 47 memoing demonstrate how the researchers perceived, exam- 48 ined and developed their understanding of the data [17, 19]. 49 Researchers sometimes use software packages to assist with References 50 storage, searching and coding of qualitative data. In addition, 51 obtaining feedback from participants on the research findings 1. Moher D, Schulz KF, Altman D. The CONSORT statement: 52 adds validity to the researcher’s interpretations by ensuring revised recommendations for improving the quality of reports 53 that the participants’ own meanings and perspectives are of parallel-group randomized trials. JAMA 2001;285:1987–91. 54 represented and not curtailed by the researchers’ own agenda 2. Moher D, Cook DJ, Eastwood S et al. Improving the quality of 55 and knowledge [23]. reports of meta-analyses of randomised controlled trials: the 56 (ii) Reporting: If supporting quotations are provided, QUOROM statement. Quality of Reporting of Meta-analyses. researchers should include quotations from different Lancet 1999;354:1896–900. 57 58 59 60 356 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 45
Consolidated criteria for reporting qualitative research BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3. STROBE Statement: Strengthening the reporting of observa- 23. Popay J, Rogers A, Williams G. Rationale and standards for the 3 tional studies in epidemiology. http://www.strobe-statement. systematic review of qualitative literature in health services 4 org/Checkliste.html research. Qual Health Res 1998;8:341–51. 5 4. Stroup DF, Berlin JA, Morton SC et al. Meta-analysis of obser- 24. Blumer H. Critiques of Research, in the Social Sciences. 6 vational studies in epidemiology: a proposal for reporting. New Brunswick, NJ: Transaction Books, 1979. Meta-analysis Of Observational Studies in Epidemiology 7 25. Delaney A, Bagshaw SM, Ferland A et al. A systematic evalu- (MOOSE) group. JAMA 2000;283:2008–12. 8 ation of the quality of meta-anlyses in the critical care literature. 9 5. Moher D, Jones A, Lepage L. Use of the CONSORT Crit Care 2005;9:575–82.
Statement and quality of reports of randomized trials. A com- Downloaded from https://academic.oup.com/intqhc/article/19/6/349/1791966 by Det Kongelige Bibliotek user on 03 September 2020 10 26. Critical Skills Appraisal Programme (CASP) 10 Questions to parative before-and-after evaluation. JAMA 2001;285:1992–5. 11 help you make sense of qualitative research: Milton Keynes 12 6. Mills E, Jadad AR, Ross C et al. Systematic review of qualitative Primary Care Trust, 2002. studies exploring parental beliefs and attitudes toward child- 13 27. Spencer L, Ritchie J, Lewis J et al. Quality in Qualitative Evaluation: hood vaccination identified common barriers to vaccination. 14 A Framework for Assessing Research Evidence. London: Cabinet J Clin Epidemiol 2005;58:1081–8. 15 Office. Government Chief Social Researcher’s Office, 2003. 16 7. Knafl KA, Howard NJ. Interpreting and reporting qualitative For peer review28. Campbell R, Pound only P, Pope C et al.Evaluatingmeta-ethnography: research. Res Nurs Health 1984;7:7–14. 17 a synthesis of qualitative research on lay experience of diabetes 18 8. Sofaer S. Qualitative research methods. Int J Qual Health Care and diabetes care. Soc Sci Med 2003;56:671–84. 19 2002;14:329–36. 29. Feder GS, Hutson M, Ramsay I et al. Women exposed to inti- 20 9. Wright EB, Holcombe C, Salmon P. Doctor’s communication mate partner violence: expectations and experiences when they 21 of trust, care, and respect in breast cancer: qualitative study. encounter health care professionals: a meta-analysis of qualita- 22 BMJ 2004;328:864–8. tive studies. Arch Intern Med 2006;166:22–37. 23 10. Liamputtong P, Ezzy D. Qualitative Research Methods. 2nd edn. 30. Pound P, Britten N, Morgan M et al. Resisting medicines: a syn- 24 Melbourne, Victoria: Oxford University Press, 2005. thesis of qualitative studies of medicine taking. Soc Sci Med 25 2005;61:133–55. 26 11. Krueger RA, Casey MA. Focus Groups. A Practical Guide for Applied Research. Thousand Oaks CA: Sage Publications, 2000. 31. Smith LK, Pope C, Botha JL. Patients’ help-seeking experiences 27 and delay in cancer presentation: a qualitative synthesis. Lancet 12. Morgan DL. Focus Groups as Qualitative Research. Newbury Park, 28 2005;366:825–31. 29 California: Sage, 1988. 32. Walter FM, Emery J, Braithwaite D et al. Lay understanding of 30 13. Giacomini MK, Cook DJ. Users’ guides to the medical litera- familial risk of common chronic diseases: a systematic review ture XXIII. Qualitative research in health care. A. Are the 31 and synthesis of qualitative research. Ann Fam Med 2004; results of the study valid? JAMA 2000;284:357–62. 32 2:583–94. 33 14. Malterud K. Qualitative research:standards challenges guide- http://bmjopen.bmj.com/ 33. Inui TS, Frankel RM. Evaluating the quality of qualitative 34 lines. Lancet 2001;358:483–8. research: a proposal pro-term. J Gen Intern Med 1991;6:485–6. 35 15. Mays N, Pope C. Qualitative research in health care: assessing 34. Boulton M, Fitzpatrick R, Swinburn C. Qualitative research in 36 quality in qualitative research. BMJ 2000;320:50–2. 37 health care: II A structured review and evaluation of studies. J Eval Clin Pract 1996;2:171–9. 38 16. Elder NC, William L. Reading and evaluating qualitative research studies. J Fam Pract 1995;41:279–85. 39 35. Dixon-Woods M, Shaw RL, Agarwal S et al. The problem of 40 17. Cote L, Turgeon J. Appraising qualitative research articles in appraising qualitative research. Qual Saf Health Care
41 medicine and medical education. Med Teach 2005;27:71–5. 2004;13:223–5. on October 1, 2021 by guest. Protected copyright. 42 18. Altheide D, Johnson J. Criteria for assessing interpretive validity 36. Hoddinott P, Pill R. A review of recently published qualitative 43 in qualitative research. In Denzin N, Lincoln Y (eds). Handbook research in general practice. More methodological questions 44 of Qualitative Research. Thousand Oaks CA: Sage Publications, than answers? Fam Pract 1997;14:313–9. 1994. 45 37. Kuzel AJ, Engel JD, Addison RB et al. Desirable features of 46 19. Fossey E, Harvey C, McDermott F et al. Understanding and eval- qualitative research. Fam Pract Res J 1994;14:369–78. uating qualitative research. Aust N Z J Psychiatry 2002;36:717–32. 47 38. Treloar C, Champness S, Simpson PL et al. Critical appraisal 48 20. Seale C, Silverman S. Ensuring rigour in qualitative research. checklist for qualitative research studies. Indian J Pediatr 49 Eur J Public Health 1997;7:379–84. 2000;67:347–51. 50 21. Scheff T. Single case analysis in the health sciences. Eur J Public 39. Cesario S, Morin K, Santa-Donato A. Evaluating the level of 51 Health 1995;5:72–4. evidence in qualitative research. J Obstet Gynecol Neonatal Nurs 52 2001;31:708–14. 53 22. Bluff R. Evaluating qualitative research. Br J Midwifery 1997;5:232–5. Accepted for publication 7 July 2007 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 357 _
) ______BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from (details
† ______
ated ** Other ______c c *:
r Where lo
information ______ary pape ) Checklist e or appendix ber) e ______m ______Pri (pag num
rnet or rnet ention, Replication
location of th g those g those eir s. v e r y n h e d
nt), describe t nt), describe ention. ention, includi any necessar cription an cription sed in the inter sed in the ention and th sm, such as int such sm, pendix, URL). a group. a group. vention provide v v v v a i g i g s s u v u r v r p p BMJ Open other mechan . a (e.g. online dividually or in /or processes /or processes sed in the inter , nursing assist rvention De ntial to the inter training of inte curred, includin ribing an inter t t e n d e n d d n d n u u e e c c e e c c http://bmjopen.bmj.com/ n delivery or in an be accesse an the interventio the ess elements face or by som .g. psychologis de when des s, activities, an s, activities, o intervention ing given. was provided i plate for Int plate ional materials - o - o c c t t s s e e e e e e e e u u n n For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only on October 1, 2021 by guest. Protected copyright. the materials tion provider ( port activities. and whether i f the procedur ry (e.g. face-to ed in interventi ical or informat y, or goal of th ny specific trai e that describe mation to incl TIDieR (TemTIDieR tures. tures. r th ion(s) where e n p n s o e s r s a The Info gory of interve ame or a phra phy scribe any the interventio or relevant fea rationale, theo enabling or su articipants or u articipants ckground and ckground and Describe each Describe each mation on wher modes of deliv type(s) of locat e f E IDED e f n y e y n y e y r e r e p p a a
Item BRIEF NAM Provide the WHY Describe an WHAT Materials: D provided to Provide info Procedures: including an WHO PROV For each cat expertise, b HOW Describe the telephone) o WHERE Describe the infrastructur
hecklist r r c c
Item numbe 1. 2. 3. 4. 5. 6. 7. TIDieR Page 45 of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
of Page 46 of 45
the
2013 item.
BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from features
reported, each Statement.
SPIRIT (see
for the being 2010
is of
design
11
trial methodological study elaboration
CONSORT Item
and
of
that and
the
of for
5 randomised
the study is complete. elements a
extension e locations such as a published protocol e locations such Item ______
______
explanation an checklist of
Other
When
as an
study.
a extension checklist.
contains of
appropriate
statement an
if information about the element is not reported/not if information about the element is not the as ?’
) TIDieR which
SPIRIT
with
the elements)
the of
is available. This may includ with part ol and cannot be described until
atement.org st as
‐ conjunction
comparison in 2014;348:g1687)
Reviewers‘ – use
used conjunction BMJ
duplicated
in BMJ Open relevant, be
www.consort (see
can been
used
(see where
guide be not
relevant to the protoc http://bmjopen.bmj.com/ TIDieR
(and
have TIDieR should
tails of where this information statement
and
the
designs,
elements
with checklist
study CONSORT checklists
TIDieR For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml the
and on October 1, 2021 by guest. Protected copyright.
intervention
the alternate
conjunction with details) or a website (provide the URL).
For peer reviewable for the intervention being described. only the in
For protocol, these items are not protocol, these items of ).
statements
reported,
checklist details
conjunction
in being
this is reporting
statement.org ‐ ). used
using reporting
be other
on
protocol by is
should www.spirit trial
network.org TIDieR recommend
covered (see If the intervention was modified during the course of the study, describe the changes (what, why, changes (what, of the study, describe the course If the intervention was modified during when, and how). to which the the extent describe adherence or fidelity was assessed, Actual: If intervention intervention was delivered as planned. Describe the number of times the intervention was delivered and over what period of time including delivered and over what period of was number of times the intervention Describe the or dose. duration, intensity and their their schedule, the number of sessions, TAILORING what, why, describe adapted, then titrated or personalised, If the intervention was planned to be when, and how. MODIFICATIONS and by whom,describe how and if any fidelity was assessed, Planned: If intervention adherence or maintain or improve fidelity, them. used to describe strategies were WHEN and HOW MUCH WHEN
- use N/A if an item is not applic of
clinical
are checklist
checklist
a
focus strongly
ǂ ǂ
sufficiently reported. sufficiently reported. Authors The We Statement studies TIDieR
8. 9. WELL 10. HOW 11. 12. When www.equator ‐ TIDieR or other published papers (provide citation
If completing the TIDieR checklist for a completing the TIDieR checklist If
* ** * ǂ † If the information is not provided in the primary† If paper, give de 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Developing an individualised cross-sectoral programme based on activity of daily living to support rehabilitation of older adults with hip fracture: a qualitative study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-044539.R1
Article Type: Original research
Date Submitted by the 22-Feb-2021 Author:
Complete List of Authors: Ropke, Alice; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences Lund, Karina; Herlev Hospital, Department of Physiotherapy and Occupational Therapy Thrane, Camilla ; Herlev Municipality, Health Promotion and Rehabilitation Juhl, Carsten; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences
Morville, Anne-Le; Jönköping University, Department of Rehabilitation http://bmjopen.bmj.com/ School of Health and Welfare
Primary Subject Qualitative research Heading:
Secondary Subject Heading: Health services research
Hip < ORTHOPAEDIC & TRAUMA SURGERY, REHABILITATION MEDICINE, Keywords: QUALITATIVE RESEARCH on October 1, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 36 BMJ Open
1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 36
1 2 3 4 1 Title page BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 2 7 3 Developing an individualised cross-sectoral programme based on activity of daily living to support 8 4 rehabilitation of older adults with hip fracture: a qualitative study 9 5 10 6 Authors: 11 7 1,2Alice Røpke 12 8 1Karina Lund 13 3 14 9 Camilla Thrane 1,2 15 10 Carsten Bogh Juhl 16 11 4Anne-Le Morville 17 12 18 13 Corresponding author:For peer review only 19 14 Alice Røpke 20 15 Herlev and Gentofte Hospital 21 22 16 Department of Physiotherapy and Occupational therapy 23 17 Borgmester Ib Juuls Vej 29 24 18 Opgang 8, 3. sal, O1 25 19 2730 Herlev 26 20 Denmark 27 21 Email (work): [email protected] 28 29 22 https://orcid.org/0000-0001-7793-5558 30 23 Phone: +45 (0) 26882002 (mobile) 31 24 32 25 1Department of Physiotherapy and Occupational Therapy 33 26 Copenhagen University Hospital, Herlev and Gentofte 34 27 Department of Physiotherapy and Occupational therapy 35 28 Borgmester Ib Juuls Vej 29 36 29 Opgang 8, 3. sal, O1 37 http://bmjopen.bmj.com/ 38 30 2730 Herlev 39 31 Denmark 40 32 41 33 2Department of Sports Science and Clinical Biomechanics 42 34 University of Southern Denmark 43 35 Campusvej 55 44 36 5230 Odense M 45 on October 1, 2021 by guest. Protected copyright. 46 37 Denmark 47 38 48 39 3Health Promotion and Rehabilitation 49 40 Tvedvangen 196 50 41 2730 Herlev 51 52 42 Denmark 53 43 54 44 4Department of Rehabilitation 55 45 School of Health and Welfare 56 46 Jönköping University 57 47 Box 1026 58 48 551 11 Jönköping 59 60
1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 36 BMJ Open
1 2 3 4 49 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 50 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 7 51 8 52 Word count: 4338 – excluding title page, references, figures and tables. 9 53 10 11 12 54 13 14 15 55 16 17 56 18 For peer review only 19 20 57 21 22 23 58 24 25 26 59 27 28 29 60 30 31 61 32 33 34 62 35 36
37 63 http://bmjopen.bmj.com/ 38 39 40 64 41 42 43 65 44
45 on October 1, 2021 by guest. Protected copyright. 66 46 47 48 67 49 50 51 68 52 53 54 69 55 56 57 70 58 59 60
2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 36
1 2 3 4 71 Developing an individualised cross-sectoral programme based on activity of daily living to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 72 support rehabilitation of older adults with hip fracture: a qualitative study 8 9 73 ABSTRACT 10 11 12 74 Objectives: To develop an individualised rehabilitation programme for personal and instrumental 13 14 15 75 activities of daily living (ADL tasks), enabling older adults with hip fractures to perform ADL 16 17 76 safely and independently. 18 For peer review only 19 77 Design: Inspired by the Complex-intervention development (Medical Research Council (MRC) 20 21 78 framework phase I) using literature search and research circles. 22 23 24 79 Settings: University Hospital of Copenhagen, Herlev and Gentofte and Herlev and Gentofte 25 26 80 municipalities. 27 28 81 Participants: One research circle with seven older adults with hip fractures, and one with seven 29 30 31 82 healthcare professionals (occupational therapists and physiotherapists). 32 33 83 Results: Three key categories were identified (1) ‘Challenge the older adults with goal-oriented 34 35 84 ADL tasks’, (2) ‘Implement strategies to enhance independent and safe performance of ADL tasks’ 36
37 http://bmjopen.bmj.com/ 38 85 and (3) ‘Communicate the important information to the target group and across sectors’. A 39 40 86 programme was developed and an intervention to enhance usual rehabilitation was designed 41 42 87 comprising: an individualised intervention component consisting of five additional therapy 43 44 88 sessions; one during hospitalisation, four in the municipality and a follow-up phone call.
45 on October 1, 2021 by guest. Protected copyright. 46 47 89 Conclusions: Engaging and integrating activities into rehabilitation treatment may support 48 49 50 90 rehabilitation. Recommendations on how to initiate, graduate and challenge the older adults with 51 52 91 hip fracture in performing daily activities; e.g. ADL-task complexity, context and duration, 53 54 92 implementing strategies such as energy-saving techniques; e.g. the use of assistive devices for 55 56 93 mobility, bathing and dressing and communicating information in transitional rehabilitation; e.g. 57 58 59 60
3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 36 BMJ Open
1 2 3 4 94 booklet following the older adults across sectors with information on procedures and patient-held BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 95 ADL-task goal-setting. 8 9 96 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 10 11 97 12 13 14 98 Strengths and limitations of this study 15 16 17 99 This study highlights that a participatory design is suitable when developing a hip fracture 18 For peer review only 19 100 rehabilitation programme 20 21 22 101 The credibility and trustworthiness of our findings were enhanced by using peer and 23 24 102 member checking 25 26 103 A comprehensive process and feasibility evaluation of the hip fracture rehabilitation 27 28 29 104 programme is needed to test adherence and compliance of the intervention 30 31 32 105 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 36
1 2 3 4 107 INTRODUCTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 108 Despite positive surgical outcomes, older adults with hip fractures (HF) need rehabilitation to 7 8 9 109 optimise their performance in Activities of Daily Living (ADL). Just one-third regain their pre- 10 11 110 fracture level of physical function and capacity to perform ADL.1 2 For the remaining two-thirds, 12 13 111 there is an increased risk of social isolation, depression and reduced Quality of Life (QoL). 3-6 14 15 112 Studies have reported poor post-fracture outcomes and coordination across the healthcare sectors 16 17 7 8 18 113 does not always meet frailFor patients’ peer needs. review Close, continuous only and efficient collaboration between 19 20 114 different professions and healthcare sectors is essential to provide patient-centred rehabilitation, 21 22 115 based on the individual’s needs, wishes and competences.9 Several studies support the effect of 23 24 25 116 multidisciplinary rehabilitation of patients with HF, combining nursing care, physiotherapy, 26 27 117 occupational therapy (OT) and/or social work.10-13 Few studies focus on occupation14 and 28 29 118 improving ADL 7 15 16, and how to support the older adult to safely and independently performing 30 31 32 119 ADL tasks. Occupation in this article refers not only to work but general activity and participation 33 34 120 in daily life.14 Thus, the use of motor- and process skills during ADL task performances is named 35 36 121 Occupational performance.14
37 http://bmjopen.bmj.com/ 38 122 Thus, the purpose of this study was to gather knowledge of experiences, needs and expectations of 39 40 41 123 rehabilitation from older adults with HF to develop an intervention programme focusing on their 42 43 124 ability to safely and independently perform ADL. To develop a sustainable intervention, with 44
45 on October 1, 2021 by guest. Protected copyright. 125 multiple perspectives from older adults with HF, their families, and the healthcare professionals 46 47 48 126 (HCP) - specifically physiotherapists (PT) and OTs are needed. This study is the first step of a 49 50 127 forthcoming trial of developing and evaluating a complex intervention for the rehabilitation of older 51 52 128 adults with HF focusing on enabling occupational performance. 53 54 55 129 56 57 130 58 59 131 60
5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 36 BMJ Open
1 2 3 4 132 INTERVENTION DESCRIPTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 17 7 133 The Template for Intervention Description and Replication (TIDieR) checklist was used to 8 9 134 evaluate the comprehensiveness of the reporting of the cross-sectorial intervention. Furthermore, 10 11 135 Standards for Reporting Qualitative Research (SRQR) checklist18 was used to show transparency in 12 13 14 136 all steps in the qualitative research (supplemental material). 15 16 137 Rationale and theory essential to the intervention 17 18 138 The intervention was consideredFor peer a complex interventionreview with onlymultiple interacting components. The 19 20 19 20 21 139 development phase was inspired by the 2008 UK Medical Research Council (MRC) framework 22 23 140 for developing and evaluating complex interventions, which presents three steps: (1) identifying the 24 25 141 evidence base, (2) identifying/developing theory and (3) modelling the process and outcomes. Older 26 27 28 142 adults with HF, HCPs, administrators and managers were continuously involved in the development 29 30 143 stage21. 31 32 144 1. IDENTIFYING THE EVIDENCE BASE 33 34 145 Identifying the evidence and specifying the content of the intervention was formulated based on a 35 36
37 146 literature search in March 2018 with regular updates on Medline, Cinahl and Embase using the http://bmjopen.bmj.com/ 38 39 147 search string: [hip fracture AND activity of daily living AND Occupational therapy]. 40 41 148 Interventions for older adults with HF dependent on support and rehabilitation are often 42 43 12 44 149 multidisciplinary. The organisation and implementation of rehabilitation services varies in length
45 on October 1, 2021 by guest. Protected copyright. 46 150 and content, but usually includes OT and physical therapy.10 22 The positive outcome would be a 47 48 151 reduced need of home care and improved occupational performance.23 Studies on occupational 49 50 51 152 performance has shown that interventions focused on ADL results in reduced dependency in 52 53 153 (Personal) PADL24 and (Instrumental) IADL24 25. Postoperative care after HF focuses on individual 54 55 154 techniques for dressing, bathing and adapting the home environment15 16, transferring, positioning 56 57 155 and postural standing, technical aids for PADL and IADL.26 In addition home visits by an OT 58 59 60
6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 36
1 2 3 4 7 15 26 27 156 assessing home environment and provides strategies for early recovery. A post-discharge BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 157 telephone call after discharge in a multidisciplinary intervention may be effective in reducing the 8 9 158 proportion of fallers27 28 Only few trials focus on providing strategies for safe and independent 10 11 159 occupational performance, focusing on the activities most important for the patient’s self-care and 12 13 14 160 independence; Sessions included a range of topics e.g. technical aids and instructions related to 15 16 161 ADL training, home environment advice, falls prevention transfer, walking and ADL.7 26 17 18 162 Advantages for an individualizedFor peer OT intervention review were found only on patients’ ability to e.g. perform 19 20 163 ADL and improvements in perceived health.7 26 21 22 23 164 24 25 165 2. IDENTIFYING/DEVELOPING THEORY 26 27 166 The theoretic foundation of the intervention was based on a transactional perspective on 28 29 29-31 30 167 occupation and inspired the development phase emphasizing (1) person-context relations, and 31 32 168 (2) occupation as a continuous response to situational elements.29 30 32 An important aspect is to 33 34 169 recognize that people cannot be separated from their experiences and context in life, emphasising 35 36 170 the importance of situating each individual into account during rehabilitation.33 What to do and 37 http://bmjopen.bmj.com/ 38 39 171 how to be occupation-centred during interventions is defined as having (1) an occupation-focused 40 41 172 approach concentrating attention on occupation with a proximal focus on e.g. body functions, 42 43 173 environment, or other contextual factors, (2) An occupation-based approach involves occupational 44
45 on October 1, 2021 by guest. Protected copyright. 14 46 174 performance as part of evaluations or as interventions engaging in e.g. cooking or reading a book. . 47 48 175 Ensuring that the intervention is occupation-centred the Occupational Therapy Intervention Process 49 50 176 Model (OTIPM) provides a frame of the intervention. The intervention process is depicted as 51 52 14 34 35 53 177 occurring over three phases: evaluation and goal setting, intervention, and re-evaluation. 54 55 178 Identifying a theory to underpin the specific essential intervention is derived from the collaboration 56 57 179 between older adults with HF and HCPs: 58 59 60
7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 36 BMJ Open
1 2 3 4 180 MATERIAL AND METHODS BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 181 Patient and public involvement 8 9 182 A participatory design was adopted, by applying the research circle method36 37, emphasising 10 11 183 engagement and collaborative action between older adults with HF, HCPs and researchers.38 39 The 12 13 14 184 research circle process is characterised by mutual reflection and engagement between participants 15 16 185 contributing with equal authority to co-create collective knowledge. Research circles are based on a 17 18 186 common theme that is Fordiscussed peer to generate reviewnew in-depth knowledge only among the included 19 20 187 participants.40-42 Two research circles were formed: one with older adults with HF and another with 21 22 23 188 HCPs- OTs and PTs - working in hospital settings and municipalities. 24 25 189 The overarching theme for each meeting was determined in advance by the first author and inspired 26 27 190 by the rehabilitation phases in practice developed by Borg43; 1) Rehabilitation during 28 29 30 191 hospitalisation, 2) Rehabilitation in transition to the municipality, 3) Rehabilitation in the 31 32 192 municipality, and 4) The resultant collective proposal for a hip rehabilitation programme. At each 33 34 193 meeting, an interview guide44 was developed based on the respective themes (figure 1). 35 36 194 37 http://bmjopen.bmj.com/ 38 39 195 Sampling and recruitment 40 41 42 196 Purposeful sampling was performed to recruit older participants with HF from a range of post- 43 44 197 acute settings and demographics e.g. type of housing, geographical district, age and sex.45 The
45 on October 1, 2021 by guest. Protected copyright. 46 198 HCPs were recruited from February to March 2018, from Herlev and Gentofte municipality 47 48 49 199 rehabilitation centres and from Copenhagen University Hospital, Herlev and Gentofte (table 1). 50 51 200 52 53 201 54 55 202 56 57 58 203 59 60
8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 36
1 2 3 4 Table 1 Inclusion and exclusion criteria for older adults with hip fracture
204 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 Inclusion criteria Exclusion criteria 6 Aged 55 years or older Not expected to be discharged to home or rehabilitation centres in the municipality 7 Recent proximal hip fracture (S 72.0 Medial femur fracture, S 72.1, Not able to speak and/or understand Danish 8 Pertrochanteric femur fracture, S 72.2, Subtrochanteric femur fracture) Severe physical and/or mental disabilities prior to the hip fracture 9 Living at home prior to hip fracture in Herlev or Gentofte municipalities 10 Ability to give informed consent 11 Discharged from hospital and receiving or having received rehabilitation 12 from the municipalities within the last 3 months from onset 13 Inclusion criteria in research circles for healthcare professionals 14 At least 2 years of experience with rehabilitation of older adults with hip fracture in the included municipalities or Hospital 15 205 16 17 18 206 HCPs at the two municipalitiesFor identifiedpeer potential review participants only and scheduled dates and times for 19 20 207 the research circle meetings for both the older adults and the HCPs. 21 22 208 To create a relaxed and trusting atmosphere, the research circles were conducted at the 23 24 209 rehabilitation facilities. Prior to the meetings, an email with information about the overall topic for 25 26 27 210 the meetings, time, place and provision of transportation were sent to the participants. 28 29 211 30 31 32 212 Data collection 33 34 213 All research circle meetings were conducted between April and June 2018. Two pilot interviews to 35 36 214 test the preliminary interview guide were performed: one with an experienced HCP and a group
37 http://bmjopen.bmj.com/ 38 215 interview with five older adults who had experienced hip fracture rehabilitation. Testing the 39 40 46 41 216 interview guide, first with the research team and subsequently with potential study participants 42 43 217 resulted in a reduced number of questions and revision of the interview guide. 44
45 on October 1, 2021 by guest. Protected copyright. 218 46 47 48 219 Insert figure 1 here 49 50 220 51 52 221 Each meeting of the research circle was prepared, recorded and facilitated by two authors (AR) and 53 54 55 222 (KL) (figure 1). Using the interview guide, open-ended questions were asked about the participants’ 56 57 223 needs, wishes and expectations for individualised occupation-based rehabilitation for adults with 58 59 224 hip fractures. The meetings were conducted every third week with the older adults and HCPs 60
9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 36 BMJ Open
1 2 3 4 225 separately for the first three meetings and together in the last meeting, to share knowledge and ideas BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 226 gathered from the previous meetings. Each meeting lasted for approximately 2 hours. Between 8 9 227 meetings, participants were encouraged to reflect and take notes in a booklet as a resource for 10 11 228 discussion at the following meeting. At the end of each meeting, the participants were asked to 12 13 14 229 highlight one idea or statement that they thought important to include in further developing the 15 16 230 intervention programme. Summary notes from each meeting were subsequently presented at the 17 18 231 next meeting to sustainFor the continuity peer of innovations review across meetings. only Further, the participants were 19 20 232 asked to verify the summaries and thereby be actively involved in the initial analysis. 21 22 23 233 Data analysis 24 25 234 The analysis procedure included two levels and was performed by two authors (AR and KL). Level 26 27 28 235 one began after the first meeting of each research circle. The summary of notes taken during the 29 30 236 meetings formed the basis of an emerging categorisation of data, confirmed by participants at the 31 32 237 end of every meeting. Level two of the analysis process involved inductive content analysis 33 34 238 performed at a manifest level in three phases as described by Elo and Kyngäs.47 During level two, 35 36
37 239 the last author (AM) joined the analysis process. In the preparation phase, each of the transcripts http://bmjopen.bmj.com/ 38 39 240 was read thoroughly several times to verify its accuracy. The organising phase included open 40 41 241 coding, where the first and second author independently highlighted the key statements in the 42 43 44 242 transcripts related to the topics in the interview guides. Using an iterative style, meaning units were
45 on October 1, 2021 by guest. Protected copyright. 46 243 then organised and condensed by the two authors using Nvivo 11 Pro.48 The analysis moved from 47 48 244 lower to higher levels of abstraction, identifying an initial interpretation of patterns, grouping, and 49 50 51 245 comparing data in subcategories and categories. In the reporting phase, a description of the 52 53 246 subcategories and categories was then articulated. The authors explored similarities and differences 54 55 247 in the analysis during meetings, which facilitated the development of categories and patterns that 56 57 58 59 60
10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 36
1 2 3 4 49 248 best illustrated the needs, expectations and experiences of the participants. Subcategories emerged BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 249 and finally the abstraction to generic categories was performed. The process is shown in figure 2. 8 9 10 250 RESULTS 11 12 251 Identifying a theory to underpin the specific essential intervention elements 13 14 15 252 In total 14 participants were included in the research circles: four OTs, three PTs and seven older 16 17 253 people with HF (six females and one male). Table 2 summarises the older adults and HCPs 18 For peer review only 19 254 demographic data. 20 21 255 22 23 24 256 Table 2 Demographic data of the participants in research circles (n=14) 25 Older Female Male Age Living situation 26 Adults (range) (range) 27 (n=7) 6 1 58-93 5 living alone 28 29 Healthcare Physiotherapist Occupational Years of experience 30 Professionals therapist (range) 31 (n=7) 3 4 2-25 years 32 33 257 34 35 258 Though the groups faced their own unique challenges, the older adults and the HCPs shared 36
37 http://bmjopen.bmj.com/ 38 259 experiences, needs and ideas for a transitional rehabilitation programme, which led to the 39 40 260 identification of three core categories: 1) Challenge the older adults with goal-oriented ADL tasks, 41 42 261 2) Implement strategies to enhance an independent, safe performance of ADL tasks, and 3) 43 44 262 Communicate the information to the target group and across healthcare sectors (figure 2). 45 on October 1, 2021 by guest. Protected copyright. 46 47 263 48 49 264 Insert figure 2 here 50 51 52 265 53 54 266 Each generic category extracted from the data is summarised and supported with quotes. The 55 56 267 supporting quotes will indicate which of the research circle meetings the quote was extracted from, 57 58 268 the research circle, group, and number e.g. (RCEHF01). 59 60
11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 36 BMJ Open
1 2 3 4 269 Challenge the older adults with goal-oriented ADL tasks BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 270 All participants emphasised the importance of older adults with HF being challenged to perform 8 9 271 PADL and IADL tasks and the importance of challenging the older adult from day one after 10 11 272 surgery. 12 13 14 273 Though, due to the influence of medication, pain, and lack of sleep and food during the hospital 15 16 274 stay, several of the older adults with HF lacked confidence in ambulation, physical- and ADL 17 18 275 abilities when discharged:For peer review only 19 20 276 ”… if you start during the 8 days (at the Hospital), before 21 22 23 277 going to the Rehabilitation Centre, and you were activated all you were 24 25 278 able to, to show what you are capable of…but they forget that the patient has to be 26 27 279 challenged…they should activate us as much as possible”. (L1, female patient, RCEHF01) 28 29 30 280 They suggested individual ADL tasks (e.g. preparing and eating fresh fruit, washing hands and 31 32 281 face, brushing teeth by the sink) matching the older adults, e.g. capacity and wanted a focus on 33 34 282 personal ADL goals while in the hospital. After discharge from hospital, more complex domestic 35 36 283 and social ADL tasks were asked for by the older adults; e.g. early independence and safety in 37 http://bmjopen.bmj.com/ 38 39 284 walking to the bathroom and managing toileting and bathing to gain previous levels of function: 40 41 285 “We want to learn to be ourselves again. As quickly as possible! 42 43 286 (W4, female participant, RC0402) 44
45 on October 1, 2021 by guest. Protected copyright. 46 287 Implement strategies to enhance independent and safe performance of ADL tasks 47 48 288 All participants emphasised “implement strategies to enhance independent and safe performance of 49 50 51 289 ADL tasks”. The older adults raised the issue of their reliance on mobility devices from day one and 52 53 290 in the following weeks or even months, as it limited their ability to perform ADL tasks. They 54 55 291 emphasised the importance of the timing of introduction and graduation of the use of a walking 56 57 292 trolley, walker and/or crutches. Strategies and ideas for carrying objects over short distances were 58 59 60
12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 36
1 2 3 4 293 discussed, e.g. using an apron with pockets or crossbody bag for carrying a mobile phone and/or BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 294 snacks/beverage: 8 9 295 “…I used a crutch indoors. So, if I want to carry anything I must run back and forth 10 11 296 17 times you know, because I can only carry one thing at a time right, but then you can 12 13 14 297 use an apron to put things in the front pocket” (LI, female patient, RCEHF03). 15 16 298 Additionally, being presented with small assistive devices, e.g. sock aid, long handled reacher etc. 17 18 299 several times was indicatedFor as necessarypeer both review during hospital onlystay and at follow up in the 19 20 300 municipality: 21 22 23 301 I was able to arrange a visit where they (OT) brought a 24 25 302 stocking aid, that was great. It was fabulous…she gave me this and 26 27 303 one, two, three, I could use it myself”. (W4, female patient, RC0402) 28 29 30 304 31 32 305 Communicate the important information to the target group and across sectors 33 34 306 The final category that emerged was the lack of information and communication across healthcare 35 36
37 307 sectors. Organisational changes in workflow are not always passed on to HCPs across sectors, i.e. http://bmjopen.bmj.com/ 38 39 308 new procedures regarding instructions in movement restrictions or new guidelines regarding 40 41 309 rehabilitation services in the municipalities. 42 43 44 310 “… we can’t promise the older adult at the hospital anything regarding
45 on October 1, 2021 by guest. Protected copyright. 46 311 the future rehabilitation in the municipality before we are sure of their opportunities”. 47 48 312 (P02, clinical specialist OT, RCHCP02) 49 50 51 313 Furthermore, the older adults with HF wanted general knowledge, e.g., a booklet about what to 52 53 314 expect during and after the operation and during rehabilitation phases, such as information 54 55 315 concerning the operation method, normal physical reactions after HF surgery, restrictions and how 56 57 316 these could influence a person’s occupational performance. 58 59 60
13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 36 BMJ Open
1 2 3 4 317 The importance and dependence on the older adult’s social network was evident when gathering BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 318 information and planning the rehabilitation. Several of the older adults with HF emphasised that 8 9 319 they were dependent on family and friends to support basic ADL tasks, both at home and at the 10 11 320 rehabilitation centre. 12 13 14 321 “I think it is important that the HCP at the hospital pays attention to whether there is 15 16 322 any network no matter how old you are…”” 17 18 323 (S4, clinical specialistFor PT, peer RC0401) review only 19 20 324 The older adults with experience from rehabilitation centre emphasised the importance of a home 21 22 23 325 visit prior to discharge, to identify potential barriers and minimise the fear of returning home. 24 25 326 Furthermore, both the older adults and HCP expressed the need for a home visit within 1 to 3 26 27 327 working days post discharge directly from the hospital or the rehabilitation centre to their home to 28 29 30 328 resolve issues associated with their home environment and plan their individual rehabilitation. 31 32 329 “A visit to the home provides valuable information about how the older adults functions 33 34 330 outside the rehabilitation setting. Maybe the older adults needs a rail in the bathroom, or 35 36 331 the carpet needs to be removed or nightlights need to be set up. So, whatever caused the fall, 37 http://bmjopen.bmj.com/ 38 39 332 you go through the environment, removing obstacles so they will feel safer at home” 40 41 333 (ML1, clinical specialist, OT, RCHCP01). 42 43 334 44
45 on October 1, 2021 by guest. Protected copyright. 46 335 3. MODELLING PROCESS AND OUTCOMES 47 48 336 A first draft of an intervention manual and expert review 49 50 337 The processes and outcomes were modelled as recommended by Sermeus et al.50 The first author 51 52 17 53 338 drafted a detailed intervention manual using the TIDierR checklist and Standards for Reporting 54 55 339 Qualitative Research (SRQR) checklist18. 56 57 340 The occupation-centred framework for conceptualizing the Hip fracture REhabilitation Programme 58 59 60
14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 36
1 2 3 4 341 (HIP-REP) is based on the OTIPM and focus on occupation and approaches identified as: an BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 342 occupation-based or, an occupation-focused, or both. 8 9 343 Following the development of a draft for the manual of the HIP-REP programme, it was 10 11 344 commented on by an impartial rehabilitation expert with knowledge and experience with older 12 13 14 345 adults with HFs and development of complex interventions. Furthermore, participants from the 15 16 346 research circles all agreed to read and comment on the draft of the manual for the HIP-REP 17 18 347 programme to verify theFor content, peer and thus verify review the relevance only and expected feasibility of its 19 20 348 implementation. 21 22 23 349 The development of the HIP-REP programme 24 25 350 The qualitative data were used to develop an overarching working theory: ‘The following will lead 26 27 28 351 to safer and more independent performance of ADL tasks: (i) challenging older adults with HF with 29 30 352 goal-specific ADL tasks through an individually tailored goal-oriented programme increasing the 31 32 353 complexity of ADL tasks in addition to usual rehabilitation, and (ii) increasing the co-ordination 33 34 354 and information of services between sectors delivering rehabilitation across sectors. 35 36
37 355 The working theory was discussed with researchers in the field of health science and from this aims http://bmjopen.bmj.com/ 38 39 40 356 and ideas for the intervention were derived. The three core categories and the working theory led to 41 42 357 the following elements; Inspiration sheets (occupation-focused and occupation-based activities), 43 44 358 Worksheets, Information sheets and pamphlets (see online supplementary file 1). The elements
45 on October 1, 2021 by guest. Protected copyright. 46 359 were then framed according to the OTIPM51 process and reorganized into the HIP-REP programme 47 48 49 360 (table 3). The HIP-REP programme focus on an individual adaptation of the programme and 50 51 361 increasing the complexity of ADL tasks with the goal of returning to an independent and safe 52 53 362 performance of relevant tasks (table 4). 54 55 56 363 A first draft of an intervention manual and expert review 57 58 59 60
15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 36 BMJ Open
1 2 3 4 364 Programme Structure BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 365 The HIP-REP programme consists of three phases over a total of 8 weeks (table 4) supervised by 8 9 366 OTs; preliminary interviews, baseline tests, five interventions focusing on ADL that each last a 10 11 367 minimum of 1 hour and a maximum of 2 hours (including transport and registration for the HCP), 12 13 14 368 and a follow-up phone call at 10 weeks post-operatively. Due to different structures in the 15 16 369 municipalities, the HIP-REP programme was divided into a ‘two-way track’ after discharge from 17 18 370 hospital. Both tracks appliedFor four peer interventions review in the municipality only undertaken in agreement with 19 20 371 the older adults. Track one involved the older adults being transferred directly to their own home. 21 22 23 372 Track two involved the older adults staying at a rehabilitation centre before discharge to their home. 24 25 373 In both tracks, the intervention was scheduled, in collaboration with the older adults as shown in 26 27 374 table 4. When discharged from either hospital or rehabilitation centre, visits to the older adult’s own 28 29 30 375 home were to be carried out between the first and third weekday after returning home. 31 32 376 33 34 377 Programme Content 35 36
37 378 The content of the HIP-REP programme is standardised and guided by a manual (table 4) but http://bmjopen.bmj.com/ 38 39 379 individually tailored to the older adults, and the intervention thus varies in the content and 40 41 380 complexity of ADL tasks, based on the older adults’ priorities, type of hip fracture and surgical 42 43 34 44 381 fixation. The OTIPM guides the HIP-REP programme, with focus on occupational performance
45 on October 1, 2021 by guest. Protected copyright. 46 382 for both intervention and evaluation as described in the manual (full version in Danish available 47 48 383 from authors on request). In general, for each intervention, the following elements appear; 1) 49 50 51 384 Interview, assessment and identification of problems and/or change in the occupational 52 53 385 performance; 2) The intervention phase with implementation of customised, purposeful activities 54 55 386 for performing ADL tasks; 3) The re-assessment phase with an initial interview to identify the older 56 57 58 59 60
16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 36
1 2 3 4 387 adults meaningful pre-hip fracture activities. Inspiration, information, - and worksheets were BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 388 prepared for each session with the older adults. 8 9 389 Expert review 10 11 390 Determining the content validity an expert44 in rehabilitation for older adults with HF suggested 12 13 14 391 structural and content considerations for the programme, e.g., a clarification on introduction and 15 16 392 education of the OTs participating in the programme and suggesting a clarification of exclusion 17 18 393 criteria. Also, suggestionFor as to whenpeer intervention review during hospitalization only could be implemented. The 19 20 394 expert reviews ideas and suggestions were considered and incorporated in manual. The participants 21 22 23 395 in the research circles commented on unclear sentences and spelling mistakes which was corrected 24 25 396 in the final manual (table 4). 26 27 397 28 398 29 30 399 31 400 32 33 401 34 402 35 36 403
37 404 http://bmjopen.bmj.com/ 38 405 39 40 406 41 407 42 43 408 44 409
45 on October 1, 2021 by guest. Protected copyright. 410 46 47 411 48 412 49 50 413 51 52 414 53 415 54 55 416 56 417 57 58 418 59 419 60
17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 36 BMJ Open
1 2 3 4 Table 3 Intervention elements incorporated in the HIP-REP programme
420 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Intervention process Specification How
7 Inform and assess Inform about the intervention Older adults with HF: 8 · HIP-REP programme informing the older adult about the plan for cross-sectional intervention · Booklet for the older adult collecting handed out information and patient-held ADL goal-setting 9 · Exploration of possible activity areas to perform ADL tasks; Hospital, Rehab, own home 10 HCPs: 11 · OTIPM inspired worksheet Clarify the older adult’s client-centred performance HCPs 12 - Interview the older adult and other HCPs - Review of existing documentation 13 - Identify aspect that supports and limits the occupational performance; personal, physical, social and institutional 14 surroundings Describe the older adults self-reported strength and HCPS: 15 problems with activity performance Interview the older adult with HF 16 - Older adults with HF: Decide and prioritize possible ADL-tasks at the hospital, rehab centre or at own dwelling 17 18 Describe which taskFor the older adult peer prioritize as a Older review adults with HF: only focus during assessment and intervention · Initiate ADL activities; ideas to graduated ADL tasks 19 · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest 20 HCPs: - · Information: Booklet for the older adult; hip fracture procedure, operation type, and “what to expect” 21 symptoms after the operation is handed out 22 Observer the older adults task performance and HCPs (OT): 23 describe the older adults starting point for activity AMPS assessment of the older adult with HF performing prioritized tasks 24 performance 25 Clarify and interpret the reasons the older adults HCPs reduced activity performance To analyse the older adult with HFs physical, personal and environmental surroundings 26 · Hip fracture information; operation and restriction movements 27 · Information and instruction; mobility devices and PADL technical aids for bathing and dressing 28 Formulate goals Older adults with HF and HCPs: 29 · Occupation-focused and/or occupation-based goals are formulated; the agreed goals are written in booklet and 30 evaluated at each meeting 31 Plan and initiate Older adults with HF and HCPs intervention In collaboration it is decided which intervention to initiate: Compensatory, Acquisitional model for skills training 32 and/or Restorative model for enhancing body functions and other client elements 33 · Initiate activities; ideas to graduated ADL tasks 34 · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest Assess the result Observe the older adults task performance and HCPs (OT) 35 describe the new level for activity performance AMPS follow-up assessment is performed 36 Compare the new level of performance with HCPs:
37 starting point and goals · Assess the AMPS results in collaboration with the older adult with HF http://bmjopen.bmj.com/ 38 Decide if the Older adults with HF and HCPs 39 intervention At the last intervention visit it is decided if the intervention should continue or end 40 continues or ends - · Follow-up phone-call to the older adult with HF 41 End the Older adult with HF and HCPs 42 intervention process Decide if further intervention is necessary and/or maybe refer to other healthcare relevant offers in the municipality 43 421 Categories from analysis informing the content of the elements in the Hip fracture Rehabilitation Programme based on OTIPM.51 44 422
45 on October 1, 2021 by guest. Protected copyright. 423 46 47 424 48 425 49 50 426 51 427 52 428 53 54 429 55 430 56 57 431 58 59 60
18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 36
1 2 3 4 432 Table 4 HIP-REP programme for older adults with hip fracture from first post-operative day to Week 12 including five interventions based on BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 433 Occupational performance: One intervention during hospital stay, and four at the rehabilitation centre and/or at home. Home visits must be carried 6 434 out in both tracks 1 and 2 7 The Progress at the hospital 8 Day Post Session Intervention Activities 9 Operative 10 Day 1 1st Inform and identify Welcome to the ward 11 Day 1-2 2nd Inform and identify Initial interview 12 13 Interview – prioritize two ADL tasks for AMPS 14 Day 3 3rd Inform and identify Observation: AMPS, as well as clarifying and interpreting cause and discussing objectives 15 Objectives, planning and implementation 16 Hip fracture information; operation, restriction movements handed out 17 18 Day 3-4 4th 1stFor ADL intervention peer reviewPADL andonly IADL tasks at the ward prioritized by older adult 19 Inform and identify, goalsetting, plan, engage and assess results 20 Day 4-5 5th Evaluate and end course Clarify and order assistive devices
21 The Progress in the municipality 22 23 Track 1 Track 2 24 Discharge from Hospital to in-patient Rehabilitation Centre Direct discharge from hospital to own dwelling to own dwelling 25 Week post- Session Intervention Activities Intervention Activities 26 operative 27 Week 2 6th 2nd ADL intervention Welcome/ Initial conversation 2nd ADL intervention at home The accessibility of the housing 28 is reviewed 29 Inform and identify, Weekday 1-3 after discharge goalsetting, plan, engage and PADL and IADL tasks as the Review of ADL tasks in own 30 assess results older adult has prioritized Inform and identify, goalsetting, plan, residence 31 engage and assess results 32 Week 3 7th 3rd ADL intervention at home PADL and IADL tasks as the 3rd ADL intervention at home PADL and IADL tasks as the if possible. older adult has prioritized older adult has prioritized 33 Inform and identify, goalsetting, plan, 34 Inform and identify, engage and assess results goalsetting, plan, engage and 35 assess results
36 Week 5 8th 4th ADL intervention The accessibility of the 4th ADL intervention at home PADL and IADL tasks as the
37 housing is reviewed older adult has prioritized http://bmjopen.bmj.com/ Home visit in connection Inform and identify, goalsetting, plan, 38 with discharge from in- Review of ADL tasks in own engage and assess results 39 patient Rehabilitation residence Centre 40 41 Inform and identify, goalsetting, plan, engage and 42 assess results
43 Week 8 9th 5th ADL intervention PADL and IADL tasks as the 5th ADL intervention at home PADL and IADL tasks as the 44 older adult has prioritized older adult has prioritized In own dwelling Inform and identify, goalsetting, plan,
45 engage, assess results, and end course on October 1, 2021 by guest. Protected copyright. 46 Inform and identify, goalsetting, plan, engage, End course and evaluate End course and evaluate 47 assess results, and end course
48 Week 10 Phone-call Assess results and evaluate Phone the older adult and Assess results and evaluate Phone the older adult and follow- 49 follow-up on the HIP-REP up on the HIP-REP intervention 50 intervention 51 Week 12 10th Evaluate Evaluate Evaluate Evaluate 52 ADL; Activity of daily living; HIP-REP; Hip fracture REhabilitation Programme; OTIPM; Occupational Therapy Intervention Process Model; PADL; Personal 53 Activity of daily living; IADL; Instrumental Activity of daily living 54 55 56 435 57 58 59 436 60
19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 36 BMJ Open
1 2 3 4 437 DISCUSSION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 438 Our main result was the identification of additional components for the rehabilitation of older adults 8 9 439 with HF. It revealed tangible strategies to facilitate the transitional rehabilitation process across 10 11 440 sectors. Three core categories emerged. 12 13 14 441 Challenge with goal-oriented ADL tasks 15 16 442 Challenges must fit the individual’s expectations, wishes and foremost their capabilities of 17 18 443 performing ADL tasks.For A previous peer study showed review that such a fitonly resulted in better outcomes when 19 20 444 tailoring the rehabilitation.52 Our findings emphasise the importance of involving the older adults in 21 22 23 445 the process as soon as possible, to set relevant goals and promote the experience of confidence and 24 25 446 active participation in their rehabilitation. Participants provided insights into what type of 26 27 447 occupation they prioritised during the first months after hip fracture, i.e. activities performed within 28 29 30 448 their own residence, including social activities. Our findings extend previous research, recognising 31 32 449 that identification of individual goals supports the participants regaining independence and 33 34 450 facilitates their recovery process.53 In addition, the older adults showed an interest in facilitating 35 36 451 individualised goals by using a booklet to document and encourage achievement of goals during the 37 http://bmjopen.bmj.com/ 38 39 452 transition between care settings and home. 40 41 453 42 43 44 454 Implement strategies to enhance independent and safe performance of ADL tasks
45 on October 1, 2021 by guest. Protected copyright. 46 455 Our study showed that older adults often developed their own strategies to enhance independent and 47 48 456 safe Occupational performance. They used work simplification and energy-saving techniques 49 50 51 457 during the first post-operative weeks including prioritisation of activities due to lack of energy, 52 53 458 adaptation of their environment, use of assistive devices for mobility, bathing and dressing. Their 54 55 459 strategies show that relatively simple solutions, such as an apron or a cross-over bag for transport of 56 57 460 devices, enabled them to move safely, independently and perform manageable activities. As 58 59 60
20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 36
1 2 3 4 461 previous literature reported, the older adult generates individual strategies to overcome the BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 54 7 462 temporary loss of independence and thus manage being at home after discharge. This shows that 8 9 463 the older adult with HF has a transactional perspective29 31 32 on their use of strategies taking into 10 11 464 account constructs such as person, occupation, and context. 12 13 14 465 Communicate the important information to the target group and across sectors 15 16 466 There is a trend towards reduction in length of stay at hospital due to early operative treatment. 52 54 17 18 467 This leaves only a few Fordays to accomplishpeer complex review aspects of only rehabilitation. In our study, the older 19 20 21 468 participants reported the rapid transition as daunting. The assessment, advice and strategies 22 23 469 regarding ADL tasks at the hospital become a challenge before discharge e.g., education in hip 24 25 470 precautions, introducing and providing small aids during their stay to become more independent. 26 27 54 28 471 Langford et al described that, becoming dependent on others regarding ADL, causes distress to 29 30 472 some older adults, as usual routines are disrupted, as another study reports a feeling of not being 31 32 473 equipped or prepared for the transition.55 Our study shows the importance of knowing what to 33 34 474 expect regarding the rehabilitation and also the need of focusing on ADL tasks during 35 36
37 475 hospitalisation, at the rehabilitation centre and at home. This applies especially to older adults with http://bmjopen.bmj.com/ 38 39 476 HF living alone, a point that was emphasised both by HCPs and the older adults, as those people are 40 41 477 more vulnerable and more need for information prior to discharge. Social support from family and 42 43 53 56 44 478 friends has been reiterated in other studies as important not only to assist with practical
45 on October 1, 2021 by guest. Protected copyright. 46 479 arrangements, but also to motivate, encourage and give emotional support. Providing patients with a 47 48 480 ‘recovery map’ including information about the hip fracture operation and which symptoms to 49 50 51 481 expect, forthcoming appointments and other resources could be beneficial, suggesting that written 52 53 482 patient-centred information enhances knowledge and facilitates decision-making and recovery.57 58 54 55 483 This stresses the importance of the HCP’s role in supporting more effective communication, 56 57 484 involving and informing older adults with HF and their relatives across professions and settings.59-61 58 59 60
21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 36 BMJ Open
1 2 3 4 485 Participants in our study found the transition from hospital or rehabilitation centre to own home as BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 486 critical. They found that home visits prior to and post discharge, to assess and/or modify 8 9 487 environmental barriers in the home, improved occupational performance and reduced the risk of 10 11 488 falling. This is consistent with results from other studies involving older people with functional 12 13 14 489 limitations in hospital discharge planning. Furthermore, including home visits has been shown to 15 16 490 result in reduced re-admission, risk of falls and improved functional performance.61 62 17 18 491 Methodological considerationsFor peer review only 19 20 21 492 Our study has some limitations as it only includes two professions in the research circles out of a 22 23 493 broader interdisciplinary team. However, the HCPs were experienced and conscious of this and 24 25 494 responded from the perspective of the broader team. At the last research circle meeting, no 26 27 28 495 additional insights or understandings were collected, indicating saturation was obtained in the 29 30 496 research circles.44 The use of research circles did not aim for a deeper analysis of feelings and 31 32 497 emotions, but provided a participatory focus, making it possible to collaborate with the older adults 33 34 498 and HCP participants throughout the research process supporting the development and gaining new 35 36 37 39 40
37 499 knowledge together through reflection. http://bmjopen.bmj.com/ 38 39 500 The study excluded older adults with severe cognitive impairments or difficulty in communicating 40 41 501 in Danish, which may limit the use of the results and the intervention may therefore need to be 42 43 44 502 adapted to other patient groups.
45 on October 1, 2021 by guest. Protected copyright. 46 503 The credibility and trustworthiness of our findings were enhanced by using peer and member 47 48 504 checking44, independent coding and experts’ views on the draft of the HIP-REP programme. This 49 50 51 505 was enabled by ensuring that all participants would feel comfortable sharing ideas and information 52 53 506 during the meetings in an open supportive environment. To ensure credibility, transparency in the 54 55 507 analysis phase using steps recommend by Elo et. al (2014) was followed as well as using quotes to 56 57 508 emphasise the similarities and differences in the categories.47 58 59 60
22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 36
1 2 3 4 509 CONCLUSIONS BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 510 Our study highlighted the need for setting individual goals and challenging the older adults with HF 8 9 511 by providing guidance in strategies to enhance safe and independent performance of ADL task. 10 11 512 Furthermore, the need for written and oral information for the older adults with HF and HCP about 12 13 14 513 goal-setting during the transitional rehabilitation phase was emphasised. Including the perspectives 15 16 514 of the older adults with HF and HCPs added value to the HIP-REP programme, and thus ensured an 17 18 515 adequate, tangible, andFor implementable peer rehabilitation review programme. only 19 20 21 22 516 Contributorship statement Study planning, conception and design: Røpke, Lund, Thrane, Juhl, 23 24 517 Morville. Drafting the work or revising it critically for important intellectual content: Røpke, Lund, 25 26 518 Thrane, Juhl, Morville. Acquisition of data: Røpke. Analysis and interpretation of data: Røpke, 27 28 29 519 Lund, Thrane, Juhl, Morville. Final approval of the version published: Røpke, Lund, Thrane, Juhl, 30 31 520 Morville. 32 33 34 521 DECLARATIONS 35 36
37 http://bmjopen.bmj.com/ 38 522 Acknowledgements 39 40 523 The authors thank the participants for sharing their insights and time with the research team. 41 42 524 Furthermore, we want to thank the two rehabilitation centres and the University Hospital for their 43 44 525 collaboration and for making their facilities available for researchers while conducting the research 45 on October 1, 2021 by guest. Protected copyright. 46 47 526 circles, and Senior Researcher Morten Tange Kristensen for his input and feedback on the first HIP- 48 49 527 REP draft. 50 51 52 528 Ethics approval 53 54 55 529 The study followed the Danish legislation regarding ethics in scientific studies and was approved by 56 57 530 Ethics Committees [H-18000881] and the Danish Data Protection Agency [Jnr no.: 2012-58-0004]. 58 59 60
23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 36 BMJ Open
1 2 3 4 531 Competing interests None declared. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 8 532 Funding This study was funded by the Region’s Research and Development fund (R26-1121); the 9 10 533 Intersectoral Research Unit (P-2017-1-11; P-2019-2-16); University College Copenhagen, 11 12 534 Department of Physiotherapy and Occupational Therapy (Internal funding), University Hospital 13 14 15 535 Copenhagen, Herlev and Gentofte (Internal funding) and Occupational Therapists Association (FF2 16 17 536 - R104-A2093). 18 For peer review only 19 537 20 21 538 Data sharing statement HIP-REP manual in Danish and data used during the current study are 22 23 539 available from the corresponding author on reasonable request. 24 25 26 27 540 28 29 541 REFERENCES 30 31 542 1. Giannoulis D, Calori GM, Giannoudis PV. Thirty-day mortality after hip fractures: has anything 32 543 changed? 33 544 Eur J Orthop Surg Traumatol 2016;26(4):365-70. 34 545 2. Le Manach Y, et al Outcomes After Hip Fracture Surgery Compared With Elective Total Hip 35 546 Replacement. JAMA, 2015:7. 36 547 3. González-Zabaleta J, Pita-Fernandez S, Seoane-Pillado T, et al. Dependence for basic and instrumental
37 548 activities of daily living after hip fractures. Arch Gerontol Geriatr 2015;60(1):66-70. http://bmjopen.bmj.com/ 38 549 4. Alarcón T, González-Montalvo JI, Gotor P, et al. Activities of daily living after hip fracture: profile and 39 550 rate of recovery during 2 years of follow-up. Osteoporos Int 2011;22(5):1609-13. 40 551 5. Orive M, Aguirre U, García-Gutiérrez S, et al. Changes in health-related quality of life and activities of 41 552 daily living after hip fracture because of a fall in elderly patients: a prospective cohort study. Int J Clin 42 553 Pract 2015;69(4):491-500. 43 554 6. Sirkka M, Bränholm I. Consequences of a hip fracture in activity performance and life satisfaction in an 44 555 elderly Swedish clientele. Scand J Occup Ther 2003;10:34-39. 45 on October 1, 2021 by guest. Protected copyright. 46 556 7. Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy training in 47 557 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand 2004;75(2):177-83. 48 558 8. Beaupre LA, Carson JL, Noveck H, et al. Recovery of Walking Ability and Return to Community Living 49 559 within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors. J Am Geriatr Soc 50 560 2015;63(8):1640-4. 51 561 9. Valentiner LS, Steen R. Genoptræningsforløbsbeskrivelse for hoftenært brud. Tværsektoriel 52 562 genoptræningsforløbsbeskrivelse. Region Hovedstaden: Den Administrative Styregruppe i Region 53 563 Hovedstaden, 2014. 54 564 10. Zidén L, Frändin K, Kreuter M. Home rehabilitation after hip fracture. A randomized controlled study on 55 565 balance confidence, physical function and everyday activities. Clin Rehabil 2008;22(12):1019-33. 56 566 11. Crotty M, Killington M, Liu E, et al. Should we provide outreach rehabilitation to very old people living 57 567 in Nursing Care Facilities after a hip fracture? A randomised controlled trial. Age Ageing 58 568 2019;48(3):373-80. 59 60
24 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 36
1 2 3 4
569 12. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 570 prospective, randomised, controlled trial. Lancet 2015;385 North American Edition(9978):1623-33. 6 571 13. Lahtinen A, Leppilahti J, Harmainen S, et al. Geriatric and physically oriented rehabilitation improves 7 572 the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison 8 9 573 of 538 patients [with consumer summary]. Clin Rehabil 2015 Sep;29(9):892-906. 10 574 14. Fisher AG. Occupation-centred, occupation-based, occupation-focused: Same, same or different? Scand 11 575 J Occup Ther 2013;20:162–73. 12 576 15. Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability concerning 13 577 ADL and IADL after hip fracture: a randomized trial. Acta orthop 2006;77(1):114-9. 14 578 16. Martin-Martin LM, Valenza-Demet G, Ariza-Vega P, et al. Effectiveness of an occupational therapy 15 579 intervention in reducing emotional distress in informal caregivers of hip fracture patients: a randomized 16 580 controlled trial. Clin Rehabil 2014 Feb 17;28(8):772-783 2014 17 581 17. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention 18 582 description and replicationFor (TIDieR) peer checklist review and guide. BMJ 2014;348:g1687.only 19 583 18. O’Brien BC, Harris IB, Beckman TJ, et al. Standards for Reporting Qualitative Research: A Synthesis of 20 584 Recommendations. Acad. Med. 2014;89(9):1245-51. 21 585 19. Fraser MW, Galinsky MJ. Steps in Intervention Research: Designing and Developing Social Programs. 22 586 Res Soc Work Prac 2010;20(5):459-66. 23 587 20. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new 24 588 Medical Research Council guidance. BMJ 2008;337 25 589 21. Richards D. The critical importance of patient and public involvement In: Richards D HI, ed. Complex 26 590 interventions in health: an overview of research methods. 1st ed. Oxon and New York: Routledge 27 2015:p. 46. 28 591 29 592 22. Roberts JL, Din NU, Williams M, et al. Development of an evidence-based complex intervention for 30 593 community rehabilitation of patients with hip fracture using realist review, survey and focus groups. 31 594 BMJ Open 2017;7(10):e014362. 32 595 23. Whitehead PJ, Walker MF, Parry RH, et al. Occupational Therapy in HomEcare Re-ablement Services 33 596 (OTHERS): results of a feasibility randomised controlled trial. BMJ Open 2016;6(8):e011868-e68. 34 597 24. Cook RJP, Berg KPPT, Lee K-AM, et al. Rehabilitation in Home Care Is Associated With Functional 35 598 Improvement and Preferred Discharge. Arch Phys Med Rehabil 2013;94(6):1038-47. 36 599 25. Lewin G, De San Miguel K, Knuiman M, et al. A randomised controlled trial of the Home Independence
37 600 Program, an Australian restorative home-care programme for older adults. Health Soc Care Community http://bmjopen.bmj.com/ 38 601 2013;21(1):69-78. 39 602 26. Martín-Martín LM, Valenza-Demet G, Jiménez-Moleón JJ, et al. Effect of occupational therapy on 40 603 functional and emotional outcomes after hip fracture treatment: a randomized controlled trial. Clin 41 604 Rehabil 2014;28(6):541-51. 42 605 27. Di Monaco M, Vallero F, De Toma E, et al. A single home visit by an occupational therapist reduces the 43 606 risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial. J Rehabil Med 44 607 2008;40(6):446-50.
45 on October 1, 2021 by guest. Protected copyright. 608 28. Di Monaco M, De Toma E, Gardin L, et al. A single postdischarge telephone call by an occupational 46 609 therapist does not reduce the risk of falling in women after hip fracture: a randomized controlled trial. 47 48 610 Eur J Phys Rehabil Med 2015;51(1):15-22. 49 611 29. Aldrich RM. From complexity theory to transactionalism: Moving occupational science forward in 50 612 theorizing the complexities of behavior. J Occup Sci 2008;15(3):147-56. 51 613 30. Cutchin MP, Aldrich RM, Bailliard AL, et al. Action theories for occupational science: The 52 614 contributions of Dewey and Bourdieu. J Occup Sci 2008;15(3):157-65. 53 615 31. Lee Bunting K. A transactional perspective on occupation: a critical reflection. Scand J Occup Ther 54 616 2016;23(5):327-36. 55 617 32. Aldrich RM, Cutchin, M. P. Dewey's concepts of embodiment, growth, and occupations: Extended bases 56 618 for a transactional perspectives. In M. P. Cutchin & V. A. Dickie (Eds.) ed: New York: Springer 2013. 57 619 33. Fisher AG, Marterella, A. Powerful Practice - A Model for Authentic Occupational Therapy. Colorado, 58 620 USA: Center for Innovative OT Solutions, Inc. 2019. 59 621 34. Fisher AG. OTIPM. København: Munkgaard 2013. 60
25 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 36 BMJ Open
1 2 3 4
622 35. Fisher AG, Jones, K B. Occupational Therapy Intervention Process Model. In: Hinojosa J, Kramer, P., BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 623 Royeen C. B., ed. Perspectives on Human Occupation - Theories Underlying Practice. Secon edition ed. 6 624 United States of America: F. A. Davis Company 2017:237-86. 7 625 36. Härnstein G. The Research Circle: Building Knowledge on Equal Terms. Swedish Trade Union 8 9 626 Confederation, Stockholm 1994. 10 627 37. Haak M, Slaug B, Oswald F, et al. Cross-national user priorities for housing provision and accessibility 11 628 findings from the European innovAge Project. Int J Environ Res Public Health 2015;12(3):2670-86. 12 629 38. Iwarsson S, Edberg A-K, Ivanoff SD, et al. Understanding User Involvement in Research in Aging and 13 630 Health. Gerontol. Geriatr. Med. 2019;5:2333721419897781. 14 631 39. Reed J, Weiner R, Cook G. Partnership research with older people – moving towards making the rhetoric 15 632 a reality. J Clin Nurs 2004;13(s1):3-10. 16 633 40. Högdin S KC. Research Circles: A Method for the development of knowlegde and the creation of change 17 634 in practice. Saber Educar 2014;19 18 635 41. Östlund B. The revivalFor of research peer circles: meeting review the needs of only modern aging and the third age. 2008; 19 636 04(34 (4)). 20 637 42. Persson S. Forskningscirklar - en vägledning. Malmö: Malmö stad, 2008. 21 638 43. Borg T. Livsførelse i hverdagen under rehabilitering. Et socialpsykologisk studie. Aalborg Universitet, 22 639 2002. 23 640 44. DePoy. E G, L.N. Gathering Information in Naturalistic Inguiry. Introduction to Research - 24 641 Understanding and Applying Multiple Strategies. 4th ed. St. Louis (USA): Elsevier Mosby 2011:p. 228. 25 642 45. Coyne IT. Sampling in qualitative research; merging or clear boundaries? J Adv Nurs 1997;26(3):7. 26 643 46. Kallio H, Pietila AM, Johnson M, et al. Systematic methodological review: developing a framework for a 27 qualitative semi-structured interview guide. J Adv Nurs 2016;72(12):2954-65. 28 644 29 645 47. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-15. 30 646 48. Nvivo 11 Pro for Windows [program]. 11.4 version: QSR International, 2017. 31 647 49. Richards L. Handling Qualitative Data. A Practical Guide. Third ed. Australia: Sage Publication 2014. 32 648 50. Sermeus W. Modelling process and outcomes in complex interventions. In: Richards D HI, ed. Complex 33 649 interventions in health: an overview of research methods. Oxon and Newe York: Routledge 2015:p.111. 34 650 51. Fisher A. Appendiks. In: Murmand L, ed. OTIPM Latvia: Munksgaard 2013:p. 209. 35 651 52. Young Y RB. Don't worry, Be Positive: Improving functional recovery 1 year after hip fracture. Rehabil 36 652 Nurs 2009;34:110-17.
37 653 53. Saul D, Riekenberg J, Ammon JC, et al. Hip Fractures: Therapy, Timing, and Complication Spectrum. http://bmjopen.bmj.com/ 38 654 Orthop Surg 2019;11(6):994-1002. 39 655 54. Langford D, Edwards N, Gray SM, et al. “Life Goes On.” Everyday Tasks, Coping Self-Efficacy, and 40 656 Independence: Exploring Older Adults’ Recovery From Hip Fracture. Qual Health Res 2018;28(8):1255- 41 657 66. 42 658 55. Tuscan J MB, Santi SM, Stolee P. "Just another fish in the pond": the transitional care experience of a hip 43 659 fracture patient. Int J Integr Care 2013;13(2) 44 660 56. Taylor NF, Harding KE, Dowling J, et al. Discharge planning for patients receiving rehabilitation after
45 on October 1, 2021 by guest. Protected copyright. 661 hip fracture: a qualitative analysis of physiotherapists’ perceptions. Disabil Rehabil 2010;32:492-99. 46 662 57. Schiller C, Franke T, Belle J, et al. Words of wisdom - patient perspectives to guide recovery for older 47 48 663 adults after hip fracture: a qualitative study. Patient Prefer Adher 2015;9:57-64. 49 664 58. Jensen CM, Smith AC, Overgaard S, et al. “If only had I known”: a qualitative study investigating a 50 665 treatment of patients with a hip fracture with short time stay in hospital. Int J Qual Stud Health Well- 51 666 being 2017;12(1):1307061. 52 667 59. Asif M, Cadel L, Kuluski K, et al. Patient and caregiver experiences on care transitions for adults with a 53 668 hip fracture: a scoping review. Disabil Rehabil 2019:1-10. 54 669 60. Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care 55 670 for Persons with Continuous Complex Care Needs. J Am Geriatr Soc 2003;51(4):549-55. 56 671 61. Lockwood KJ, Harding KE, Boyd JN, et al. Predischarge home visits after hip fracture: a randomized 57 672 controlled trial. Clin Rehabil 2019;33(4):681-92. 58 59 60
26 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 36
1 2 3 4
673 62. Stark S, Keglovits M, Arbesman M, et al. Effect of Home Modification Interventions on the Participation BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 674 of Community-Dwelling Adults With Health Conditions: A Systematic Review. Am J Occup Ther 6 675 2017;71(2):1-11A. 7 676 8 9 677 10 678 Figure legends 11 679 Figure 1 Research circle process with overall topics discussed 12 13 680 Figure 2 Analysis process: abstraction of subcategory to generic category 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
27 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 Research circle process with overall topics discussed 46 47 209x297mm (300 x 300 DPI) 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 36 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 Analysis process: abstraction of subcategory to generic category 30 31 297x209mm (300 x 300 DPI) 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 31 of 36 BMJ Open
1 2 3 4 - 5 6 7 8 9 · 10 11 12 For peer review· only 13 · - 14 15 16 17 http://bmjopen.bmj.com/ 18 - · 19 · - - 20 21 22 23 24 · on October 1, 2021 by guest. Protected copyright. - 25 - - 26 27 · - - 28 29 30 · 31 32 · 33 34 · - - 35 36 - 37 38 39 40 41 42 43 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 32 of 36
1 The TIDieR (Template for Intervention Description and Replication) Checklist*: 2 3 Information to include when describing an intervention and the location of the information 4 5 Item Item Where located ** 6 number Primary paper Other † (details) 7 8 (page or appendix 9 number) 10 11 12 BRIEF NAME For peer review only 13 1. Provide the name or a phrase that describes the intervention. P. 5, l. 122-126 ______14 15 WHY 16
2. Describe any rationale, theory, or goal of the elements essential to the intervention. http://bmjopen.bmj.com/ P. 5, l. 122-128, ______17 18 P. 6, l. 137-143 19 WHAT 20 21 3. Materials: Describe any physical or informational materials used in the intervention, including those P. 16-17, L. 377- ______22 23 provided to participants or used in intervention delivery or in training of intervention providers. 388 + table 3 + 24
Provide information on where the materials can be accessed (e.g. online appendix, URL). on October 1, 2021 by guest. Protected copyright. figure 3 25 26 (supplementary 27 file 1) and table 28 29 4 30 31 32 4. Procedures: Describe each of the procedures, activities, and/or processes used in the intervention, P. 16, L. 364- ______33 34 including any enabling or support activities. 375 + table 3 + 35 table 4 36 37 38 39 40 WHO PROVIDED 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 33 of 36 BMJ Open
1 5. For each category of intervention provider (e.g. psychologist, nursing assistant), describe their P. 16, L. 365- ______2 expertise, background and any specific training given. 367 3 4 HOW 5 6 6. Describe the modes of delivery (e.g. face-to-face or by some other mechanism, such as internet or P. 16, L. 365- ______7 telephone) of the intervention and whether it was provided individually or in a group. 367 8 9 10 WHERE 11 12 7. Describe the type(s) of location(s)For where the peer intervention occurred, review including any necessary only P. 16, L. 368- ______13 infrastructure or relevant features. 375 14 15 16 WHEN and HOW MUCH 17 http://bmjopen.bmj.com/ 18 8. Describe the number of times the intervention was delivered and over what period of time including P. 16, L. 365- ______19 the number of sessions, their schedule, and their duration, intensity or dose. 375 + table 4 20 21 TAILORING 22 9. If the intervention was planned to be personalised, titrated or adapted, then describe what, why, P. 16, L. 379 ______23 24 when, and how. 25 on October 1, 2021 by guest. Protected copyright. 26 MODIFICATIONS 27 10.ǂ If the intervention was modified during the course of the study, describe the changes (what, why, N/A ______28 29 when, and how). 30 HOW WELL 31 32 11. Planned: If intervention adherence or fidelity was assessed, describe how and by whom, and if any N/A ______33 34 strategies were used to maintain or improve fidelity, describe them. 35 12.ǂ Actual: If intervention adherence or fidelity was assessed, describe the extent to which the N/A ______36 37 intervention was delivered as planned. 38 39 ** Authors - use N/A if an item is not applicable for the intervention being described. Reviewers – use ‘?’ if information about the element is not reported/not 40 41 sufficiently reported. 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 34 of 36
1 † If the information is not provided in the primary paper, give details of where this information is available. This may include locations such as a published protocol 2 or other published papers (provide citation details) or a website (provide the URL). 3 ǂ If completing the TIDieR checklist for a protocol, these items are not relevant to the protocol and cannot be described until the study is complete. 4 5 * We strongly recommend using this checklist in conjunction with the TIDieR guide (see BMJ 2014;348:g1687) which contains an explanation and elaboration for each item. 6 7 * The focus of TIDieR is on reporting details of the intervention elements (and where relevant, comparison elements) of a study. Other elements and methodological features of 8 9 studies are covered by other reporting statements and checklists and have not been duplicated as part of the TIDieR checklist. When a randomised trial is being reported, the 10 TIDieR checklist should be used in conjunction with the CONSORT statement (see www.consort-statement.org) as an extension of Item 5 of the CONSORT 2010 Statement. 11 When a clinical trial protocol is being reported, the TIDieR checklist should be used in conjunction with the SPIRIT statement as an extension of Item 11 of the SPIRIT 2013 12 Statement (see www.spirit-statement.org). ForFor alternate study peer designs, TIDieR can review be used in conjunction with only the appropriate checklist for that study design (see 13 www.equator-network.org). 14 15 16 17 http://bmjopen.bmj.com/ 18 19 20 21 22 23 24 25 on October 1, 2021 by guest. Protected copyright. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 35 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 Standards for Reporting Qualitative Research (SRQR)* 2 http://www.equator-network.org/reporting-guidelines/srqr/ 3 4 Page/line no(s). 5 Title and abstract 6 7 Title - Concise description of the nature and topic of the study Identifying the 8 study as qualitative or indicating the approach (e.g., ethnography, grounded 9 theory) or data collection methods (e.g., interview, focus group) is recommended 10 3 11 Abstract - Summary of key elements of the study using the abstract format of the 12 intended publication; typically includes background, purpose, methods, results, 13 14 and conclusions 3 15 16 Introduction For peer review only 17 18 19 Problem formulation - Description and significance of the problem/phenomenon P. 6-7 / l. 144- 20 studied; review of relevant theory and empirical work; problem statement 163 21 Purpose or research question - Purpose of the study and specific objectives or 22 questions P. 5 / l. 122-128 23 24 25 Methods 26 27 28 Qualitative approach and research paradigm - Qualitative approach (e.g., 29 ethnography, grounded theory, case study, phenomenology, narrative research) 30 and guiding theory if appropriate; identifying the research paradigm (e.g., 31 postpositivist, constructivist/ interpretivist) is also recommended; rationale** P. 8 / l. 182-193 32
33 http://bmjopen.bmj.com/ 34 Researcher characteristics and reflexivity - Researchers’ characteristics that may 35 influence the research, including personal attributes, qualifications/experience, 36 37 relationship with participants, assumptions, and/or presuppositions; potential or 38 actual interaction between researchers’ characteristics and the research P. 8-9 / l. 195- 39 questions, approach, methods, results, and/or transferability 210 + table 1 40 P. 8-9 / l. 195- 41 Context - Setting/site and salient contextual factors; rationale** 210 on October 1, 2021 by guest. Protected copyright. 42 43 Sampling strategy - How and why research participants, documents, or events 44 were selected; criteria for deciding when no further sampling was necessary (e.g., P. 8-9 / l. 195- 45 sampling saturation); rationale** 210 46 Ethical issues pertaining to human subjects - Documentation of approval by an 47 48 appropriate ethics review board and participant consent, or explanation for lack P. 23 / l. 528- 49 thereof; other confidentiality and data security issues 530 50 Data collection methods - Types of data collected; details of data collection 51 52 procedures including (as appropriate) start and stop dates of data collection and 53 analysis, iterative process, triangulation of sources/methods, and modification of P. 9-10 / l. 213- 54 procedures in response to evolving study findings; rationale** 232 + figure 1 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 36 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 Data collection instruments and technologies - Description of instruments (e.g., 3 interview guides, questionnaires) and devices (e.g., audio recorders) used for data P. 10-11 / l. 234- 4 collection; if/how the instrument(s) changed over the course of the study 249 5 6 7 Units of study - Number and relevant characteristics of participants, documents, P. 11 / l. 251-254 8 or events included in the study; level of participation (could be reported in results) + table 2 9 Data processing - Methods for processing data prior to and during analysis, 10 11 including transcription, data entry, data management and security, verification of P. 9-10 / l. 212- 12 data integrity, data coding, and anonymization/de-identification of excerpts 232 + figure 2 13 Data analysis - Process by which inferences, themes, etc., were identified and 14 developed, including the researchers involved in data analysis; usually references a P. 10-11 / l. 233- 15 specific paradigm or approach; rationale** 249 + figure 2 16 For peer review only 17 Techniques to enhance trustworthiness - Techniques to enhance trustworthiness P. 15 / l. 343-348 18 and credibility of data analysis (e.g., member checking, audit trail, triangulation); + p. 17 / l. 389- 19 rationale** 396 20 21 22 Results/findings 23 Synthesis and interpretation - Main findings (e.g., interpretations, inferences, and 24 25 themes); might include development of a theory or model, or integration with P. 11-14 / l- 251- 26 prior research or theory 333 27 Links to empirical data - Evidence (e.g., quotes, field notes, text excerpts, P. 11-14 / l. 266- 28 photographs) to substantiate analytic findings 333 29 30 31 Discussion 32
33 Integration with prior work, implications, transferability, and contribution(s) to http://bmjopen.bmj.com/ 34 the field - Short summary of main findings; explanation of how findings and 35 conclusions connect to, support, elaborate on, or challenge conclusions of earlier 36 scholarship; discussion of scope of application/generalizability; identification of P. 20-22/ l. 438- 37 unique contribution(s) to scholarship in a discipline or field 490 38 Limitations - Trustworthiness and limitations of findings P. 22 / l. 503-508 39 40
41 Other on October 1, 2021 by guest. Protected copyright. 42 Conflicts of interest - Potential sources of influence or perceived influence on 43 study conduct and conclusions; how these were managed P. 24 / l. 531 44 45 Funding - Sources of funding and other support; role of funders in data collection, 46 interpretation, and reporting P. 24 / l. 532-536 47 48 49 *The authors created the SRQR by searching the literature to identify guidelines, reporting 50 standards, and critical appraisal criteria for qualitative research; reviewing the reference 51 lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to 52 improve the transparency of all aspects of qualitative research by providing clear standards 53 for reporting qualitative research. 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 **The rationale should briefly discuss the justification for choosing that theory, approach, 2 method, or technique rather than other options available, the assumptions and limitations 3 4 implicit in those choices, and how those choices influence study conclusions and 5 transferability. As appropriate, the rationale for several items might be discussed together. 6 7 Reference: 8 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative 9 research: a synthesis of recommendations. Academic Medicine, Vol. 89, No. 9 / Sept 2014 10 DOI: 10.1097/ACM.0000000000000388 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Developing an individualised cross-sectoral programme based on activity of daily living to support rehabilitation of older adults with hip fracture: a qualitative study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-044539.R2
Article Type: Original research
Date Submitted by the 23-Apr-2021 Author:
Complete List of Authors: Ropke, Alice; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences Lund, Karina; Herlev Hospital, Department of Physiotherapy and Occupational Therapy Thrane, Camilla ; Herlev Municipality, Health Promotion and Rehabilitation Juhl, Carsten; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences
Morville, Anne-Le; Jönköping University, Department of Rehabilitation http://bmjopen.bmj.com/ School of Health and Welfare
Primary Subject Qualitative research Heading:
Secondary Subject Heading: Health services research
Hip < ORTHOPAEDIC & TRAUMA SURGERY, REHABILITATION MEDICINE, Keywords: QUALITATIVE RESEARCH on October 1, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 36 BMJ Open
1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 36
1 2 3 4 1 Title page BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 2 7 3 Developing an individualised cross-sectoral programme based on activity of daily living to support 8 4 rehabilitation of older adults with hip fracture: a qualitative study 9 5 10 6 Authors: 11 7 1,2Alice Røpke 12 8 1Karina Lund 13 3 14 9 Camilla Thrane 1,2 15 10 Carsten Bogh Juhl 16 11 4Anne-Le Morville 17 12 18 13 Corresponding author:For peer review only 19 14 Alice Røpke 20 15 Herlev and Gentofte Hospital 21 22 16 Department of Physiotherapy and Occupational therapy 23 17 Borgmester Ib Juuls Vej 29 24 18 Opgang 8, 3. sal, O1 25 19 2730 Herlev 26 20 Denmark 27 21 Email (work): [email protected] 28 29 22 https://orcid.org/0000-0001-7793-5558 30 23 Phone: +45 (0) 26882002 (mobile) 31 24 32 25 1Department of Physiotherapy and Occupational Therapy 33 26 Copenhagen University Hospital, Herlev and Gentofte 34 27 Department of Physiotherapy and Occupational therapy 35 28 Borgmester Ib Juuls Vej 29 36 29 Opgang 8, 3. sal, O1 37 http://bmjopen.bmj.com/ 38 30 2730 Herlev 39 31 Denmark 40 32 41 33 2Department of Sports Science and Clinical Biomechanics 42 34 University of Southern Denmark 43 35 Campusvej 55 44 36 5230 Odense M 45 on October 1, 2021 by guest. Protected copyright. 46 37 Denmark 47 38 48 39 3Health Promotion and Rehabilitation 49 40 Tvedvangen 196 50 41 2730 Herlev 51 52 42 Denmark 53 43 54 44 4Department of Rehabilitation 55 45 School of Health and Welfare 56 46 Jönköping University 57 47 Box 1026 58 48 551 11 Jönköping 59 60
1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 36 BMJ Open
1 2 3 4 49 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 50 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 7 51 8 52 Word count: 4479 – excluding title page, references, figures and tables. 9 53 10 11 12 54 13 14 15 55 16 17 56 18 For peer review only 19 20 57 21 22 23 58 24 25 26 59 27 28 29 60 30 31 61 32 33 34 62 35 36
37 63 http://bmjopen.bmj.com/ 38 39 40 64 41 42 43 65 44
45 on October 1, 2021 by guest. Protected copyright. 66 46 47 48 67 49 50 51 68 52 53 54 69 55 56 57 70 58 59 60
2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 36
1 2 3 4 71 Developing an individualised cross-sectoral programme based on activity of daily living to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 72 support rehabilitation of older adults with hip fracture: a qualitative study 8 9 73 ABSTRACT 10 11 12 74 Objectives: To develop an individualised rehabilitation programme for personal and instrumental 13 14 15 75 activities of daily living (ADL tasks), enabling older adults with hip fractures to perform ADL 16 17 76 safely and independently. 18 For peer review only 19 77 Design: Qualitative study inspired by the Complex-intervention development (Medical Research 20 21 78 Council (MRC) framework phase I) using literature search and research circles. 22 23 24 79 Settings: University Hospital of Copenhagen, Herlev and Gentofte and Herlev and Gentofte 25 26 80 municipalities. 27 28 81 Participants: One research circle with seven older adults with hip fractures, and one with seven 29 30 31 82 healthcare professionals (occupational therapists and physiotherapists). 32 33 83 Results: Three generic categories were identified (1) ‘Challenge older adults with goal-oriented 34 35 84 ADL tasks’, (2) ‘Implement strategies to enhance independent and safe performance of ADL tasks’ 36
37 http://bmjopen.bmj.com/ 38 85 and (3) ‘Communicate the important information to the target group and across sectors’. A 39 40 86 programme was developed and an intervention to enhance usual rehabilitation was designed 41 42 87 comprising: an individualised intervention component consisting of five additional therapy 43 44 88 sessions; one during hospitalisation, four in the municipality and a follow-up phone call.
45 on October 1, 2021 by guest. Protected copyright. 46 47 89 Conclusions: Engaging and integrating activities into rehabilitation treatment may support 48 49 50 90 rehabilitation. Recommendations on how to initiate, graduate and challenge older adults with hip 51 52 91 fracture in performing daily activities, e.g. ADL-task complexity, context and duration, 53 54 92 implementing strategies such as energy-saving techniques; e.g. the use of assistive devices for 55 56 93 mobility, bathing and dressing and communicating information in transitional rehabilitation; e.g. 57 58 59 60
3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 36 BMJ Open
1 2 3 4 94 booklet following older adults across sectors with information on procedures and patient-held ADL- BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 95 task goal-setting. 8 9 96 Keywords: Activity of daily living, hip fracture, qualitative research, rehabilitation. 10 11 97 12 13 14 98 Strengths and limitations of this study 15 16 17 99 This study highlights that a participatory design is suitable when developing a hip fracture 18 For peer review only 19 100 rehabilitation programme. 20 21 22 101 The credibility and trustworthiness of our findings were enhanced by using peer and 23 24 102 member checking. 25 26 103 A comprehensive process and feasibility evaluation of the hip fracture rehabilitation 27 28 29 104 programme is needed to test adherence to and compliance with the intervention. 30 31 32 105 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 36
1 2 3 4 107 INTRODUCTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 108 Despite positive surgical outcomes, older adults with hip fractures (HF) need rehabilitation to 7 8 9 109 optimise their performance in Activities of Daily Living (ADL). Just one-third regain their pre- 10 11 110 fracture level of physical function and capacity to perform ADL.1 2 For the remaining two-thirds, 12 13 111 there is an increased risk of social isolation, depression and reduced Quality of Life (QoL). 3-6 14 15 112 Studies have reported poor post-fracture outcomes and coordination across the healthcare sectors 16 17 7 8 18 113 does not always meet frailFor patients’ peer needs. review Close, continuous only and efficient collaboration between 19 20 114 different professions and healthcare sectors is essential to provide patient-centred rehabilitation 21 22 115 based on the individual’s needs, wishes and competences.9 Several studies support the effect of 23 24 25 116 multidisciplinary rehabilitation of patients with HF, combining nursing care, physiotherapy, 26 27 117 occupational therapy and/or social work.10-13 Few studies focus on occupation14 and improving 28 29 118 ADL 7 15 16, and how to support the older adult to safely and independently perform ADL tasks. 30 31 32 119 Occupation in this article refers not only to work but general activity and participation in daily 33 34 120 life.14 Thus, the use of motor skills and process skills during ADL task performances is named 35 36 121 occupational performance.14
37 http://bmjopen.bmj.com/ 38 122 Thus, the purpose of this study was to gather knowledge of experiences, needs and expectations of 39 40 41 123 rehabilitation from older adults with HF to develop an intervention programme focusing on their 42 43 124 ability to safely and independently perform ADL. To develop a sustainable intervention, with 44
45 on October 1, 2021 by guest. Protected copyright. 125 multiple perspectives from older adults with HF, their families, and the healthcare professionals 46 47 48 126 (HCP) - specifically physiotherapists (PT) and occupational therapists (OT) are needed. This study 49 50 127 is the first step of a forthcoming trial of developing and evaluating a complex intervention for the 51 52 128 rehabilitation of older adults with HF focusing on enabling occupational performance. 53 54 55 129 56 57 130 58 59 131 60
5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 36 BMJ Open
1 2 3 4 132 INTERVENTION DESCRIPTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 17 7 133 The Template for Intervention Description and Replication (TIDieR) checklist was used to 8 9 134 evaluate the comprehensiveness of the reporting of the cross-sectorial intervention. Furthermore, 10 11 135 Standards for Reporting Qualitative Research (SRQR) checklist18 was used to show transparency in 12 13 14 136 all steps in the qualitative research (supplemental material). 15 16 137 Rationale and theory essential to the intervention 17 18 138 The intervention was consideredFor peer a complex interventionreview with onlymultiple interacting components. The 19 20 19 20 21 139 development phase was inspired by the 2008 UK Medical Research Council (MRC) framework 22 23 140 for developing and evaluating complex interventions, which presents three steps: (1) identifying the 24 25 141 evidence base, (2) identifying/developing theory and (3) modelling the process and outcomes. Older 26 27 28 142 adults with HF, HCPs, administrators and managers were continuously involved in the development 29 30 143 stage21. 31 32 144 1. IDENTIFYING THE EVIDENCE BASE 33 34 145 Identifying the evidence and specifying the content of the intervention was formulated based on a 35 36
37 146 literature search carried out in March 2018 with regular updates on Medline, Cinahl and Embase http://bmjopen.bmj.com/ 38 39 147 using the search string: [hip fracture AND activity of daily living AND occupational therapy]. 40 41 148 Interventions for older adults with HF dependent on support and rehabilitation are often 42 43 12 44 149 multidisciplinary. The organisation and implementation of rehabilitation services varies in length
45 on October 1, 2021 by guest. Protected copyright. 46 150 and content, but usually includes occupational therapy and physical therapy.10 22 The positive 47 48 151 outcome would be a reduced need of home care and improved occupational performance.23 Studies 49 50 51 152 on occupational performance have shown that interventions focused on ADL results reduced 52 53 153 dependency in (Personal) PADL24 and (Instrumental) IADL24 25. Postoperative care after HF 54 55 154 focuses on individual techniques for dressing, bathing and adapting the home environment15 16, 56 57 155 transferring, positioning and postural standing, technical aids for PADL and IADL.26 In addition, 58 59 60
6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 36
1 2 3 4 156 home visits by an occupational therapist assessing home environment provides strategies for early BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 15 26 27 7 157 recovery. A post-discharge telephone call in a multidisciplinary intervention may be 8 9 158 effective in reducing the proportion of fallers27 28 Only a few trials focus on providing strategies for 10 11 159 safe and independent occupational performance, focusing on the activities most important for the 12 13 14 160 patient’s self-care and independence. Sessions included a range of topics, e.g. technical aids and 15 16 161 instructions related to ADL training, home environment advice, fall prevention, transfer, walking 17 18 162 and ADL.7 26 IndividualisedFor occupational peer therapy review intervention only was found to have advantages in 19 20 163 relation to patients’ ability, e.g. their ability to perform ADL and improvements in perceived 21 22 7 26 23 164 health. 24 25 165 26 27 166 2. IDENTIFYING/DEVELOPING THEORY 28 29 30 167 The theoretic foundation of the intervention was based on a transactional perspective on 31 32 168 occupation29-31 and inspired the development phase emphasising (1) person-context relations, and 33 34 169 (2) occupation as a continuous response to situational elements.29 30 32 An important aspect is to 35 36 170 recognise that people cannot be separated from their experiences and context in life, emphasising 37 http://bmjopen.bmj.com/ 38 39 171 the importance of taking each individual’s circumstances into account during rehabilitation.33 What 40 41 172 to do and how to be occupation-centred during interventions is defined as having (1) an occupation- 42 43 173 focused approach concentrating attention on occupation with a proximal focus on e.g. body 44
45 on October 1, 2021 by guest. Protected copyright. 46 174 functions, environment or other contextual factors (2). An occupation-based approach involves 47 48 175 occupational performance as part of evaluations or as interventions engaging in, e.g. cooking or 49 50 176 reading a book.14. Ensuring that the intervention is occupation-centred, the Occupational Therapy 51 52 53 177 Intervention Process Model (OTIPM) provides a frame for the intervention. The intervention 54 55 178 process is depicted as occurring over three phases: evaluation and goal setting, intervention, and re- 56 57 58 59 60
7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 36 BMJ Open
1 2 3 4 14 34 35 179 evaluation. Identifying a theory to underpin the specific essential intervention is derived from BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 180 the collaboration between older adults with HF and HCPs. 8 9 10 181 MATERIAL AND METHODS 11 12 182 A qualitative participatory design was adopted, by applying the research circle method36 37, 13 14 15 183 emphasising engagement and collaborative action between older adults with HF, HCPs and 16 17 184 researchers.38 39 The research circle process is characterised by mutual reflection and engagement 18 For peer review only 19 185 between participants contributing with equal authority to co-create collective knowledge. Research 20 21 186 circles are based on a common theme that is discussed to generate new in-depth knowledge among 22 23 40-42 24 187 the included participants. Two research circles were formed: one with older adults with HF, and 25 26 188 another with HCPs, OTs and PTs who either work in hospital settings or in municipalities. 27 28 189 The overarching theme for each meeting was determined in advance by Alice Røpke (AR) the first 29 30 43 31 190 author and inspired by the rehabilitation phases in practice developed by Borg ; 1) Rehabilitation 32 33 191 during hospitalisation, 2) Rehabilitation in transition to the municipality, 3) Rehabilitation in the 34 35 192 municipality, and 4) The resultant collective proposal for a hip rehabilitation programme. At each 36
37 44 http://bmjopen.bmj.com/ 38 193 meeting, an interview guide was developed based on the respective themes (figure 1). 39 40 194 Sampling and recruitment 41 42 43 195 Purposeful sampling was performed to recruit older participants with HF from a range of post-acute 44 45 45 196 settings and demographics, e.g. type of housing, geographical district, age and sex. The HCPs on October 1, 2021 by guest. Protected copyright. 46 47 197 were recruited from Herlev and Gentofte municipality rehabilitation centres and from Copenhagen 48 49 50 198 University Hospital, Herlev and Gentofte (table 1) during the period February to March 2018. 51 52 199 53 54 200 55 56 201 57 58 59 202 60
8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 36
1 2 3 4 Table 1 Inclusion and exclusion criteria for older adults with hip fracture
203 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 Inclusion criteria Exclusion criteria 6 Aged 55 years or older Not expected to be discharged to home or rehabilitation centres in the municipality 7 Recent proximal hip fracture (S 72.0 Medial femur fracture, S 72.1, Not able to speak and/or understand Danish 8 Pertrochanteric femur fracture, S 72.2, Subtrochanteric femur fracture) Severe physical and/or mental disabilities prior to the hip fracture 9 Living at home prior to hip fracture in Herlev or Gentofte municipalities 10 Ability to give informed consent 11 Discharged from hospital and receiving or having received rehabilitation 12 from the municipalities within the last 3 months from onset 13 Inclusion criteria in research circles for healthcare professionals 14 At least 2 years of experience with rehabilitation of older adults with hip fracture in the included municipalities or Hospital 15 204 16 17 18 205 HCPs at the two municipalitiesFor identifiedpeer potential review participants only and scheduled dates and times for 19 20 206 the research circle meetings for both older adults and the HCPs. 21 22 207 To create a relaxed and trusting atmosphere, the research circles were conducted at the 23 24 208 rehabilitation facilities. Prior to the meetings, an email with information about the overall topic for 25 26 27 209 the meetings, time, place and provision of transportation were sent to the participants. 28 29 210 30 31 32 211 Data collection 33 34 212 All research circle meetings were conducted between April and June 2018. Two pilot interviews to 35 36 213 test the preliminary interview guide were performed: one with an experienced HCP and a group
37 http://bmjopen.bmj.com/ 38 214 interview with five older adults who had experienced hip fracture rehabilitation. Testing the 39 40 46 41 215 interview guide, first with the research team and subsequently with potential study participants 42 43 216 resulted in a reduced number of questions and revision of the interview guide. 44
45 on October 1, 2021 by guest. Protected copyright. 217 46 47 48 218 Insert figure 1 here 49 50 219 51 52 220 Each meeting of the research circle was prepared, recorded and facilitated by two authors (AR) and 53 54 55 221 Karina Lund (KL) (figure 1). Using the interview guide, open-ended questions were asked about the 56 57 222 participants’ needs, wishes and expectations for individualised occupation-based rehabilitation for 58 59 223 adults with hip fractures. The meetings were conducted every third week with older adults and 60
9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 36 BMJ Open
1 2 3 4 224 HCPs separately for the first three meetings and together in the last meeting, to share knowledge BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 225 and ideas gathered from the previous meetings. Each meeting lasted for approximately two hours. 8 9 226 Between meetings, participants were encouraged to reflect and take notes in a booklet as a resource 10 11 227 for discussion at the following meeting. At the end of each meeting, the participants were asked to 12 13 14 228 highlight one idea or statement that they thought important to include in further developing the 15 16 229 intervention programme. Summary notes from each meeting were subsequently presented at the 17 18 230 next meeting to sustainFor the continuity peer of innovations review across meetings. only The participants were also 19 20 231 asked to verify the summaries, thus ensuring they were actively involved in the initial analysis. 21 22 23 232 Data analysis 24 25 233 The analysis procedure included two levels and was performed by two authors (AR and KL). Level 26 27 28 234 one began after the first meeting of each research circle. The summary of notes taken during the 29 30 235 meetings formed the basis of an emerging categorisation of data, confirmed by participants at the 31 32 236 end of every meeting. Level two of the analysis process involved inductive content analysis 33 34 237 performed at a manifest level in three phases as described by Elo and Kyngäs.47 During level two, a 35 36
37 238 third author, Anne-Le Morville (AM), joined the analysis process. In the preparation phase, each of http://bmjopen.bmj.com/ 38 39 239 the transcripts was read thoroughly several times to verify its accuracy. The organising phase 40 41 240 included open coding, where AR and KL independently highlighted the key statements in the 42 43 44 241 transcripts related to the topics in the interview guides. Using an iterative style, meaning units were
45 on October 1, 2021 by guest. Protected copyright. 46 242 then organised and condensed by the two authors using Nvivo 11 Pro.48 The analysis moved from 47 48 243 lower to higher levels of abstraction, identifying an initial interpretation of patterns, grouping, and 49 50 51 244 comparing data in subcategories and categories. A description of the subcategories and categories 52 53 245 was then articulated during the reporting phase. The authors explored similarities and differences in 54 55 246 the analysis during meetings, which facilitated the development of categories and patterns that best 56 57 58 59 60
10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 36
1 2 3 4 49 247 illustrated the needs, expectations and experiences of the participants. Subcategories emerged and BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 248 finally the abstraction to generic categories was performed. The process is shown in figure 2. 8 9 249 10 11 250 PATIENT AND PUBLIC INVOLVEMENT 12 13 14 251 One of the strengths of this study has been the involvement of the patient and public representatives 15 16 252 in the overall study design from the start. From the initial idea raised at a cross-sectoral workshop 17 18 For peer review only 19 253 with HCPs involvement of patients and HCPs providing input, to content of the intervention for the 20 21 254 final HIP-REP manual and on the choice of outcome measures, both patients and public have been 22 23 255 involved. Afterwards all participants of the patient and public representatives were invited to review 24 25 26 256 and comment on the draft HIP-REP manual, and thus formed an important part of assessing 27 28 257 acceptability of the intervention. Two co-authors on this paper were key members of the research 29 30 258 team and contributed to the development and refinement of the content for the HIP-REP manual 31 32 33 259 and manuscript revision. 34 35 36 260 RESULTS 37 http://bmjopen.bmj.com/ 38 39 261 Identifying a theory to underpin the specific essential intervention elements 40 41 262 A total of 14 participants were included in the research circles: four OTs, three PTs and seven older 42 43 263 people with HF (six females and one male). Table 2 summarises the demographic data of the older 44
45 on October 1, 2021 by guest. Protected copyright. 46 264 adults and HCPs. 47 48 265 49 50 266 Table 2 Demographic data of the participants in research circles (n=14) 51 52 Older Female Male Age Living situation Adults (range) (range) 53 54 (n=7) 6 1 58-93 5 living alone 55 Healthcare Physiotherapist Occupational Years of experience 56 Professionals therapist (range) 57 58 (n=7) 3 4 2-25 years 59 60
11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 36 BMJ Open
1 2 3 4 267 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 268 Though the groups faced their own unique challenges, older adults and the HCPs shared 8 9 269 experiences, needs and ideas for a transitional rehabilitation programme, which led to the 10 11 270 identification of three generic categories: 1) Challenge older adults with goal-oriented ADL tasks, 12 13 14 271 2) Implement strategies to enhance an independent, safe performance of ADL tasks, and 3) 15 16 272 Communicate the information to the target group and across healthcare sectors (figure 2). 17 18 273 For peer review only 19 20 274 Insert figure 2 here 21 22 23 275 24 25 276 26 27 277 Each generic category extracted from the data is summarised and supported with quotes. The 28 29 30 278 supporting quotes will indicate which of the research circle meetings the quote was extracted from, 31 32 279 the research circle, group, and number e.g. (RCOHF01). 33 34 280 Challenge older adults with goal-oriented ADL tasks 35 36
37 281 All participants emphasised the importance of older adults with HF being challenged to perform http://bmjopen.bmj.com/ 38 39 282 PADL and IADL tasks and the importance of challenging the older adult from day one after 40 41 283 surgery. 42 43 44 284 However, due to the influence of medication, pain, and lack of sleep and food during the hospital
45 on October 1, 2021 by guest. Protected copyright. 46 285 stay, several of the older adults with HF lacked confidence in ambulation, physical and ADL 47 48 286 abilities when discharged: 49 50 51 287 “… if you start during the 8 days (at the Hospital), before 52 53 288 going to the Rehabilitation Centre, and you were activated all you were 54 55 289 able to, to show what you are capable of…but they forget that the patient has to be 56 57 290 challenged…they should activate us as much as possible.” (L1, female patient, RCOHF01) 58 59 60
12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 36
1 2 3 4 291 They suggested individual ADL tasks (e.g. preparing and eating fresh fruit, washing hands and BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 292 face, brushing teeth by the sink) matching older adults, e.g. in relation to capacity and wanted a 8 9 293 focus on personal ADL goals while in the hospital. After discharge from hospital, more complex 10 11 294 domestic and social ADL tasks were asked for by older adults. For example, early independence 12 13 14 295 and safety in walking to the bathroom and managing toileting and bathing to gain previous levels of 15 16 296 function: 17 18 297 “We wantFor to learn peer to be ourselves review again. As quickly only as possible!” 19 20 298 (W4, female participant, RCOHF02) 21 22 23 299 Implement strategies to enhance independent and safe performance of ADL tasks 24 25 300 All participants emphasised “implement strategies to enhance independent and safe performance of 26 27 28 301 ADL tasks”. Older adults raised the issue of their reliance on mobility devices from day one and in 29 30 302 the following weeks or even months, as this limited their ability to perform ADL tasks. They 31 32 303 emphasised the importance of the timing of introduction and graduation of the use of a rollator, 33 34 304 walker and/or crutches. Strategies and ideas for carrying objects over short distances were 35 36
37 305 discussed, e.g. using an apron with pockets or crossbody bag for carrying a mobile phone and/or http://bmjopen.bmj.com/ 38 39 306 snacks/beverage: 40 41 307 “…I used a crutch indoors. So, if I want to carry anything I must run back and forth 42 43 44 308 17 times you know, because I can only carry one thing at a time right, but then you can
45 on October 1, 2021 by guest. Protected copyright. 46 309 use an apron to put things in the front pocket.” (LI, female patient, RCOHF03). 47 48 310 Additionally, being presented with small assistive devices, e.g. sock aid, long handled reacher, etc. 49 50 51 311 several times was indicated as necessary both during hospital stay and at follow up in the 52 53 312 municipality: 54 55 313 “I was able to arrange a visit where they (OT) brought a 56 57 314 stocking aid, that was great. It was fabulous…she gave me this and 58 59 60
13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 36 BMJ Open
1 2 3 4 315 one, two, three, I could use it myself.” (W4, female patient, RCOHF04) BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 316 8 9 317 Communicate the important information to the target group and across sectors 10 11 318 The final category that emerged was the lack of information and communication across healthcare 12 13 14 319 sectors. Organisational changes in workflow are not always passed on to HCPs across sectors, i.e. 15 16 320 new procedures regarding instructions in movement restrictions or new guidelines regarding 17 18 321 rehabilitation services Forin the municipalities. peer review only 19 20 21 322 “…we can’t promise the older adult at the hospital anything in regard to future 22 23 323 rehabilitation in the municipality before we are sure of their options.” 24 25 324 (P02, clinical specialist OT, RCHCP02) 26 27 28 325 Furthermore, older adults with HF wanted general knowledge, such as a booklet about what to 29 30 326 expect during and after the operation and during rehabilitation phases, such as information 31 32 327 concerning the operation method, normal physical reactions after HF surgery, restrictions and how 33 34 328 these could influence a person’s occupational performance. 35 36
37 329 The importance and dependence on the older adult’s social network were evident when gathering http://bmjopen.bmj.com/ 38 39 330 information and planning the rehabilitation. Several of the older adults with HF emphasised that 40 41 331 they were dependent on family and friends to support basic ADL tasks, both at home and at the 42 43 44 332 rehabilitation centre.
45 on October 1, 2021 by guest. Protected copyright. 46 333 “I think it is important that the HCP at the hospital pays attention to whether there is 47 48 334 any network no matter how old you are…” 49 50 51 335 (S4, clinical specialist PT, RC0401) 52 53 336 Older adults with experience from a rehabilitation centre, emphasised the importance of a home 54 55 337 visit prior to discharge, to identify potential barriers and minimise the fear of returning home. 56 57 338 Furthermore, both older adults and HCP expressed the need for a home visit within one to three 58 59 60
14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 36
1 2 3 4 339 working days post discharge directly from the hospital or the rehabilitation centre to their home to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 340 resolve issues associated with their home environment and plan their individual rehabilitation. 8 9 341 “A visit to the home provides valuable information about how older adults function outside 10 11 342 the rehabilitation setting. Maybe older adults need a rail in the bathroom, or the carpet 12 13 14 343 needs to be removed or nightlights need to be set up. So, whatever caused the fall, 15 16 344 you go through the environment, removing obstacles so they will feel safer at home.” 17 18 345 (ML1, clinical Forspecialist, peer OT, RCHCP01). review only 19 20 346 21 22 23 347 3. MODELLING PROCESS AND OUTCOMES 24 25 348 A first draft of an intervention manual and expert review 26 27 349 The processes and outcomes were modelled as recommended by Sermeus et al.50 The first author 28 29 17 30 350 drafted a detailed intervention manual using the TIDierR checklist and Standards for Reporting 31 32 351 Qualitative Research (SRQR) checklist18. 33 34 352 The occupation-centred framework for conceptualising the Hip Fracture Rehabilitation Programme 35 36 353 (HIP-REP) is based on the OTIPM14 and focuses on occupation and approaches identified as: an 37 http://bmjopen.bmj.com/ 38 39 354 occupation-based approach, an occupation-focused approach or both. 40 41 355 Following the development of a draft for the manual of the HIP-REP programme, it was 42 43 356 commented on by an impartial rehabilitation expert with knowledge and experience with older 44
45 on October 1, 2021 by guest. Protected copyright. 46 357 adults with HFs and in the development of complex interventions. Furthermore, participants from 47 48 358 the research circles all agreed to read and comment on the draft of the manual for the HIP-REP 49 50 359 programme to verify the content, and thus verify the relevance and expected feasibility of its 51 52 53 360 implementation. 54 55 56 57 58 59 60
15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 36 BMJ Open
1 2 3 4 361 The development of the HIP-REP programme BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 362 The qualitative data were used to develop an overarching working theory: ‘The following will lead 8 9 363 to safer and more independent performance of ADL tasks: (i) challenging older adults with HF with 10 11 364 goal-specific ADL tasks through an individually tailored goal-oriented programme increasing the 12 13 14 365 complexity of ADL tasks in addition to usual rehabilitation, and (ii) increasing the co-ordination 15 16 366 and information of services between sectors delivering rehabilitation across sectors. 17 18 For peer review only 19 367 The working theory was discussed with researchers in the field of health science and from this, aims 20 21 368 and ideas for the intervention were derived. The three generic categories and the working theory 22 23 369 led to the following elements: Inspiration sheets (occupation-focused and occupation-based 24 25 26 370 activities), Worksheets, Information sheets and pamphlets (see online supplementary file 1). The 27 28 371 elements were then framed according to the OTIPM51 process and reorganised into the HIP-REP 29 30 372 programme (table 3). The HIP-REP programme focuses on an individual adaptation of the 31 32 373 programme and increasing the complexity of ADL tasks with the goal of returning to an 33 34 35 374 independent and safe performance of relevant tasks (table 4). 36
37 http://bmjopen.bmj.com/ 38 375 A first draft of an intervention manual and expert review 39 40 376 Programme Structure 41 42 377 The HIP-REP programme consists of three phases over a total of eight weeks (table 4) supervised 43 44 378 by OTs; preliminary interviews, baseline tests, five interventions focusing on ADL that each last a 45 on October 1, 2021 by guest. Protected copyright. 46 47 379 minimum of one hour and a maximum of two hours (including transport and registration for the 48 49 380 HCP), and a follow-up phone call at 10 weeks post-operatively. Due to different structures in the 50 51 52 381 municipalities, the HIP-REP programme was divided into a ‘two-way track’ after discharge from 53 54 382 hospital. Both tracks applied four interventions in the municipality undertaken in agreement with 55 56 383 the older adults. Track one involved older adults being transferred directly to their own home. Track 57 58 384 two involved older adults staying at a rehabilitation centre before discharge to their home. In both 59 60
16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 36
1 2 3 4 385 tracks, the intervention was scheduled, in collaboration with the older adults as shown in table 4. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 386 When discharged from either hospital or rehabilitation centre, visits to the older adult’s own home 8 9 387 were to be carried out between the first and third weekday after returning home. 10 11 388 12 13 14 389 Programme Content 15 16 390 The content of the HIP-REP programme is standardised and guided by a manual (table 4) but 17 18 391 individually tailored forFor older adults, peer and the review intervention thus only varies in the content and complexity 19 20 21 392 of ADL tasks, based on older adults’ priorities, their type of hip fracture and surgical fixation. The 22 23 393 OTIPM34 guides the HIP-REP programme, with focus on occupational performance for both 24 25 394 intervention and evaluation as described in the manual (full version in Danish available from 26 27 28 395 authors on request). In general, for each intervention, the following elements appear: 1) Interview, 29 30 396 assessment and identification of problems and/or change in the occupational performance, 2) The 31 32 397 intervention phase with implementation of tailored, purposeful activities for performing ADL tasks, 33 34 398 3) The re-assessment phase with an initial interview to identify older adults’ meaningful pre-hip 35 36
37 399 fracture activities. Inspiration and information material and worksheets were prepared for each http://bmjopen.bmj.com/ 38 39 400 session with older adults. 40 41 401 Expert review 42 43 44 44 402 Determining the content validity an expert in rehabilitation for older adults with HF suggested
45 on October 1, 2021 by guest. Protected copyright. 46 403 structural and content considerations for the programme, e.g., a clarification on introduction and 47 48 404 education of the OTs participating in the programme and suggesting a clarification of exclusion 49 50 51 405 criteria. There was also a suggestion as to when intervention during hospitalization could be 52 53 406 implemented. The expert reviews, ideas and suggestions were considered and incorporated into 54 55 407 manual. The participants in the research circles commented on unclear sentences and spelling 56 57 408 mistakes which was corrected in the final manual (table 4). 58 59 60
17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 36 BMJ Open
1 2 3 4
409 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 410 Table 3 Intervention elements incorporated in the HIP-REP programme 7 Intervention process Specification How 8 9 Inform and assess Inform about the intervention Older adults with HF: · HIP-REP programme informing the older adult about the plan for cross-sectional intervention 10 · Booklet handed out to the older adult for the recording of information and patient-held ADL goal-setting · Exploration of possible activity areas to perform ADL tasks; Hospital, Rehab, own home 11 HCPs: 12 · OTIPM inspired worksheet 13 Clarify the older adult’s client-centred performance HCPs - Interview the older adult and other HCPs 14 - Review of existing documentation 15 - Identify aspect that supports and limits the occupational performance; personal, physical, social and institutional surroundings 16 Describe older adults self-reported strength and HCPS: 17 problems with activity performance Interview the older adult with HF - Older adults with HF: 18 For peer Decide review and prioritise possible ADL-tasks only at the hospital, rehab centre or at own dwelling 19 Describe which task the older adult prioritize as a Older adults with HF: 20 focus during assessment and intervention · Initiate ADL activities; ideas to graduated ADL tasks · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest 21 HCPs: 22 - · Information: Booklet for the older adult; hip fracture procedure, operation type, and “what to expect” 23 symptoms after the operation was handed out 24 Observer older adults task performance and HCPs (OT): describe older adults starting point for activity AMPS assessment of the older adult with HF performing prioritised tasks 25 performance 26 Clarify and interpret the reasons older adults HCPs 27 reduced activity performance To analyse the older adult with HFs physical, personal and environmental surroundings 28 · Hip fracture information; operation and restriction movements
29 · Information and instruction; mobility devices and PADL technical aids for bathing and dressing 30 Formulate goals Older adults with HF and HCPs: · Occupation-focused and/or occupation-based goals are formulated; the agreed goals are written in booklet and 31 evaluated at each meeting 32 Plan and initiate Older adults with HF and HCPs 33 intervention In collaboration it is decided which intervention to initiate: Compensatory, Acquisitional model for skills training 34 and/or Restorative model for enhancing body functions and other client elements · Initiate activities; ideas to graduated ADL tasks 35 · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest 36 Assess the result Observe older adults task performance and HCPs (OT) describe the new level for activity performance AMPS follow-up assessment is performed 37 http://bmjopen.bmj.com/ 38 Compare the new level of performance with HCPs: 39 starting point and goals · Assess the AMPS results in collaboration with the older adult with HF 40 Decide if the Older adults with HF and HCPs intervention At the last intervention visit it is decided if the intervention should continue or end 41 continues or ends - · Follow-up phone-call to the older adult with HF 42 End the Older adults with HF and HCPs 43 intervention process Decide if further intervention is necessary and/or maybe refer to other healthcare relevant offers in the municipality 44 411 Categories from analysis informing the content of the elements in the Hip fracture Rehabilitation Programme based on OTIPM.51
45 on October 1, 2021 by guest. Protected copyright. 412 46 47 413 48 414 49 50 415 51 416 52 53 417 54 418 55 419 56 57 420 58 421 59 60
18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 36
1 2 3 4 422 Table 4 HIP-REP programme for older adults with hip fracture from first post-operative day to Week 12 including five interventions based on BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 423 Occupational performance: One intervention during hospital stay, and four at the rehabilitation centre and/or at home. Home visits must be carried 6 424 out in both tracks 1 and 2 7 The Progress at the hospital 8 Day Post Session Intervention Activities 9 Operative 10 Day 1 1st Inform and identify Welcome to the ward 11 Day 1-2 2nd Inform and identify Initial interview 12 13 Interview – prioritise two ADL tasks for AMPS 14 Day 3 3rd Inform and identify Observation: AMPS, as well as clarifying and interpreting cause and discussing objectives 15 Objectives, planning and implementation 16 Hip fracture information; operation, restriction movements handed out 17 18 Day 3-4 4th 1stFor ADL intervention peer reviewPADL andonly IADL tasks at the ward prioritised by older adult 19 Inform and identify, goalsetting, plan, engage and assess results 20 Day 4-5 5th Evaluate and end course Clarify and order assistive devices
21 The Progress in the municipality 22 23 Track 1 Track 2 24 Discharge from Hospital to in-patient Rehabilitation Centre Direct discharge from hospital to own dwelling to own residence 25 Week post- Session Intervention Activities Intervention Activities 26 operative 27 Week 2 6th 2nd ADL intervention Welcome/ Initial conversation 2nd ADL intervention at home The accessibility of the housing 28 is reviewed 29 Inform and identify, Weekday 1-3 after discharge goalsetting, plan, engage and PADL and IADL tasks as Review of ADL tasks in own 30 assess results older adult has prioritized Inform and identify, goalsetting, plan, residence 31 engage and assess results 32 Week 3 7th 3rd ADL intervention at home PADL and IADL tasks as 3rd ADL intervention at home PADL and IADL tasks as older if possible. older adult has prioritised adult has prioritised 33 Inform and identify, goalsetting, plan, 34 Inform and identify, engage and assess results goalsetting, plan, engage and 35 assess results
36 Week 5 8th 4th ADL intervention The accessibility of the 4th ADL intervention at home PADL and IADL tasks as older
37 housing is reviewed adult has prioritised http://bmjopen.bmj.com/ Home visit in connection Inform and identify, goalsetting, plan, 38 with discharge from in- Review of ADL tasks in own engage and assess results 39 patient Rehabilitation residence Centre 40 41 Inform and identify, goalsetting, plan, engage and 42 assess results
43 Week 8 9th 5th ADL intervention PADL and IADL tasks as 5th ADL intervention at home PADL and IADL tasks as older 44 older adult has prioritised adult has prioritised In own residence Inform and identify, goalsetting, plan,
45 engage, assess results, and end course on October 1, 2021 by guest. Protected copyright. 46 Inform and identify, goalsetting, plan, engage, End course and evaluate End course and evaluate 47 assess results, and end course
48 Week 10 Phone-call Assess results and evaluate Phone older adult and follow- Assess results and evaluate Phone older adult and follow-up 49 up on the HIP-REP on the HIP-REP intervention 50 intervention 51 Week 12 10th Evaluate Evaluate Evaluate Evaluate 52 ADL; Activity of daily living; HIP-REP; Hip fracture REhabilitation Programme; OTIPM; Occupational Therapy Intervention Process Model; PADL; Personal 53 Activity of daily living; IADL; Instrumental Activity of daily living 54 55 56 425 57 58 59 426 60
19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 36 BMJ Open
1 2 3 4 427 DISCUSSION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 428 Our main result was the identification of additional components for the rehabilitation of older adults 8 9 429 with HF. It revealed tangible strategies to facilitate the transitional rehabilitation process across 10 11 430 sectors. Three generic categories emerged. 12 13 14 431 Challenge with goal-oriented ADL tasks 15 16 432 Challenges must fit the individual’s expectations, wishes and foremost their capabilities of 17 18 433 performing ADL tasks.For A previous peer study showed review that such a fitonly resulted in better outcomes when 19 20 434 tailoring the rehabilitation.52 Our findings emphasise the importance of involving older adults in the 21 22 23 435 process as soon as possible, to set relevant goals and to promote the experience of confidence and 24 25 436 active participation in their rehabilitation. Participants provided insights into what type of 26 27 437 occupation they prioritised during the first months after hip fracture, i.e. activities performed within 28 29 30 438 their own residence, including social activities. Our findings extend previous research, recognising 31 32 439 that identification of individual goals supports the participants in regaining independence and 33 34 440 facilitates their recovery process.53 In addition, older adults showed an interest in facilitating 35 36 441 individualised goals by using a booklet to document and encourage achievement of goals during the 37 http://bmjopen.bmj.com/ 38 39 442 transition between care settings and home. 40 41 443 42 43 44 444 Implement strategies to enhance independent and safe performance of ADL tasks
45 on October 1, 2021 by guest. Protected copyright. 46 445 Our study showed that older adults often developed their own strategies to enhance independent and 47 48 446 safe occupational performance. They used work simplification and energy-saving techniques during 49 50 51 447 the first post-operative weeks, including prioritisation of activities due to lack of energy, adaptation 52 53 448 of their environment, use of assistive devices for mobility, bathing and dressing. Their strategies 54 55 449 show that relatively simple solutions, such as an apron or a cross-over bag for transport of devices, 56 57 450 enabled them to move safely, independently and perform manageable activities. As previous 58 59 60
20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 36
1 2 3 4 451 literature reported, the older adult generates individual strategies to overcome the temporary loss of BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 54 7 452 independence and thus manages to live at home after discharge. This shows that the older adult 8 9 453 with HF has a transactional perspective29 31 32 on their use of strategies taking into account 10 11 454 constructs such as person, occupation, and context. 12 13 14 455 Communicate the important information to the target group and across sectors 15 16 456 There is a trend towards reduction in length of stays at hospital due to early operative treatment. 52 54 17 18 457 This leaves only a few Fordays to accomplishpeer complex review aspects of only rehabilitation. In our study, the older 19 20 21 458 participants reported that they found that the rapid transition was daunting. The assessment, advice 22 23 459 and strategies regarding ADL tasks at the hospital become a challenge before discharge, e.g. 24 25 460 education in hip precautions, introducing and providing small aids during their stay to become more 26 27 54 28 461 independent. Langford et al described that with regard to ADL, becoming dependent on others 29 30 462 causes distress to some older adults, as usual routines are disrupted, and another study55 reports a 31 32 463 feeling of not being equipped or prepared for the transition. Our study shows the importance of 33 34 464 knowing what to expect regarding the rehabilitation and also the need of focusing on ADL tasks 35 36
37 465 during hospitalisation, at the rehabilitation centre and at home. This applies especially to older http://bmjopen.bmj.com/ 38 39 466 adults living alone with HF, a point that was emphasised both by HCPs and older adults, as those 40 41 467 people are more vulnerable and have greater need for information prior to discharge. Social support 42 43 53 56 44 468 from family and friends has been reiterated in other studies as important not only to assist with
45 on October 1, 2021 by guest. Protected copyright. 46 469 practical arrangements, but also to motivate, encourage and give emotional support. Providing 47 48 470 patients with a ‘recovery map’ including information about the hip fracture operation and which 49 50 51 471 symptoms to expect, forthcoming appointments and other resources could be beneficial, suggesting 52 53 472 that written patient-centred information enhances knowledge and facilitates decision-making and 54 55 473 recovery.57 58 This stresses the importance of the HCP’s role in supporting more effective 56 57 474 communication, involving and informing older adults with HF and their relatives across professions 58 59 60
21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 36 BMJ Open
1 2 3 4 59-61 475 and settings. Participants in our study found the transition from the hospital or rehabilitation BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 476 centre to their own home as critical. They found that home visits prior to discharge and after 8 9 477 discharge that were carried out to assess and/or modify environmental barriers in the home, 10 11 478 improved occupational performance and reduced the risk of falling. This is consistent with results 12 13 14 479 from other studies involving older people with functional limitations in hospital discharge planning. 15 16 480 Furthermore, including home visits has been shown to result in reduced re-admission, risk of falls 17 18 481 and improved functionalFor performance. peer61 62 review only 19 20 21 482 Methodological considerations 22 23 483 Our study has some limitations as it only includes two professions in the research circles out of a 24 25 484 broader interdisciplinary team. However, the HCPs were experienced and conscious of this and 26 27 28 485 responded from the perspective of the broader team. At the last research circle meeting, no 29 30 486 additional insights or understandings were collected, indicating saturation was obtained in the 31 32 487 research circles.44 The use of research circles did not aim for a deeper analysis of feelings and 33 34 488 emotions, but provided a participatory focus, making it possible to collaborate with older adults and 35 36
37 489 HCP participants throughout the research process, supporting the development and gaining new http://bmjopen.bmj.com/ 38 39 490 knowledge together through reflection. 37 39 40 40 41 491 The study excluded older adults with severe cognitive impairments or difficulty in communicating 42 43 44 492 in Danish, which may limit the use of the results and the intervention may therefore need to be
45 on October 1, 2021 by guest. Protected copyright. 46 493 adapted to other patient groups. 47 48 494 The credibility and trustworthiness of our findings were enhanced by using peer and member 49 50 44 51 495 checking , independent coding and experts’ views on the draft of the HIP-REP programme. This 52 53 496 was enabled by ensuring that all participants would feel comfortable sharing ideas and information 54 55 497 during the meetings in an open and supportive environment. To ensure credibility, transparency in 56 57 58 59 60
22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 36
1 2 3 4 498 the analysis phase using steps recommend by Elo et. al (2014) was followed as well as using quotes BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 47 7 499 to emphasise the similarities and differences in the categories. 8 9 10 500 CONCLUSIONS 11 12 501 Our study highlighted the need for setting individual goals and challenging older adults with HF by 13 14 15 502 providing guidance in strategies to enhance safe and independent performance of ADL task. 16 17 503 Furthermore, the need for written and oral information for older adults with HF and HCP about 18 For peer review only 19 504 goal-setting during the transitional rehabilitation phase was emphasised. Including the perspectives 20 21 505 of older adults with HF and HCPs added value to the HIP-REP programme, and thus ensured an 22 23 24 506 adequate, tangible, and implementable rehabilitation programme. 25 26 27 507 Contributorship statement Study planning, conception and design: Røpke, Lund, Thrane, Juhl, 28 29 30 508 Morville. Drafting the work or revising it critically for important intellectual content: Røpke, Lund, 31 32 509 Thrane, Juhl, Morville. Acquisition of data: Røpke. Analysis and interpretation of data: Røpke, 33 34 510 Lund, Thrane, Juhl, Morville. Final approval of the version published: Røpke, Lund, Thrane, Juhl, 35 36 511 Morville.
37 http://bmjopen.bmj.com/ 38 39 40 512 DECLARATIONS 41 42 43 513 Acknowledgements 44
45 on October 1, 2021 by guest. Protected copyright. 46 514 The authors thank the participants for sharing their insights and time with the research team. 47 48 515 Furthermore, we want to thank the two rehabilitation centres and the University Hospital for their 49 50 516 collaboration and for making their facilities available for researchers while conducting the research 51 52 517 circles, and Senior Researcher Morten Tange Kristensen for his input and feedback on the first HIP- 53 54 55 518 REP draft. 56 57 58 59 60
23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 36 BMJ Open
1 2 3 4 519 Ethics approval BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 520 The study followed the Danish legislation regarding ethics in scientific studies and was approved by 8 9 521 Ethics Committees [H-18000881] and the Danish Data Protection Agency [Jnr no.: 2012-58-0004]. 10 11 12 522 Competing interests None declared. 13 14 15 16 523 Funding This study was funded by the Region’s Research and Development fund (R26-1121); the 17 18 524 Intersectoral Research ForUnit (P-2017-1-11; peer P-2019-2-16); review University only College Copenhagen, 19 20 21 525 Department of Physiotherapy and Occupational Therapy (Internal funding), University Hospital 22 23 526 Copenhagen, Herlev and Gentofte (Internal funding) and Occupational Therapists Association (FF2 24 25 527 - R104-A2093). 26 27 528 28 29 529 Data sharing statement HIP-REP manual in Danish and data used during the current study are 30 31 530 available from the corresponding author on reasonable request. 32 33 34 35 531 36
37 532 REFERENCES http://bmjopen.bmj.com/ 38 39 533 1. Giannoulis D, Calori GM, Giannoudis PV. Thirty-day mortality after hip fractures: has anything 40 534 changed? 41 535 Eur J Orthop Surg Traumatol 2016;26(4):365-70. 42 536 2. Le Manach Y, et al Outcomes After Hip Fracture Surgery Compared With Elective Total Hip 43 537 Replacement. JAMA, 2015:7. 44 538 3. González-Zabaleta J, Pita-Fernandez S, Seoane-Pillado T, et al. Dependence for basic and instrumental
45 539 activities of daily living after hip fractures. Arch Gerontol Geriatr 2015;60(1):66-70. on October 1, 2021 by guest. Protected copyright. 46 540 4. Alarcón T, González-Montalvo JI, Gotor P, et al. Activities of daily living after hip fracture: profile and 47 541 rate of recovery during 2 years of follow-up. Osteoporos Int 2011;22(5):1609-13. 48 542 5. Orive M, Aguirre U, García-Gutiérrez S, et al. Changes in health-related quality of life and activities of 49 543 daily living after hip fracture because of a fall in elderly patients: a prospective cohort study. Int J Clin 50 544 Pract 2015;69(4):491-500. 51 6. Sirkka M, Bränholm I. Consequences of a hip fracture in activity performance and life satisfaction in an 52 545 53 546 elderly Swedish clientele. Scand J Occup Ther 2003;10:34-39. 54 547 7. Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy training in 55 548 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand 2004;75(2):177-83. 56 549 8. Beaupre LA, Carson JL, Noveck H, et al. Recovery of Walking Ability and Return to Community Living 57 550 within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors. J Am Geriatr Soc 58 551 2015;63(8):1640-4. 59 60
24 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 36
1 2 3 4
552 9. Valentiner LS, Steen R. Genoptræningsforløbsbeskrivelse for hoftenært brud. Tværsektoriel BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 553 genoptræningsforløbsbeskrivelse. Region Hovedstaden: Den Administrative Styregruppe i Region 6 554 Hovedstaden, 2014. 7 555 10. Zidén L, Frändin K, Kreuter M. Home rehabilitation after hip fracture. A randomized controlled study on 8 9 556 balance confidence, physical function and everyday activities. Clin Rehabil 2008;22(12):1019-33. 10 557 11. Crotty M, Killington M, Liu E, et al. Should we provide outreach rehabilitation to very old people living 11 558 in Nursing Care Facilities after a hip fracture? A randomised controlled trial. Age Ageing 12 559 2019;48(3):373-80. 13 560 12. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a 14 561 prospective, randomised, controlled trial. Lancet 2015;385 North American Edition(9978):1623-33. 15 562 13. Lahtinen A, Leppilahti J, Harmainen S, et al. Geriatric and physically oriented rehabilitation improves 16 563 the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison 17 564 of 538 patients [with consumer summary]. Clin Rehabil 2015 Sep;29(9):892-906. 18 565 14. Fisher AG. Occupation-centred,For peer occupation-based, review occupation-focused: only Same, same or different? Scand 19 566 J Occup Ther 2013;20:162–73. 20 567 15. Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability concerning 21 568 ADL and IADL after hip fracture: a randomized trial. Acta orthop 2006;77(1):114-9. 22 569 16. Martin-Martin LM, Valenza-Demet G, Ariza-Vega P, et al. Effectiveness of an occupational therapy 23 570 intervention in reducing emotional distress in informal caregivers of hip fracture patients: a randomized 24 571 controlled trial. Clin Rehabil 2014 Feb 17;28(8):772-783 2014 25 572 17. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention 26 573 description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687. 27 18. O’Brien BC, Harris IB, Beckman TJ, et al. Standards for Reporting Qualitative Research: A Synthesis of 28 574 29 575 Recommendations. Acad. Med. 2014;89(9):1245-51. 30 576 19. Fraser MW, Galinsky MJ. Steps in Intervention Research: Designing and Developing Social Programs. 31 577 Res Soc Work Prac 2010;20(5):459-66. 32 578 20. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new 33 579 Medical Research Council guidance. BMJ 2008;337 34 580 21. Richards D. The critical importance of patient and public involvement In: Richards D HI, ed. Complex 35 581 interventions in health: an overview of research methods. 1st ed. Oxon and New York: Routledge 36 582 2015:p. 46.
37 583 22. Roberts JL, Din NU, Williams M, et al. Development of an evidence-based complex intervention for http://bmjopen.bmj.com/ 38 584 community rehabilitation of patients with hip fracture using realist review, survey and focus groups. 39 585 BMJ Open 2017;7(10):e014362. 40 586 23. Whitehead PJ, Walker MF, Parry RH, et al. Occupational Therapy in HomEcare Re-ablement Services 41 587 (OTHERS): results of a feasibility randomised controlled trial. BMJ Open 2016;6(8):e011868-e68. 42 588 24. Cook RJP, Berg KPPT, Lee K-AM, et al. Rehabilitation in Home Care Is Associated With Functional 43 589 Improvement and Preferred Discharge. Arch Phys Med Rehabil 2013;94(6):1038-47. 44 590 25. Lewin G, De San Miguel K, Knuiman M, et al. A randomised controlled trial of the Home Independence
45 on October 1, 2021 by guest. Protected copyright. 591 Program, an Australian restorative home-care programme for older adults. Health Soc Care Community 46 592 2013;21(1):69-78. 47 48 593 26. Martín-Martín LM, Valenza-Demet G, Jiménez-Moleón JJ, et al. Effect of occupational therapy on 49 594 functional and emotional outcomes after hip fracture treatment: a randomized controlled trial. Clin 50 595 Rehabil 2014;28(6):541-51. 51 596 27. Di Monaco M, Vallero F, De Toma E, et al. A single home visit by an occupational therapist reduces the 52 597 risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial. J Rehabil Med 53 598 2008;40(6):446-50. 54 599 28. Di Monaco M, De Toma E, Gardin L, et al. A single postdischarge telephone call by an occupational 55 600 therapist does not reduce the risk of falling in women after hip fracture: a randomized controlled trial. 56 601 Eur J Phys Rehabil Med 2015;51(1):15-22. 57 602 29. Aldrich RM. From complexity theory to transactionalism: Moving occupational science forward in 58 603 theorizing the complexities of behavior. J Occup Sci 2008;15(3):147-56. 59 60
25 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 36 BMJ Open
1 2 3 4
604 30. Cutchin MP, Aldrich RM, Bailliard AL, et al. Action theories for occupational science: The BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 605 contributions of Dewey and Bourdieu. J Occup Sci 2008;15(3):157-65. 6 606 31. Lee Bunting K. A transactional perspective on occupation: a critical reflection. Scand J Occup Ther 7 607 2016;23(5):327-36. 8 9 608 32. Aldrich RM, Cutchin, M. P. Dewey's concepts of embodiment, growth, and occupations: Extended bases 10 609 for a transactional perspectives. In M. P. Cutchin & V. A. Dickie (Eds.) ed: New York: Springer 2013. 11 610 33. Fisher AG, Marterella, A. Powerful Practice - A Model for Authentic Occupational Therapy. Colorado, 12 611 USA: Center for Innovative OT Solutions, Inc. 2019. 13 612 34. Fisher AG. OTIPM. København: Munkgaard 2013. 14 613 35. Fisher AG, Jones, K B. Occupational Therapy Intervention Process Model. In: Hinojosa J, Kramer, P., 15 614 Royeen C. B., ed. Perspectives on Human Occupation - Theories Underlying Practice. Secon edition ed. 16 615 United States of America: F. A. Davis Company 2017:237-86. 17 616 36. Härnstein G. The Research Circle: Building Knowledge on Equal Terms. Swedish Trade Union 18 617 Confederation, StockholmFor 1994. peer review only 19 618 37. Haak M, Slaug B, Oswald F, et al. Cross-national user priorities for housing provision and accessibility 20 619 findings from the European innovAge Project. Int J Environ Res Public Health 2015;12(3):2670-86. 21 620 38. Iwarsson S, Edberg A-K, Ivanoff SD, et al. Understanding User Involvement in Research in Aging and 22 621 Health. Gerontol. Geriatr. Med. 2019;5:2333721419897781. 23 622 39. Reed J, Weiner R, Cook G. Partnership research with older people – moving towards making the rhetoric 24 623 a reality. J Clin Nurs 2004;13(s1):3-10. 25 624 40. Högdin S KC. Research Circles: A Method for the development of knowlegde and the creation of change 26 625 in practice. Saber Educar 2014;19 27 41. Östlund B. The revival of research circles: meeting the needs of modern aging and the third age. 2008; 28 626 29 627 04(34 (4)). 30 628 42. Persson S. Forskningscirklar - en vägledning. Malmö: Malmö stad, 2008. 31 629 43. Borg T. Livsførelse i hverdagen under rehabilitering. Et socialpsykologisk studie. Aalborg Universitet, 32 630 2002. 33 631 44. DePoy. E G, L.N. Gathering Information in Naturalistic Inguiry. Introduction to Research - 34 632 Understanding and Applying Multiple Strategies. 4th ed. St. Louis (USA): Elsevier Mosby 2011:p. 228. 35 633 45. Coyne IT. Sampling in qualitative research; merging or clear boundaries? J Adv Nurs 1997;26(3):7. 36 634 46. Kallio H, Pietila AM, Johnson M, et al. Systematic methodological review: developing a framework for a
37 635 qualitative semi-structured interview guide. J Adv Nurs 2016;72(12):2954-65. http://bmjopen.bmj.com/ 38 636 47. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-15. 39 637 48. Nvivo 11 Pro for Windows [program]. 11.4 version: QSR International, 2017. 40 638 49. Richards L. Handling Qualitative Data. A Practical Guide. Third ed. Australia: Sage Publication 2014. 41 639 50. Sermeus W. Modelling process and outcomes in complex interventions. In: Richards D HI, ed. Complex 42 640 interventions in health: an overview of research methods. Oxon and Newe York: Routledge 2015:p.111. 43 641 51. Fisher A. Appendiks. In: Murmand L, ed. OTIPM Latvia: Munksgaard 2013:p. 209. 44 642 52. Young Y RB. Don't worry, Be Positive: Improving functional recovery 1 year after hip fracture. Rehabil
45 on October 1, 2021 by guest. Protected copyright. 643 Nurs 2009;34:110-17. 46 644 53. Saul D, Riekenberg J, Ammon JC, et al. Hip Fractures: Therapy, Timing, and Complication Spectrum. 47 48 645 Orthop Surg 2019;11(6):994-1002. 49 646 54. Langford D, Edwards N, Gray SM, et al. “Life Goes On.” Everyday Tasks, Coping Self-Efficacy, and 50 647 Independence: Exploring Older Adults’ Recovery From Hip Fracture. Qual Health Res 2018;28(8):1255- 51 648 66. 52 649 55. Tuscan J MB, Santi SM, Stolee P. "Just another fish in the pond": the transitional care experience of a hip 53 650 fracture patient. Int J Integr Care 2013;13(2) 54 651 56. Taylor NF, Harding KE, Dowling J, et al. Discharge planning for patients receiving rehabilitation after 55 652 hip fracture: a qualitative analysis of physiotherapists’ perceptions. Disabil Rehabil 2010;32:492-99. 56 653 57. Schiller C, Franke T, Belle J, et al. Words of wisdom - patient perspectives to guide recovery for older 57 654 adults after hip fracture: a qualitative study. Patient Prefer Adher 2015;9:57-64. 58 59 60
26 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 36
1 2 3 4
655 58. Jensen CM, Smith AC, Overgaard S, et al. “If only had I known”: a qualitative study investigating a BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 656 treatment of patients with a hip fracture with short time stay in hospital. Int J Qual Stud Health Well- 6 657 being 2017;12(1):1307061. 7 658 59. Asif M, Cadel L, Kuluski K, et al. Patient and caregiver experiences on care transitions for adults with a 8 9 659 hip fracture: a scoping review. Disabil Rehabil 2019:1-10. 10 660 60. Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care 11 661 for Persons with Continuous Complex Care Needs. J Am Geriatr Soc 2003;51(4):549-55. 12 662 61. Lockwood KJ, Harding KE, Boyd JN, et al. Predischarge home visits after hip fracture: a randomized 13 663 controlled trial. Clin Rehabil 2019;33(4):681-92. 14 664 62. Stark S, Keglovits M, Arbesman M, et al. Effect of Home Modification Interventions on the Participation 15 665 of Community-Dwelling Adults With Health Conditions: A Systematic Review. Am J Occup Ther 16 666 2017;71(2):1-11A. 17 667 18 668 For peer review only 19 669 Figure legends 20 670 Figure 1 Research circle process with overall topics discussed 21 22 671 Figure 2 Analysis process: abstraction of subcategory to generic category 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
27 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 36 BMJ Open
1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Reflection Reflection Reflection RC I RC II RC I RC II RC I RC II RC I + RC II Develop final 7 1. meeting: 1. meeting: 2. meeting: 2. meeting: 3. meeting: 3. meeting: 4. meeting: rehabilitation 8 Rehabilitation Rehabilitation Rehabilitation Rehabilitation Rehabilitation Rehabilitation A joint programme at at transition to transition to in the in the proposal for a including 9 hospitalization hospitalization municipality municipality municipality municipality rehabilitation expert 10 programme assessment Reflection Reflection Reflection Final analysis 11 12 13 RC I, Research circle with older adults with hip fracture; RC II, Research circle with healthcare professionals 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 36
1 2 3 4
BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Sub-category Generic category 8
9 • Learn to be oneself as quick
10 as possible
11 • Urge and follow-up goal-oriented Challenge with goal-oriented 12 performance of daily tasks ADL tasks 13 • Surroundings here and there 14
15 16 17 • Short time to learn 18 • Apron and nightlightFor peer review only 19 • Movement restrictions – maybe? Strategies to enhance 20 • Deliver, instruct and follow-up on independent and safe 21 assistive devices performance of ADL tasks 22 23 24 25 26 • Information and active involvement 27 in rehabilitation plan 28 • 29 Clarification of network Communicate the important 30 • Confusion about transitional hip information to the target 31 fracture rehabilitation group and across sectors 32 • Need for coherent support 33 34 35 36
37 http://bmjopen.bmj.com/
38
39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 31 of 36 BMJ Open
1 2 3 4 - 5 6 7 8 9 · 10 11 12 For peer review· only 13 · - 14 15 16 17 http://bmjopen.bmj.com/ 18 - · 19 · - - 20 21 22 23 24 · on October 1, 2021 by guest. Protected copyright. - 25 - - 26 27 · - - 28 29 30 · 31 32 · 33 34 · - - 35 36 - 37 38 39 40 41 42 43 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 32 of 36
1 The TIDieR (Template for Intervention Description and Replication) Checklist*: 2 3 Information to include when describing an intervention and the location of the information 4 5 Item Item Where located ** 6 number Primary paper Other † (details) 7 8 (page or appendix 9 number) 10 11 12 BRIEF NAME For peer review only 13 1. Provide the name or a phrase that describes the intervention. P. 5, l. 122-126 ______14 15 WHY 16
2. Describe any rationale, theory, or goal of the elements essential to the intervention. http://bmjopen.bmj.com/ P. 5, l. 122-128, ______17 18 P. 6, l. 137-143 19 WHAT 20 21 3. Materials: Describe any physical or informational materials used in the intervention, including those P. 17, L. 389- ______22 23 provided to participants or used in intervention delivery or in training of intervention providers. 400 + table 3 + 24
Provide information on where the materials can be accessed (e.g. online appendix, URL). on October 1, 2021 by guest. Protected copyright. figure 3 25 26 (supplementary 27 file 1) and table 28 29 4 30 31 32 4. Procedures: Describe each of the procedures, activities, and/or processes used in the intervention, P. 16-17, L. 376- ______33 34 including any enabling or support activities. 387 + table 3 + 35 table 4 36 37 38 39 40 WHO PROVIDED 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 33 of 36 BMJ Open
1 5. For each category of intervention provider (e.g. psychologist, nursing assistant), describe their P. 16, L. 377- ______2 expertise, background and any specific training given. 378 3 4 HOW 5 6 6. Describe the modes of delivery (e.g. face-to-face or by some other mechanism, such as internet or P. 16, L. 377- ______7 telephone) of the intervention and whether it was provided individually or in a group. 378 8 9 10 WHERE 11 12 7. Describe the type(s) of location(s)For where the peer intervention occurred, review including any necessary only P. 16, L. 377- ______13 infrastructure or relevant features. 387 14 15 16 WHEN and HOW MUCH 17 http://bmjopen.bmj.com/ 18 8. Describe the number of times the intervention was delivered and over what period of time including P. 16-17, L. 377- ______19 the number of sessions, their schedule, and their duration, intensity or dose. 387 + table 4 20 21 TAILORING 22 9. If the intervention was planned to be personalised, titrated or adapted, then describe what, why, P. 16, L. 364 + ______23 24 when, and how. 397 25 on October 1, 2021 by guest. Protected copyright. 26 MODIFICATIONS 27 10.ǂ If the intervention was modified during the course of the study, describe the changes (what, why, N/A ______28 29 when, and how). 30 HOW WELL 31 32 11. Planned: If intervention adherence or fidelity was assessed, describe how and by whom, and if any N/A ______33 34 strategies were used to maintain or improve fidelity, describe them. 35 12.ǂ Actual: If intervention adherence or fidelity was assessed, describe the extent to which the N/A ______36 37 intervention was delivered as planned. 38 39 ** Authors - use N/A if an item is not applicable for the intervention being described. Reviewers – use ‘?’ if information about the element is not reported/not 40 41 sufficiently reported. 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 34 of 36
1 † If the information is not provided in the primary paper, give details of where this information is available. This may include locations such as a published protocol 2 or other published papers (provide citation details) or a website (provide the URL). 3 ǂ If completing the TIDieR checklist for a protocol, these items are not relevant to the protocol and cannot be described until the study is complete. 4 5 * We strongly recommend using this checklist in conjunction with the TIDieR guide (see BMJ 2014;348:g1687) which contains an explanation and elaboration for each item. 6 7 * The focus of TIDieR is on reporting details of the intervention elements (and where relevant, comparison elements) of a study. Other elements and methodological features of 8 9 studies are covered by other reporting statements and checklists and have not been duplicated as part of the TIDieR checklist. When a randomised trial is being reported, the 10 TIDieR checklist should be used in conjunction with the CONSORT statement (see www.consort-statement.org) as an extension of Item 5 of the CONSORT 2010 Statement. 11 When a clinical trial protocol is being reported, the TIDieR checklist should be used in conjunction with the SPIRIT statement as an extension of Item 11 of the SPIRIT 2013 12 Statement (see www.spirit-statement.org). ForFor alternate study peer designs, TIDieR can review be used in conjunction with only the appropriate checklist for that study design (see 13 www.equator-network.org). 14 15 16 17 http://bmjopen.bmj.com/ 18 19 20 21 22 23 24 25 on October 1, 2021 by guest. Protected copyright. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 35 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 Standards for Reporting Qualitative Research (SRQR)* 2 http://www.equator-network.org/reporting-guidelines/srqr/ 3 4 Page/line no(s). 5 Title and abstract 6 7 Title - Concise description of the nature and topic of the study Identifying the 8 study as qualitative or indicating the approach (e.g., ethnography, grounded 9 theory) or data collection methods (e.g., interview, focus group) is recommended 10 3 11 Abstract - Summary of key elements of the study using the abstract format of the 12 intended publication; typically includes background, purpose, methods, results, 13 14 and conclusions 3 15 16 Introduction For peer review only 17 18 19 Problem formulation - Description and significance of the problem/phenomenon P. 6-7 / l. 144- 20 studied; review of relevant theory and empirical work; problem statement 163 21 Purpose or research question - Purpose of the study and specific objectives or 22 questions P. 5 / l. 122-128 23 24 25 Methods 26 27 28 Qualitative approach and research paradigm - Qualitative approach (e.g., 29 ethnography, grounded theory, case study, phenomenology, narrative research) 30 and guiding theory if appropriate; identifying the research paradigm (e.g., 31 postpositivist, constructivist/ interpretivist) is also recommended; rationale** P. 8 / l. 182-193 32
33 http://bmjopen.bmj.com/ 34 Researcher characteristics and reflexivity - Researchers’ characteristics that may 35 influence the research, including personal attributes, qualifications/experience, 36 37 relationship with participants, assumptions, and/or presuppositions; potential or 38 actual interaction between researchers’ characteristics and the research P. 8-9 / l. 195- 39 questions, approach, methods, results, and/or transferability 210 + table 1 40 P. 8-9 / l. 195- 41 Context - Setting/site and salient contextual factors; rationale** 210 on October 1, 2021 by guest. Protected copyright. 42 43 Sampling strategy - How and why research participants, documents, or events 44 were selected; criteria for deciding when no further sampling was necessary (e.g., P. 8-9 / l. 195- 45 sampling saturation); rationale** 210 46 Ethical issues pertaining to human subjects - Documentation of approval by an 47 48 appropriate ethics review board and participant consent, or explanation for lack P. 23 / l. 513- 49 thereof; other confidentiality and data security issues 518 50 Data collection methods - Types of data collected; details of data collection 51 52 procedures including (as appropriate) start and stop dates of data collection and 53 analysis, iterative process, triangulation of sources/methods, and modification of P. 9-10 / l. 213- 54 procedures in response to evolving study findings; rationale** 232 + figure 1 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 36 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 Data collection instruments and technologies - Description of instruments (e.g., 3 interview guides, questionnaires) and devices (e.g., audio recorders) used for data P. 10-11 / l. 234- 4 collection; if/how the instrument(s) changed over the course of the study 249 5 6 7 Units of study - Number and relevant characteristics of participants, documents, P. 11 / l. 261-264 8 or events included in the study; level of participation (could be reported in results) + table 2 9 Data processing - Methods for processing data prior to and during analysis, 10 11 including transcription, data entry, data management and security, verification of P. 9-10 / l. 212- 12 data integrity, data coding, and anonymization/de-identification of excerpts 232 + figure 2 13 Data analysis - Process by which inferences, themes, etc., were identified and 14 developed, including the researchers involved in data analysis; usually references a P. 10-11 / l. 233- 15 specific paradigm or approach; rationale** 249 + figure 2 16 For peer review only 17 Techniques to enhance trustworthiness - Techniques to enhance trustworthiness P. 15 / l. 355-360 18 and credibility of data analysis (e.g., member checking, audit trail, triangulation); + p. 17 / l. 401- 19 rationale** 408 20 21 22 Results/findings 23 Synthesis and interpretation - Main findings (e.g., interpretations, inferences, and 24 25 themes); might include development of a theory or model, or integration with P. 11-15 / l- 260- 26 prior research or theory 345 27 Links to empirical data - Evidence (e.g., quotes, field notes, text excerpts, P. 12-15 / l. 287- 28 photographs) to substantiate analytic findings 345 29 30 31 Discussion 32
33 Integration with prior work, implications, transferability, and contribution(s) to http://bmjopen.bmj.com/ 34 the field - Short summary of main findings; explanation of how findings and 35 conclusions connect to, support, elaborate on, or challenge conclusions of earlier 36 scholarship; discussion of scope of application/generalizability; identification of P. 20-22/ l. 427- 37 unique contribution(s) to scholarship in a discipline or field 481 38 P. 22-23 / l. 482- 39 Limitations - Trustworthiness and limitations of findings 499 40
41 on October 1, 2021 by guest. Protected copyright. 42 Other 43 Conflicts of interest - Potential sources of influence or perceived influence on 44 study conduct and conclusions; how these were managed P. 24 / l. 522 45 46 Funding - Sources of funding and other support; role of funders in data collection, 47 interpretation, and reporting P. 24 / l. 523-527 48 49 50 *The authors created the SRQR by searching the literature to identify guidelines, reporting 51 standards, and critical appraisal criteria for qualitative research; reviewing the reference 52 lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to 53 improve the transparency of all aspects of qualitative research by providing clear standards 54 for reporting qualitative research. 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 **The rationale should briefly discuss the justification for choosing that theory, approach, 2 method, or technique rather than other options available, the assumptions and limitations 3 4 implicit in those choices, and how those choices influence study conclusions and 5 transferability. As appropriate, the rationale for several items might be discussed together. 6 7 Reference: 8 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative 9 research: a synthesis of recommendations. Academic Medicine, Vol. 89, No. 9 / Sept 2014 10 DOI: 10.1097/ACM.0000000000000388 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Developing an individualised cross-sectoral programme based on activity of daily living to support rehabilitation of older adults with hip fracture: a qualitative study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-044539.R3
Article Type: Original research
Date Submitted by the 05-May-2021 Author:
Complete List of Authors: Ropke, Alice; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences Lund, Karina; Herlev Hospital, Department of Physiotherapy and Occupational Therapy Thrane, Camilla ; Herlev Municipality, Health Promotion and Rehabilitation Juhl, Carsten; Herlev Hospital, Department of Physiotherapy and Occupational Therapy; University of Southern Denmark, Research Unit Musculoskeletal Function and Physiotherapy, Institute of Sports and Clinical Biomechanics, Faculty of Health Sciences
Morville, Anne-Le; Jönköping University, Department of Rehabilitation http://bmjopen.bmj.com/ School of Health and Welfare
Primary Subject Qualitative research Heading:
Secondary Subject Heading: Health services research
Hip < ORTHOPAEDIC & TRAUMA SURGERY, REHABILITATION MEDICINE, Keywords: QUALITATIVE RESEARCH on October 1, 2021 by guest. Protected copyright.
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 36 BMJ Open
1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 36
1 2 3 4 1 Title page BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 2 7 3 Developing an individualised cross-sectoral programme based on activity of daily living to support 8 4 rehabilitation of older adults with hip fracture: a qualitative study 9 5 10 6 Authors: 11 7 1,2Alice Røpke 12 8 1Karina Lund 13 3 14 9 Camilla Thrane 1,2 15 10 Carsten Bogh Juhl 16 11 4Anne-Le Morville 17 12 18 13 Corresponding author:For peer review only 19 14 Alice Røpke 20 15 Herlev and Gentofte Hospital 21 22 16 Department of Physiotherapy and Occupational therapy 23 17 Borgmester Ib Juuls Vej 29 24 18 Opgang 8, 3. sal, O1 25 19 2730 Herlev 26 20 Denmark 27 21 Email (work): [email protected] 28 29 22 https://orcid.org/0000-0001-7793-5558 30 23 Phone: +45 (0) 26882002 (mobile) 31 24 32 25 1Department of Physiotherapy and Occupational Therapy 33 26 Copenhagen University Hospital, Herlev and Gentofte 34 27 Department of Physiotherapy and Occupational therapy 35 28 Borgmester Ib Juuls Vej 29 36 29 Opgang 8, 3. sal, O1 37 http://bmjopen.bmj.com/ 38 30 2730 Herlev 39 31 Denmark 40 32 41 33 2Department of Sports Science and Clinical Biomechanics 42 34 University of Southern Denmark 43 35 Campusvej 55 44 36 5230 Odense M 45 on October 1, 2021 by guest. Protected copyright. 46 37 Denmark 47 38 48 39 3Health Promotion and Rehabilitation 49 40 Tvedvangen 196 50 41 2730 Herlev 51 52 42 Denmark 53 43 54 44 4Department of Rehabilitation 55 45 School of Health and Welfare 56 46 Jönköping University 57 47 Box 1026 58 48 551 11 Jönköping 59 60
1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 36 BMJ Open
1 2 3 4 49 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 50 Keywords: Activity of daily living; hip fracture; qualitative research; rehabilitation. 7 51 8 52 Word count: 4482 – excluding title page, references, figures and tables. 9 53 10 11 12 54 13 14 15 55 16 17 56 18 For peer review only 19 20 57 21 22 23 58 24 25 26 59 27 28 29 60 30 31 61 32 33 34 62 35 36
37 63 http://bmjopen.bmj.com/ 38 39 40 64 41 42 43 65 44
45 on October 1, 2021 by guest. Protected copyright. 66 46 47 48 67 49 50 51 68 52 53 54 69 55 56 57 70 58 59 60
2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 36
1 2 3 4 71 Developing an individualised cross-sectoral programme based on activity of daily living to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 72 support rehabilitation of older adults with hip fracture: a qualitative study 8 9 73 ABSTRACT 10 11 12 74 Objectives: To develop an individualised rehabilitation programme for personal and instrumental 13 14 15 75 activities of daily living (ADL tasks), enabling older adults with hip fractures to perform ADL 16 17 76 safely and independently. 18 For peer review only 19 77 Design: Qualitative study inspired by the Complex-intervention development (Medical Research 20 21 78 Council (MRC) framework phase I) using literature search and research circles. 22 23 24 79 Settings: University Hospital of Copenhagen, Herlev and Gentofte and Herlev and Gentofte 25 26 80 municipalities. 27 28 81 Participants: One research circle with seven older adults with hip fractures, and one with seven 29 30 31 82 healthcare professionals (occupational therapists and physiotherapists). 32 33 83 Results: Three generic categories were identified (1) ‘Challenge older adults with goal-oriented 34 35 84 ADL tasks’, (2) ‘Implement strategies to enhance independent and safe performance of ADL tasks’ 36
37 http://bmjopen.bmj.com/ 38 85 and (3) ‘Communicate the important information to the target group and across sectors’. A 39 40 86 programme was developed and an intervention to enhance usual rehabilitation was designed 41 42 87 comprising: an individualised intervention component consisting of five additional therapy 43 44 88 sessions; one during hospitalisation, four in the municipality and a follow-up phone call.
45 on October 1, 2021 by guest. Protected copyright. 46 47 89 Conclusions: Engaging and integrating activities into rehabilitation treatment may support 48 49 50 90 rehabilitation. Our study highlighted the need for setting individual goals and challenging older 51 52 91 adults with hip fracture by providing guidance in strategies to enhance safe and independent 53 54 92 performance of ADL tasks. Furthermore, the need for providing older adults with hip fracture and 55 56 93 healthcare professionals with written and oral information about goal setting during the transitional 57 58 59 94 rehabilitation phase was emphasised. Including the perspectives of older adults with hip fracture 60
3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 36 BMJ Open
1 2 3 4 95 and healthcare professionals added value to the rehabilitation, and thus ensured an adequate, BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 96 tangible, and implementable rehabilitation programme. 8 9 97 10 11 98 Keywords: Activity of daily living, hip fracture, qualitative research, rehabilitation. 12 13 14 99 15 16 100 Strengths and limitations of this study 17 18 For peer review only 19 101 The development of the rehabilitation programme was based on results from research circles, 20 21 22 102 in collaboration with healthcare professionals and the target population, to ensure cocreation. 23 24 103 The credibility and trustworthiness of our findings were enhanced by using peer and member 25 26 104 checking. 27 28 29 105 We recruited participants from one geographical area in Denmark, so findings may not be 30 31 106 transferable to other localities. 32 33 107 Qualitative methods provide in-depth and rich data, but we are unable to generalise these 34 35 36 108 results and a comprehensive process and feasibility evaluation of the hip fracture
37 http://bmjopen.bmj.com/ 38 109 rehabilitation programme is needed to test adherence to and compliance with the 39 40 110 intervention. 41 42 43 111 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 36
1 2 3 4 113 INTRODUCTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 114 Despite positive surgical outcomes, older adults with hip fractures (HF) need rehabilitation to 7 8 9 115 optimise their performance in Activities of Daily Living (ADL). Just one-third regain their pre- 10 11 116 fracture level of physical function and capacity to perform ADL.1 2 For the remaining two-thirds, 12 13 117 there is an increased risk of social isolation, depression and reduced Quality of Life (QoL). 3-6 14 15 118 Studies have reported poor post-fracture outcomes and coordination across the healthcare sectors 16 17 7 8 18 119 does not always meet frailFor patients’ peer needs. review Close, continuous only and efficient collaboration between 19 20 120 different professions and healthcare sectors is essential to provide patient-centred rehabilitation 21 22 121 based on the individual’s needs, wishes and competences.9 Several studies support the effect of 23 24 25 122 multidisciplinary rehabilitation of patients with HF, combining nursing care, physiotherapy, 26 27 123 occupational therapy and/or social work.10-13 Few studies focus on occupation14 and improving 28 29 124 ADL 7 15 16, and how to support the older adult to safely and independently perform ADL tasks. 30 31 32 125 Occupation in this article refers not only to work but general activity and participation in daily 33 34 126 life.14 Thus, the use of motor skills and process skills during ADL task performances is named 35 36 127 occupational performance.14
37 http://bmjopen.bmj.com/ 38 128 Thus, the purpose of this study was to gather knowledge of experiences, needs and expectations of 39 40 41 129 rehabilitation from older adults with HF to develop an intervention programme focusing on their 42 43 130 ability to safely and independently perform ADL. To develop a sustainable intervention with 44
45 on October 1, 2021 by guest. Protected copyright. 131 multiple perspectives from older adults with HF, their families and healthcare professionals (HCP) - 46 47 48 132 specifically physiotherapists (PT) and occupational therapists (OT) - are needed. This study is the 49 50 133 first step of a forthcoming trial of developing and evaluating a complex intervention for the 51 52 134 rehabilitation of older adults with HF focusing on enabling occupational performance. 53 54 55 135 56 57 136 58 59 137 60
5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 36 BMJ Open
1 2 3 4 138 INTERVENTION DESCRIPTION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 17 7 139 The Template for Intervention Description and Replication (TIDieR) checklist was used to 8 9 140 evaluate the comprehensiveness of the reporting of the cross-sectorial intervention. Furthermore, 10 11 141 Standards for Reporting Qualitative Research (SRQR) checklist18 was used to show transparency in 12 13 14 142 all steps in the qualitative research (supplemental material). 15 16 143 Rationale and theory essential to the intervention 17 18 144 The intervention was consideredFor peer a complex interventionreview with onlymultiple interacting components. The 19 20 19 20 21 145 development phase was inspired by the 2008 UK Medical Research Council (MRC) framework 22 23 146 for developing and evaluating complex interventions, which presents three steps: (1) identifying the 24 25 147 evidence base, (2) identifying/developing theory and (3) modelling the process and outcomes. Older 26 27 28 148 adults with HF, HCPs, administrators and managers were continuously involved in the development 29 30 149 stage.21 31 32 150 1. IDENTIFYING THE EVIDENCE BASE 33 34 151 Identifying the evidence and specifying the content of the intervention was formulated based on a 35 36
37 152 literature search carried out in March 2018 with regular updates on Medline, Cinahl and Embase http://bmjopen.bmj.com/ 38 39 153 using the search string: [hip fracture AND activity of daily living AND occupational therapy]. 40 41 154 Interventions for older adults with HF dependent on support and rehabilitation are often 42 43 12 44 155 multidisciplinary. The organisation and implementation of rehabilitation services varies in length
45 on October 1, 2021 by guest. Protected copyright. 46 156 and content, but usually includes occupational therapy and physical therapy.10 22 The positive 47 48 157 outcome would be a reduced need of home care and improved occupational performance.23 Studies 49 50 51 158 on occupational performance have shown that interventions focused on ADL results reduced 52 53 159 dependency in (Personal) PADL24 and (Instrumental) IADL24 25. Postoperative care after HF 54 55 160 focuses on individual techniques for dressing, bathing and adapting the home environment15 16, 56 57 161 transferring, positioning and postural standing, technical aids for PADL and IADL.26 In addition, 58 59 60
6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 36
1 2 3 4 162 home visits by an occupational therapist assessing home environment provides strategies for early BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 15 26 27 7 163 recovery. A post-discharge telephone call in a multidisciplinary intervention may be 8 9 164 effective in reducing the proportion of fallers27 28 Only a few trials focus on providing strategies for 10 11 165 safe and independent occupational performance, focusing on the activities most important for the 12 13 14 166 patient’s self-care and independence. Sessions included a range of topics, e.g. technical aids and 15 16 167 instructions related to ADL training, home environment advice, fall prevention, transfer, walking 17 18 168 and ADL.7 26 IndividualisedFor occupational peer therapy review intervention only was found to have advantages in 19 20 169 relation to patients’ ability, e.g. their ability to perform ADL and improvements in perceived 21 22 7 26 23 170 health. 24 25 171 26 27 172 2. IDENTIFYING/DEVELOPING THEORY 28 29 30 173 The theoretic foundation of the intervention was based on a transactional perspective on 31 32 174 occupation29-31 and inspired the development phase emphasising (1) person-context relations, and 33 34 175 (2) occupation as a continuous response to situational elements.29 30 32 An important aspect is to 35 36 176 recognise that people cannot be separated from their experiences and context in life, emphasising 37 http://bmjopen.bmj.com/ 38 39 177 the importance of taking each individual’s circumstances into account during rehabilitation.33 What 40 41 178 to do and how to be occupation-centred during interventions is defined as having (1) an occupation- 42 43 179 focused approach concentrating attention on occupation with a proximal focus on e.g. body 44
45 on October 1, 2021 by guest. Protected copyright. 46 180 functions, environment or other contextual factors (2). An occupation-based approach involves 47 48 181 occupational performance as part of evaluations or as interventions engaging in, e.g. cooking or 49 50 182 reading a book.14 Ensuring that the intervention is occupation-centred, the Occupational Therapy 51 52 53 183 Intervention Process Model (OTIPM) provides a frame for the intervention. The intervention 54 55 184 process is depicted as occurring over three phases: evaluation and goal setting, intervention, and re- 56 57 58 59 60
7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 36 BMJ Open
1 2 3 4 14 34 35 185 evaluation. Identifying a theory to underpin the specific essential intervention is derived from BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 186 the collaboration between older adults with HF and HCPs. 8 9 10 187 MATERIAL AND METHODS 11 12 188 A qualitative participatory design was adopted, by applying the research circle method36 37, 13 14 15 189 emphasising engagement and collaborative action between older adults with HF, HCPs and 16 17 190 researchers.38 39 The research circle process is characterised by mutual reflection and engagement 18 For peer review only 19 191 between participants contributing with equal authority to co-create collective knowledge. Research 20 21 192 circles are based on a common theme that is discussed to generate new in-depth knowledge among 22 23 40-42 24 193 the included participants. Two research circles were formed: one with older adults with HF, and 25 26 194 another with HCPs, OTs and PTs who either work in hospital settings or in municipalities. 27 28 195 The overarching theme for each meeting was determined in advance by Alice Røpke (AR) the first 29 30 43 31 196 author and inspired by the rehabilitation phases in practice developed by Borg ; 1) Rehabilitation 32 33 197 during hospitalisation, 2) Rehabilitation in transition to the municipality, 3) Rehabilitation in the 34 35 198 municipality, and 4) The resultant collective proposal for a hip rehabilitation programme. At each 36
37 44 http://bmjopen.bmj.com/ 38 199 meeting, an interview guide was developed based on the respective themes (figure 1). 39 40 200 Sampling and recruitment 41 42 43 201 Purposeful sampling was performed to recruit older participants with HF from a range of post-acute 44 45 45 202 settings and demographics, e.g. type of housing, geographical district, age and sex. The HCPs on October 1, 2021 by guest. Protected copyright. 46 47 203 were recruited from Herlev and Gentofte municipality rehabilitation centres and from Copenhagen 48 49 50 204 University Hospital, Herlev and Gentofte (table 1) during the period February to March 2018. 51 52 205 53 54 206 55 56 207 57 58 59 208 60
8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 36
1 2 3 4 Table 1 Inclusion and exclusion criteria for older adults with hip fracture
209 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 Inclusion criteria Exclusion criteria 6 Aged 55 years or older Not expected to be discharged to home or rehabilitation centres in the municipality 7 Recent proximal hip fracture (S 72.0 Medial femur fracture, S 72.1, Not able to speak and/or understand Danish 8 Pertrochanteric femur fracture, S 72.2, Subtrochanteric femur fracture) Severe physical and/or mental disabilities prior to the hip fracture 9 Living at home prior to hip fracture in Herlev or Gentofte municipalities 10 Ability to give informed consent 11 Discharged from hospital and receiving or having received rehabilitation 12 from the municipalities within the last 3 months from onset 13 Inclusion criteria in research circles for healthcare professionals 14 At least 2 years of experience with rehabilitation of older adults with hip fracture in the included municipalities or Hospital 15 210 16 17 18 211 HCPs at the two municipalitiesFor identifiedpeer potential review participants only and scheduled dates and times for 19 20 212 the research circle meetings for both older adults and the HCPs. 21 22 213 To create a relaxed and trusting atmosphere, the research circles were conducted at the 23 24 214 rehabilitation facilities. Prior to the meetings, an email with information about the overall topic for 25 26 27 215 the meetings, time, place and provision of transportation were sent to the participants. 28 29 216 30 31 32 217 Data collection 33 34 218 All research circle meetings were conducted between April and June 2018. Two pilot interviews to 35 36 219 test the preliminary interview guide were performed: one with an experienced HCP and a group
37 http://bmjopen.bmj.com/ 38 220 interview with five older adults who had experienced hip fracture rehabilitation. Testing the 39 40 46 41 221 interview guide, first with the research team and subsequently with potential study participants 42 43 222 resulted in a reduced number of questions and revision of the interview guide. 44
45 on October 1, 2021 by guest. Protected copyright. 223 46 47 48 224 Insert figure 1 here 49 50 225 51 52 226 Each meeting of the research circle was prepared, recorded and facilitated by two authors (AR) and 53 54 55 227 Karina Lund (KL) (figure 1). Using the interview guide, open-ended questions were asked about the 56 57 228 participants’ needs, wishes and expectations for individualised occupation-based rehabilitation for 58 59 229 adults with HF. The meetings were conducted every third week with older adults and HCPs 60
9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 36 BMJ Open
1 2 3 4 230 separately for the first three meetings and together in the last meeting, to share knowledge and ideas BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 231 gathered from the previous meetings. Each meeting lasted for approximately two hours. Between 8 9 232 meetings, participants were encouraged to reflect and take notes in a booklet as a resource for 10 11 233 discussion at the following meeting. At the end of each meeting, the participants were asked to 12 13 14 234 highlight one idea or statement that they thought important to include in further developing the 15 16 235 intervention programme. Summary notes from each meeting were subsequently presented at the 17 18 236 next meeting to sustainFor the continuity peer of innovations review across meetings. only The participants were also 19 20 237 asked to verify the summaries, thus ensuring they were actively involved in the initial analysis. 21 22 23 238 Data analysis 24 25 239 The analysis procedure included two levels and was performed by two authors (AR and KL). Level 26 27 28 240 one began after the first meeting of each research circle. The summary of notes taken during the 29 30 241 meetings formed the basis of an emerging categorisation of data, confirmed by participants at the 31 32 242 end of every meeting. Level two of the analysis process involved inductive content analysis 33 34 243 performed at a manifest level in three phases as described by Elo and Kyngäs.47 During level two, a 35 36
37 244 third author, Anne-Le Morville (AM), joined the analysis process. In the preparation phase, each of http://bmjopen.bmj.com/ 38 39 245 the transcripts was read thoroughly several times to verify its accuracy. The organising phase 40 41 246 included open coding, where AR and KL independently highlighted the key statements in the 42 43 44 247 transcripts related to the topics in the interview guides. Using an iterative style, meaning units were
45 on October 1, 2021 by guest. Protected copyright. 46 248 then organised and condensed by the two authors using Nvivo 11 Pro.48 The analysis moved from 47 48 249 lower to higher levels of abstraction, identifying an initial interpretation of patterns, grouping, and 49 50 51 250 comparing data in subcategories and categories. A description of the subcategories and categories 52 53 251 was then articulated during the reporting phase. The authors explored similarities and differences in 54 55 252 the analysis during meetings, which facilitated the development of categories and patterns that best 56 57 58 59 60
10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 36
1 2 3 4 49 253 illustrated the needs, expectations and experiences of the participants. Subcategories emerged and BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 254 finally the abstraction to generic categories was performed. The process is shown in figure 2. 8 9 255 10 11 256 PATIENT AND PUBLIC INVOLVEMENT 12 13 14 257 One of the strengths of this study has been the involvement of the patient and public representatives 15 16 258 in the overall study design from the start. From the initial idea raised at a cross-sectoral workshop 17 18 For peer review only 19 259 with HCPs involvement of patients and HCPs providing input, to content of the intervention for the 20 21 260 final HIP-REP manual and on the choice of outcome measures, both patients and public have been 22 23 261 involved. Afterwards all participants of the patient and public representatives were invited to review 24 25 26 262 and comment on the draft HIP-REP manual, and thus formed an important part of assessing 27 28 263 acceptability of the intervention. Two co-authors on this paper were key members of the research 29 30 264 team and contributed to the development and refinement of the content for the HIP-REP manual 31 32 33 265 and manuscript revision. 34 35 36 266 RESULTS 37 http://bmjopen.bmj.com/ 38 39 267 Identifying a theory to underpin the specific essential intervention elements 40 41 268 A total of 14 participants were included in the research circles: four OTs, three PTs and seven older 42 43 269 people with HF (six females and one male). Table 2 summarises the demographic data of the older 44
45 on October 1, 2021 by guest. Protected copyright. 46 270 adults and HCPs. 47 48 271 49 50 272 Table 2 Demographic data of the participants in research circles (n=14) 51 52 Older Female Male Age Living situation Adults (range) (range) 53 54 (n=7) 6 1 58-93 5 living alone 55 Healthcare Physiotherapist Occupational Years of experience 56 Professionals therapist (range) 57 58 (n=7) 3 4 2-25 years 59 60
11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 36 BMJ Open
1 2 3 4 273 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 274 Though the groups faced their own unique challenges, older adults and the HCPs shared 8 9 275 experiences, needs and ideas for a transitional rehabilitation programme, which led to the 10 11 276 identification of three generic categories: 1) Challenge older adults with goal-oriented ADL tasks, 12 13 14 277 2) Implement strategies to enhance an independent, safe performance of ADL tasks, and 3) 15 16 278 Communicate the information to the target group and across healthcare sectors (figure 2). 17 18 279 For peer review only 19 20 280 Insert figure 2 here 21 22 23 281 24 25 282 26 27 283 Each generic category extracted from the data is summarised and supported with quotes. The 28 29 30 284 supporting quotes will indicate which of the research circle meetings the quote was extracted from, 31 32 285 the research circle, group, and number e.g. (RCOHF01). 33 34 286 Challenge older adults with goal-oriented ADL tasks 35 36
37 287 All participants emphasised the importance of older adults with HF being challenged to perform http://bmjopen.bmj.com/ 38 39 288 PADL and IADL tasks and the importance of challenging the older adult from day one after 40 41 289 surgery. 42 43 44 290 However, due to the influence of medication, pain, and lack of sleep and food during the hospital
45 on October 1, 2021 by guest. Protected copyright. 46 291 stay, several of the older adults with HF lacked confidence in ambulation, physical and ADL 47 48 292 abilities when discharged: 49 50 51 293 “… if you start during the 8 days (at the Hospital), before 52 53 294 going to the Rehabilitation Centre, and you were activated all you were 54 55 295 able to, to show what you are capable of…but they forget that the patient has to be 56 57 296 challenged…they should activate us as much as possible.” (L1, female patient, RCOHF01) 58 59 60
12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 36
1 2 3 4 297 They suggested individual ADL tasks (e.g. preparing and eating fresh fruit, washing hands and BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 298 face, brushing teeth by the sink) matching older adults, e.g. in relation to capacity and wanted a 8 9 299 focus on personal ADL goals while in the hospital. After discharge from hospital, more complex 10 11 300 domestic and social ADL tasks were asked for by older adults. For example, early independence 12 13 14 301 and safety in walking to the bathroom and managing toileting and bathing to gain previous levels of 15 16 302 function: 17 18 303 “We wantFor to learn peer to be ourselves review again. As quickly only as possible!” 19 20 304 (W4, female participant, RCOHF02) 21 22 23 305 Implement strategies to enhance independent and safe performance of ADL tasks 24 25 306 All participants emphasised “implement strategies to enhance independent and safe performance of 26 27 28 307 ADL tasks”. Older adults raised the issue of their reliance on mobility devices from day one and in 29 30 308 the following weeks or even months, as this limited their ability to perform ADL tasks. They 31 32 309 emphasised the importance of the timing of introduction and graduation of the use of a rollator, 33 34 310 walker and/or crutches. Strategies and ideas for carrying objects over short distances were 35 36
37 311 discussed, e.g. using an apron with pockets or crossbody bag for carrying a mobile phone and/or http://bmjopen.bmj.com/ 38 39 312 snacks/beverage: 40 41 313 “…I used a crutch indoors. So, if I want to carry anything I must run back and forth 42 43 44 314 17 times you know, because I can only carry one thing at a time right, but then you can
45 on October 1, 2021 by guest. Protected copyright. 46 315 use an apron to put things in the front pocket.” (LI, female patient, RCOHF03). 47 48 316 Additionally, being presented with small assistive devices, e.g. sock aid, long handled reacher, etc. 49 50 51 317 several times was indicated as necessary both during hospital stay and at follow up in the 52 53 318 municipality: 54 55 319 “I was able to arrange a visit where they (OT) brought a 56 57 320 stocking aid, that was great. It was fabulous…she gave me this and 58 59 60
13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 36 BMJ Open
1 2 3 4 321 one, two, three, I could use it myself.” (W4, female patient, RCOHF04) BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 322 8 9 323 Communicate the important information to the target group and across sectors 10 11 324 The final category that emerged was the lack of information and communication across healthcare 12 13 14 325 sectors. Organisational changes in workflow are not always passed on to HCPs across sectors, i.e. 15 16 326 new procedures regarding instructions in movement restrictions or new guidelines regarding 17 18 327 rehabilitation services Forin the municipalities. peer review only 19 20 21 328 “…we can’t promise the older adult at the hospital anything in regard to future 22 23 329 rehabilitation in the municipality before we are sure of their options.” 24 25 330 (P02, clinical specialist OT, RCHCP02) 26 27 28 331 Furthermore, older adults with HF wanted general knowledge, such as a booklet about what to 29 30 332 expect during and after the operation and during rehabilitation phases, such as information 31 32 333 concerning the operation method, normal physical reactions after HF surgery, restrictions and how 33 34 334 these could influence a person’s occupational performance. 35 36
37 335 The importance and dependence on the older adult’s social network were evident when gathering http://bmjopen.bmj.com/ 38 39 336 information and planning the rehabilitation. Several of the older adults with HF emphasised that 40 41 337 they were dependent on family and friends to support basic ADL tasks, both at home and at the 42 43 44 338 rehabilitation centre.
45 on October 1, 2021 by guest. Protected copyright. 46 339 “I think it is important that the HCP at the hospital pays attention to whether there is 47 48 340 any network no matter how old you are…” 49 50 51 341 (S4, clinical specialist PT, RC0401) 52 53 342 Older adults with experience from a rehabilitation centre, emphasised the importance of a home 54 55 343 visit prior to discharge, to identify potential barriers and minimise the fear of returning home. 56 57 344 Furthermore, both older adults and HCP expressed the need for a home visit within one to three 58 59 60
14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 36
1 2 3 4 345 working days post discharge directly from the hospital or the rehabilitation centre to their home to BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 346 resolve issues associated with their home environment and plan their individual rehabilitation. 8 9 347 “A visit to the home provides valuable information about how older adults function outside 10 11 348 the rehabilitation setting. Maybe older adults need a rail in the bathroom, or the carpet 12 13 14 349 needs to be removed or nightlights need to be set up. So, whatever caused the fall, 15 16 350 you go through the environment, removing obstacles so they will feel safer at home.” 17 18 351 (ML1, clinical Forspecialist, peer OT, RCHCP01). review only 19 20 352 21 22 23 353 3. MODELLING PROCESS AND OUTCOMES 24 25 354 A first draft of an intervention manual and expert review 26 27 355 The processes and outcomes were modelled as recommended by Sermeus et al.50 The first author 28 29 17 30 356 drafted a detailed intervention manual using the TIDierR checklist and Standards for Reporting 31 32 357 Qualitative Research (SRQR) checklist18. 33 34 358 The occupation-centred framework for conceptualising the Hip Fracture Rehabilitation Programme 35 36 359 (HIP-REP) is based on the OTIPM14 and focuses on occupation and approaches identified as: an 37 http://bmjopen.bmj.com/ 38 39 360 occupation-based approach, an occupation-focused approach or both. 40 41 361 Following the development of a draft for the manual of the HIP-REP programme, it was 42 43 362 commented on by an impartial rehabilitation expert with knowledge and experience with older 44
45 on October 1, 2021 by guest. Protected copyright. 46 363 adults with HFs and in the development of complex interventions. Furthermore, participants from 47 48 364 the research circles all agreed to read and comment on the draft of the manual for the HIP-REP 49 50 365 programme to verify the content, and thus verify the relevance and expected feasibility of its 51 52 53 366 implementation. 54 55 56 57 58 59 60
15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 36 BMJ Open
1 2 3 4 367 The development of the HIP-REP programme BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 368 The qualitative data were used to develop an overarching working theory: ‘The following will lead 8 9 369 to safer and more independent performance of ADL tasks: (i) challenging older adults with HF with 10 11 370 goal-specific ADL tasks through an individually tailored goal-oriented programme increasing the 12 13 14 371 complexity of ADL tasks in addition to usual rehabilitation, and (ii) increasing the co-ordination 15 16 372 and information of services between sectors delivering rehabilitation across sectors. 17 18 For peer review only 19 373 The working theory was discussed with researchers in the field of health science and from this, aims 20 21 374 and ideas for the intervention were derived. The three generic categories and the working theory 22 23 375 led to the following elements: Inspiration sheets (occupation-focused and occupation-based 24 25 26 376 activities), Worksheets, Information sheets and pamphlets (see online supplementary file 1). The 27 28 377 elements were then framed according to the OTIPM51 process and reorganised into the HIP-REP 29 30 378 programme (table 3). The HIP-REP programme focuses on an individual adaptation of the 31 32 379 programme and increasing the complexity of ADL tasks with the goal of returning to an 33 34 35 380 independent and safe performance of relevant tasks (table 4). 36
37 http://bmjopen.bmj.com/ 38 381 A first draft of an intervention manual and expert review 39 40 382 Programme Structure 41 42 383 The HIP-REP programme consists of three phases over a total of eight weeks (table 4) supervised 43 44 384 by OTs; preliminary interviews, baseline tests, five interventions focusing on ADL that each last a 45 on October 1, 2021 by guest. Protected copyright. 46 47 385 minimum of one hour and a maximum of two hours (including transport and registration for the 48 49 386 HCP), and a follow-up phone call at 10 weeks post-operatively. Due to different structures in the 50 51 52 387 municipalities, the HIP-REP programme was divided into a ‘two-way track’ after discharge from 53 54 388 hospital. Both tracks applied four interventions in the municipality undertaken in agreement with 55 56 389 the older adults. Track one involved older adults being transferred directly to their own home. Track 57 58 390 two involved older adults staying at a rehabilitation centre before discharge to their home. In both 59 60
16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 36
1 2 3 4 391 tracks, the intervention was scheduled, in collaboration with the older adults as shown in table 4. BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 392 When discharged from either hospital or rehabilitation centre, visits to the older adult’s own home 8 9 393 were to be carried out between the first and third weekday after returning home. 10 11 394 12 13 14 395 Programme Content 15 16 396 The content of the HIP-REP programme is standardised and guided by a manual (table 4) but 17 18 397 individually tailored forFor older adults, peer and the review intervention thus only varies in the content and complexity 19 20 21 398 of ADL tasks, based on older adults’ priorities, their type of hip fracture and surgical fixation. The 22 23 399 OTIPM34 guides the HIP-REP programme, with focus on occupational performance for both 24 25 400 intervention and evaluation as described in the manual (full version in Danish available from 26 27 28 401 authors on request). In general, for each intervention, the following elements appear: 1) Interview, 29 30 402 assessment and identification of problems and/or change in the occupational performance, 2) The 31 32 403 intervention phase with implementation of tailored, purposeful activities for performing ADL tasks, 33 34 404 3) The re-assessment phase with an initial interview to identify older adults’ meaningful pre-hip 35 36
37 405 fracture activities. Inspiration and information material and worksheets were prepared for each http://bmjopen.bmj.com/ 38 39 406 session with older adults. 40 41 407 Expert review 42 43 44 44 408 Determining the content validity an expert in rehabilitation for older adults with HF suggested
45 on October 1, 2021 by guest. Protected copyright. 46 409 structural and content considerations for the programme, e.g., a clarification on introduction and 47 48 410 education of the OTs participating in the programme and suggesting a clarification of exclusion 49 50 51 411 criteria. There was also a suggestion as to when intervention during hospitalization could be 52 53 412 implemented. The expert reviews, ideas and suggestions were considered and incorporated into 54 55 413 manual. The participants in the research circles commented on unclear sentences and spelling 56 57 414 mistakes which was corrected in the final manual (table 4). 58 59 60
17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 36 BMJ Open
1 2 3 4
415 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 416 Table 3 Intervention elements incorporated in the HIP-REP programme 7 Intervention process Specification How 8 9 Inform and assess Inform about the intervention Older adults with HF: · HIP-REP programme informing the older adult about the plan for cross-sectional intervention 10 · Booklet handed out to the older adult for the recording of information and patient-held ADL goal-setting · Exploration of possible activity areas to perform ADL tasks; Hospital, Rehab, own home 11 HCPs: 12 · OTIPM inspired worksheet 13 Clarify the older adult’s client-centred performance HCPs - Interview the older adult and other HCPs 14 - Review of existing documentation 15 - Identify aspect that supports and limits the occupational performance; personal, physical, social and institutional surroundings 16 Describe older adults self-reported strength and HCPS: 17 problems with activity performance Interview the older adult with HF - Older adults with HF: 18 For peer Decide review and prioritise possible ADL-tasks only at the hospital, rehab centre or at own dwelling 19 Describe which task the older adult prioritize as a Older adults with HF: 20 focus during assessment and intervention · Initiate ADL activities; ideas to graduated ADL tasks · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest 21 HCPs: 22 - · Information: Booklet for the older adult; hip fracture procedure, operation type, and “what to expect” 23 symptoms after the operation was handed out 24 Observer older adults task performance and HCPs (OT): describe older adults starting point for activity AMPS assessment of the older adult with HF performing prioritised tasks 25 performance 26 Clarify and interpret the reasons older adults HCPs 27 reduced activity performance To analyse the older adult with HFs physical, personal and environmental surroundings 28 · Hip fracture information; operation and restriction movements
29 · Information and instruction; mobility devices and PADL technical aids for bathing and dressing 30 Formulate goals Older adults with HF and HCPs: · Occupation-focused and/or occupation-based goals are formulated; the agreed goals are written in booklet and 31 evaluated at each meeting 32 Plan and initiate Older adults with HF and HCPs 33 intervention In collaboration it is decided which intervention to initiate: Compensatory, Acquisitional model for skills training 34 and/or Restorative model for enhancing body functions and other client elements · Initiate activities; ideas to graduated ADL tasks 35 · Strategies for graduated ADL tasks; energy saving techniques, sleep and bed rest 36 Assess the result Observe older adults task performance and HCPs (OT) describe the new level for activity performance AMPS follow-up assessment is performed 37 http://bmjopen.bmj.com/ 38 Compare the new level of performance with HCPs: 39 starting point and goals · Assess the AMPS results in collaboration with the older adult with HF 40 Decide if the Older adults with HF and HCPs intervention At the last intervention visit it is decided if the intervention should continue or end 41 continues or ends - · Follow-up phone-call to the older adult with HF 42 End the Older adults with HF and HCPs 43 intervention process Decide if further intervention is necessary and/or maybe refer to other healthcare relevant offers in the municipality 44 417 Categories from analysis informing the content of the elements in the Hip fracture Rehabilitation Programme based on OTIPM.51
45 on October 1, 2021 by guest. Protected copyright. 418 46 47 419 48 420 49 50 421 51 422 52 53 423 54 424 55 425 56 57 426 58 427 59 60
18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 36
1 2 3 4 428 Table 4 HIP-REP programme for older adults with hip fracture from first post-operative day to Week 12 including five interventions based on BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 429 Occupational performance: One intervention during hospital stay, and four at the rehabilitation centre and/or at home. Home visits must be carried 6 430 out in both tracks 1 and 2 7 The Progress at the hospital 8 Day Post Session Intervention Activities 9 Operative 10 Day 1 1st Inform and identify Welcome to the ward 11 Day 1-2 2nd Inform and identify Initial interview 12 13 Interview – prioritise two ADL tasks for AMPS 14 Day 3 3rd Inform and identify Observation: AMPS, as well as clarifying and interpreting cause and discussing objectives 15 Objectives, planning and implementation 16 Hip fracture information; operation, restriction movements handed out 17 18 Day 3-4 4th 1stFor ADL intervention peer reviewPADL andonly IADL tasks at the ward prioritised by older adult 19 Inform and identify, goalsetting, plan, engage and assess results 20 Day 4-5 5th Evaluate and end course Clarify and order assistive devices
21 The Progress in the municipality 22 23 Track 1 Track 2 24 Discharge from Hospital to in-patient Rehabilitation Centre Direct discharge from hospital to own dwelling to own residence 25 Week post- Session Intervention Activities Intervention Activities 26 operative 27 Week 2 6th 2nd ADL intervention Welcome/ Initial conversation 2nd ADL intervention at home The accessibility of the housing 28 is reviewed 29 Inform and identify, Weekday 1-3 after discharge goalsetting, plan, engage and PADL and IADL tasks as Review of ADL tasks in own 30 assess results older adult has prioritized Inform and identify, goalsetting, plan, residence 31 engage and assess results 32 Week 3 7th 3rd ADL intervention at home PADL and IADL tasks as 3rd ADL intervention at home PADL and IADL tasks as older if possible. older adult has prioritised adult has prioritised 33 Inform and identify, goalsetting, plan, 34 Inform and identify, engage and assess results goalsetting, plan, engage and 35 assess results
36 Week 5 8th 4th ADL intervention The accessibility of the 4th ADL intervention at home PADL and IADL tasks as older
37 housing is reviewed adult has prioritised http://bmjopen.bmj.com/ Home visit in connection Inform and identify, goalsetting, plan, 38 with discharge from in- Review of ADL tasks in own engage and assess results 39 patient Rehabilitation residence Centre 40 41 Inform and identify, goalsetting, plan, engage and 42 assess results
43 Week 8 9th 5th ADL intervention PADL and IADL tasks as 5th ADL intervention at home PADL and IADL tasks as older 44 older adult has prioritised adult has prioritised In own residence Inform and identify, goalsetting, plan,
45 engage, assess results, and end course on October 1, 2021 by guest. Protected copyright. 46 Inform and identify, goalsetting, plan, engage, End course and evaluate End course and evaluate 47 assess results, and end course
48 Week 10 Phone-call Assess results and evaluate Phone older adult and follow- Assess results and evaluate Phone older adult and follow-up 49 up on the HIP-REP on the HIP-REP intervention 50 intervention 51 Week 12 10th Evaluate Evaluate Evaluate Evaluate 52 ADL; Activity of daily living; HIP-REP; Hip fracture REhabilitation Programme; OTIPM; Occupational Therapy Intervention Process Model; PADL; Personal 53 Activity of daily living; IADL; Instrumental Activity of daily living 54 55 56 431 57 58 59 432 60
19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 36 BMJ Open
1 2 3 4 433 DISCUSSION BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 434 Our main result was the identification of additional components for the rehabilitation of older adults 8 9 435 with HF. It revealed tangible strategies to facilitate the transitional rehabilitation process across 10 11 436 sectors. Three generic categories emerged: 12 13 14 437 Challenge with goal-oriented ADL tasks 15 16 438 Challenges must fit the individual’s expectations, wishes and foremost their capabilities of 17 18 439 performing ADL tasks.For A previous peer study showed review that such a fitonly resulted in better outcomes when 19 20 440 tailoring the rehabilitation.52 Our findings emphasise the importance of involving older adults in the 21 22 23 441 process as soon as possible, to set relevant goals and to promote the experience of confidence and 24 25 442 active participation in their rehabilitation. Participants provided insights into what type of 26 27 443 occupation they prioritised during the first months after hip fracture, i.e. activities performed within 28 29 30 444 their own residence, including social activities. Our findings extend previous research, recognising 31 32 445 that identification of individual goals supports the participants in regaining independence and 33 34 446 facilitates their recovery process.53 In addition, older adults showed an interest in facilitating 35 36 447 individualised goals by using a booklet to document and encourage achievement of goals during the 37 http://bmjopen.bmj.com/ 38 39 448 transition between care settings and home. 40 41 449 42 43 44 450 Implement strategies to enhance independent and safe performance of ADL tasks
45 on October 1, 2021 by guest. Protected copyright. 46 451 Our study showed that older adults often developed their own strategies to enhance independent and 47 48 452 safe occupational performance. They used work simplification and energy-saving techniques during 49 50 51 453 the first post-operative weeks, including prioritisation of activities due to lack of energy, adaptation 52 53 454 of their environment, use of assistive devices for mobility, bathing and dressing. Their strategies 54 55 455 show that relatively simple solutions, such as an apron or a cross-over bag for transport of devices, 56 57 456 enabled them to move safely, independently and perform manageable activities. As previous 58 59 60
20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 36
1 2 3 4 457 literature reported, the older adult generates individual strategies to overcome the temporary loss of BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 54 7 458 independence and thus manages to live at home after discharge. This shows that the older adult 8 9 459 with HF has a transactional perspective29 31 32 on their use of strategies taking into account 10 11 460 constructs such as person, occupation, and context. 12 13 14 461 Communicate the important information to the target group and across sectors 15 16 462 There is a trend towards reduction in length of stays at hospital due to early operative treatment. 52 54 17 18 463 This leaves only a few Fordays to accomplishpeer complex review aspects of only rehabilitation. In our study, the older 19 20 21 464 participants reported that they found that the rapid transition was daunting. The assessment, advice 22 23 465 and strategies regarding ADL tasks at the hospital become a challenge before discharge, e.g. 24 25 466 education in hip precautions, introducing and providing small aids during their stay to become more 26 27 54 28 467 independent. Langford et al described that with regard to ADL, becoming dependent on others 29 30 468 causes distress to some older adults, as usual routines are disrupted, and another study55 reports a 31 32 469 feeling of not being equipped or prepared for the transition. Our study shows the importance of 33 34 470 knowing what to expect regarding the rehabilitation and also the need of focusing on ADL tasks 35 36
37 471 during hospitalisation, at the rehabilitation centre and at home. This applies especially to older http://bmjopen.bmj.com/ 38 39 472 adults living alone with HF, a point that was emphasised both by HCPs and older adults, as those 40 41 473 people are more vulnerable and have greater need for information prior to discharge. Social support 42 43 53 56 44 474 from family and friends has been reiterated in other studies as important not only to assist with
45 on October 1, 2021 by guest. Protected copyright. 46 475 practical arrangements, but also to motivate, encourage and give emotional support. Providing 47 48 476 patients with a ‘recovery map’ including information about the hip fracture operation and which 49 50 51 477 symptoms to expect, forthcoming appointments and other resources could be beneficial, suggesting 52 53 478 that written patient-centred information enhances knowledge and facilitates decision-making and 54 55 479 recovery.57 58 This stresses the importance of the HCP’s role in supporting more effective 56 57 480 communication, involving and informing older adults with HF and their relatives across professions 58 59 60
21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 36 BMJ Open
1 2 3 4 59-61 481 and settings. Participants in our study found the transition from the hospital or rehabilitation BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 482 centre to their own home as critical. They found that home visits prior to discharge and after 8 9 483 discharge that were carried out to assess and/or modify environmental barriers in the home, 10 11 484 improved occupational performance and reduced the risk of falling. This is consistent with results 12 13 14 485 from other studies involving older people with functional limitations in hospital discharge planning. 15 16 486 Furthermore, including home visits has been shown to result in reduced re-admission, risk of falls 17 18 487 and improved functionalFor performance. peer61 62 review only 19 20 21 488 Methodological considerations 22 23 489 Our study has some limitations as it only includes two professions in the research circles out of a 24 25 490 broader interdisciplinary team. However, the HCPs were experienced and conscious of this and 26 27 28 491 responded from the perspective of the broader team. At the last research circle meeting, no 29 30 492 additional insights or understandings were collected, indicating saturation was obtained in the 31 32 493 research circles.44 The use of research circles did not aim for a deeper analysis of feelings and 33 34 494 emotions, but provided a participatory focus, making it possible to collaborate with older adults and 35 36
37 495 HCP participants throughout the research process, supporting the development and gaining new http://bmjopen.bmj.com/ 38 39 496 knowledge together through reflection. 37 39 40 40 41 497 The study excluded older adults with severe cognitive impairments or difficulty in communicating 42 43 44 498 in Danish, which may limit the use of the results and the intervention may therefore need to be
45 on October 1, 2021 by guest. Protected copyright. 46 499 adapted to other patient groups. 47 48 500 The credibility and trustworthiness of our findings were enhanced by using peer and member 49 50 44 51 501 checking , independent coding and experts’ views on the draft of the HIP-REP programme. This 52 53 502 was enabled by ensuring that all participants would feel comfortable sharing ideas and information 54 55 503 during the meetings in an open and supportive environment. To ensure credibility, transparency in 56 57 58 59 60
22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 36
1 2 3 4 504 the analysis phase using steps recommend by Elo et al. (2014) was followed as well as using quotes BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 47 7 505 to emphasise the similarities and differences in the categories. 8 9 10 506 CONCLUSIONS 11 12 507 Our study highlighted the need for setting individual goals and challenging older adults with HF by 13 14 15 508 providing guidance in strategies to enhance safe and independent performance of ADL tasks. 16 17 509 Furthermore, the need for providing older adults with HF and HCP written and oral information 18 For peer review only 19 510 about goal setting during the transitional rehabilitation phase was emphasised. Including the 20 21 511 perspectives of older adults with HF and HCPs added value to the HIP-REP programme, and thus 22 23 24 512 ensured an adequate, tangible, and implementable rehabilitation programme. 25 26 27 513 Contributorship statement Study planning, conception and design: Røpke, Lund, Thrane, Juhl, 28 29 30 514 Morville. Drafting the work or revising it critically for important intellectual content: Røpke, Lund, 31 32 515 Thrane, Juhl, Morville. Acquisition of data: Røpke. Analysis and interpretation of data: Røpke, 33 34 516 Lund, Thrane, Juhl, Morville. Final approval of the version published: Røpke, Lund, Thrane, Juhl, 35 36 517 Morville.
37 http://bmjopen.bmj.com/ 38 39 40 518 DECLARATIONS 41 42 43 519 Acknowledgements 44
45 on October 1, 2021 by guest. Protected copyright. 46 520 The authors thank the participants for sharing their insights and time with the research team. 47 48 521 Furthermore, we want to thank the two rehabilitation centres and the University Hospital for their 49 50 522 collaboration and for making their facilities available for researchers while conducting the research 51 52 523 circles, and Senior Researcher Morten Tange Kristensen for his input and feedback on the first HIP- 53 54 55 524 REP draft. 56 57 58 59 60
23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 36 BMJ Open
1 2 3 4 525 Ethics approval BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 526 The study followed the Danish legislation regarding ethics in scientific studies and was approved by 8 9 527 Ethics Committees [H-18000881] and the Danish Data Protection Agency [Jnr no.: 2012-58-0004]. 10 11 12 528 Competing interests None declared. 13 14 15 16 529 Funding This study was funded by the Region’s Research and Development fund (R26-1121); the 17 18 530 Intersectoral Research ForUnit (P-2017-1-11; peer P-2019-2-16); review University only College Copenhagen, 19 20 21 531 Department of Physiotherapy and Occupational Therapy (Internal funding), University Hospital 22 23 532 Copenhagen, Herlev and Gentofte (Internal funding) and Occupational Therapists Association (FF2 24 25 533 - R104-A2093). 26 27 534 28 29 535 Data sharing statement HIP-REP manual in Danish and data used during the current study are 30 31 536 available from the corresponding author on reasonable request. 32 33 34 35 537 36
37 538 REFERENCES http://bmjopen.bmj.com/ 38 39 539 1. Giannoulis D, Calori GM, Giannoudis PV. Thirty-day mortality after hip fractures: has anything 40 540 changed? 41 541 Eur J Orthop Surg Traumatol 2016;26(4):365-70. 42 542 2. Le Manach Y, et al Outcomes After Hip Fracture Surgery Compared With Elective Total Hip 43 543 Replacement. JAMA, 2015:7. 44 544 3. González-Zabaleta J, Pita-Fernandez S, Seoane-Pillado T, et al. Dependence for basic and instrumental
45 545 activities of daily living after hip fractures. Arch Gerontol Geriatr 2015;60(1):66-70. on October 1, 2021 by guest. Protected copyright. 46 546 4. Alarcón T, González-Montalvo JI, Gotor P, et al. Activities of daily living after hip fracture: profile and 47 547 rate of recovery during 2 years of follow-up. Osteoporos Int 2011;22(5):1609-13. 48 548 5. Orive M, Aguirre U, García-Gutiérrez S, et al. Changes in health-related quality of life and activities of 49 549 daily living after hip fracture because of a fall in elderly patients: a prospective cohort study. Int J Clin 50 550 Pract 2015;69(4):491-500. 51 6. Sirkka M, Bränholm I. Consequences of a hip fracture in activity performance and life satisfaction in an 52 551 53 552 elderly Swedish clientele. Scand J Occup Ther 2003;10:34-39. 54 553 7. Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy training in 55 554 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand 2004;75(2):177-83. 56 555 8. Beaupre LA, Carson JL, Noveck H, et al. Recovery of Walking Ability and Return to Community Living 57 556 within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors. J Am Geriatr Soc 58 557 2015;63(8):1640-4. 59 60
24 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 36
1 2 3 4
558 9. Valentiner LS, Steen R. Genoptræningsforløbsbeskrivelse for hoftenært brud. Tværsektoriel BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 559 genoptræningsforløbsbeskrivelse. Region Hovedstaden: Den Administrative Styregruppe i Region 6 560 Hovedstaden, 2014. 7 561 10. Zidén L, Frändin K, Kreuter M. Home rehabilitation after hip fracture. A randomized controlled study on 8 9 562 balance confidence, physical function and everyday activities. Clin Rehabil 2008;22(12):1019-33. 10 563 11. Crotty M, Killington M, Liu E, et al. Should we provide outreach rehabilitation to very old people living 11 564 in Nursing Care Facilities after a hip fracture? A randomised controlled trial. Age Ageing 12 565 2019;48(3):373-80. 13 566 12. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a 14 567 prospective, randomised, controlled trial. Lancet 2015;385 North American Edition(9978):1623-33. 15 568 13. Lahtinen A, Leppilahti J, Harmainen S, et al. Geriatric and physically oriented rehabilitation improves 16 569 the ability of independent living and physical rehabilitation reduces mortality: a randomised comparison 17 570 of 538 patients [with consumer summary]. Clin Rehabil 2015 Sep;29(9):892-906. 18 571 14. Fisher AG. Occupation-centred,For peer occupation-based, review occupation-focused: only Same, same or different? Scand 19 572 J Occup Ther 2013;20:162–73. 20 573 15. Hagsten B, Svensson O, Gardulf A. Health-related quality of life and self-reported ability concerning 21 574 ADL and IADL after hip fracture: a randomized trial. Acta orthop 2006;77(1):114-9. 22 575 16. Martin-Martin LM, Valenza-Demet G, Ariza-Vega P, et al. Effectiveness of an occupational therapy 23 576 intervention in reducing emotional distress in informal caregivers of hip fracture patients: a randomized 24 577 controlled trial. Clin Rehabil 2014 Feb 17;28(8):772-783 2014 25 578 17. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention 26 579 description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687. 27 18. O’Brien BC, Harris IB, Beckman TJ, et al. Standards for Reporting Qualitative Research: A Synthesis of 28 580 29 581 Recommendations. Acad. Med. 2014;89(9):1245-51. 30 582 19. Fraser MW, Galinsky MJ. Steps in Intervention Research: Designing and Developing Social Programs. 31 583 Res Soc Work Prac 2010;20(5):459-66. 32 584 20. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new 33 585 Medical Research Council guidance. BMJ 2008;337 34 586 21. Richards D. The critical importance of patient and public involvement In: Richards D HI, ed. Complex 35 587 interventions in health: an overview of research methods. 1st ed. Oxon and New York: Routledge 36 588 2015:p. 46.
37 589 22. Roberts JL, Din NU, Williams M, et al. Development of an evidence-based complex intervention for http://bmjopen.bmj.com/ 38 590 community rehabilitation of patients with hip fracture using realist review, survey and focus groups. 39 591 BMJ Open 2017;7(10):e014362. 40 592 23. Whitehead PJ, Walker MF, Parry RH, et al. Occupational Therapy in HomEcare Re-ablement Services 41 593 (OTHERS): results of a feasibility randomised controlled trial. BMJ Open 2016;6(8):e011868-e68. 42 594 24. Cook RJP, Berg KPPT, Lee K-AM, et al. Rehabilitation in Home Care Is Associated With Functional 43 595 Improvement and Preferred Discharge. Arch Phys Med Rehabil 2013;94(6):1038-47. 44 596 25. Lewin G, De San Miguel K, Knuiman M, et al. A randomised controlled trial of the Home Independence
45 on October 1, 2021 by guest. Protected copyright. 597 Program, an Australian restorative home-care programme for older adults. Health Soc Care Community 46 598 2013;21(1):69-78. 47 48 599 26. Martín-Martín LM, Valenza-Demet G, Jiménez-Moleón JJ, et al. Effect of occupational therapy on 49 600 functional and emotional outcomes after hip fracture treatment: a randomized controlled trial. Clin 50 601 Rehabil 2014;28(6):541-51. 51 602 27. Di Monaco M, Vallero F, De Toma E, et al. A single home visit by an occupational therapist reduces the 52 603 risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial. J Rehabil Med 53 604 2008;40(6):446-50. 54 605 28. Di Monaco M, De Toma E, Gardin L, et al. A single postdischarge telephone call by an occupational 55 606 therapist does not reduce the risk of falling in women after hip fracture: a randomized controlled trial. 56 607 Eur J Phys Rehabil Med 2015;51(1):15-22. 57 608 29. Aldrich RM. From complexity theory to transactionalism: Moving occupational science forward in 58 609 theorizing the complexities of behavior. J Occup Sci 2008;15(3):147-56. 59 60
25 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 36 BMJ Open
1 2 3 4
610 30. Cutchin MP, Aldrich RM, Bailliard AL, et al. Action theories for occupational science: The BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 611 contributions of Dewey and Bourdieu. J Occup Sci 2008;15(3):157-65. 6 612 31. Lee Bunting K. A transactional perspective on occupation: a critical reflection. Scand J Occup Ther 7 613 2016;23(5):327-36. 8 9 614 32. Aldrich RM, Cutchin, M. P. Dewey's concepts of embodiment, growth, and occupations: Extended bases 10 615 for a transactional perspectives. In M. P. Cutchin & V. A. Dickie (Eds.) ed: New York: Springer 2013. 11 616 33. Fisher AG, Marterella, A. Powerful Practice - A Model for Authentic Occupational Therapy. Colorado, 12 617 USA: Center for Innovative OT Solutions, Inc. 2019. 13 618 34. Fisher AG. OTIPM. København: Munkgaard 2013. 14 619 35. Fisher AG, Jones, K B. Occupational Therapy Intervention Process Model. In: Hinojosa J, Kramer, P., 15 620 Royeen C. B., ed. Perspectives on Human Occupation - Theories Underlying Practice. Secon edition ed. 16 621 United States of America: F. A. Davis Company 2017:237-86. 17 622 36. Härnstein G. The Research Circle: Building Knowledge on Equal Terms. Swedish Trade Union 18 623 Confederation, StockholmFor 1994. peer review only 19 624 37. Haak M, Slaug B, Oswald F, et al. Cross-national user priorities for housing provision and accessibility 20 625 findings from the European innovAge Project. Int J Environ Res Public Health 2015;12(3):2670-86. 21 626 38. Iwarsson S, Edberg A-K, Ivanoff SD, et al. Understanding User Involvement in Research in Aging and 22 627 Health. Gerontol. Geriatr. Med. 2019;5:2333721419897781. 23 628 39. Reed J, Weiner R, Cook G. Partnership research with older people – moving towards making the rhetoric 24 629 a reality. J Clin Nurs 2004;13(s1):3-10. 25 630 40. Högdin S KC. Research Circles: A Method for the development of knowlegde and the creation of change 26 631 in practice. Saber Educar 2014;19 27 41. Östlund B. The revival of research circles: meeting the needs of modern aging and the third age. 2008; 28 632 29 633 04(34 (4)). 30 634 42. Persson S. Forskningscirklar - en vägledning. Malmö: Malmö stad, 2008. 31 635 43. Borg T. Livsførelse i hverdagen under rehabilitering. Et socialpsykologisk studie. Aalborg Universitet, 32 636 2002. 33 637 44. DePoy. E G, L.N. Gathering Information in Naturalistic Inguiry. Introduction to Research - 34 638 Understanding and Applying Multiple Strategies. 4th ed. St. Louis (USA): Elsevier Mosby 2011:p. 228. 35 639 45. Coyne IT. Sampling in qualitative research; merging or clear boundaries? J Adv Nurs 1997;26(3):7. 36 640 46. Kallio H, Pietila AM, Johnson M, et al. Systematic methodological review: developing a framework for a
37 641 qualitative semi-structured interview guide. J Adv Nurs 2016;72(12):2954-65. http://bmjopen.bmj.com/ 38 642 47. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008;62(1):107-15. 39 643 48. Nvivo 11 Pro for Windows [program]. 11.4 version: QSR International, 2017. 40 644 49. Richards L. Handling Qualitative Data. A Practical Guide. Third ed. Australia: Sage Publication 2014. 41 645 50. Sermeus W. Modelling process and outcomes in complex interventions. In: Richards D HI, ed. Complex 42 646 interventions in health: an overview of research methods. Oxon and Newe York: Routledge 2015:p.111. 43 647 51. Fisher A. Appendiks. In: Murmand L, ed. OTIPM Latvia: Munksgaard 2013:p. 209. 44 648 52. Young Y RB. Don't worry, Be Positive: Improving functional recovery 1 year after hip fracture. Rehabil
45 on October 1, 2021 by guest. Protected copyright. 649 Nurs 2009;34:110-17. 46 650 53. Saul D, Riekenberg J, Ammon JC, et al. Hip Fractures: Therapy, Timing, and Complication Spectrum. 47 48 651 Orthop Surg 2019;11(6):994-1002. 49 652 54. Langford D, Edwards N, Gray SM, et al. “Life Goes On.” Everyday Tasks, Coping Self-Efficacy, and 50 653 Independence: Exploring Older Adults’ Recovery From Hip Fracture. Qual Health Res 2018;28(8):1255- 51 654 66. 52 655 55. Tuscan J MB, Santi SM, Stolee P. "Just another fish in the pond": the transitional care experience of a hip 53 656 fracture patient. Int J Integr Care 2013;13(2) 54 657 56. Taylor NF, Harding KE, Dowling J, et al. Discharge planning for patients receiving rehabilitation after 55 658 hip fracture: a qualitative analysis of physiotherapists’ perceptions. Disabil Rehabil 2010;32:492-99. 56 659 57. Schiller C, Franke T, Belle J, et al. Words of wisdom - patient perspectives to guide recovery for older 57 660 adults after hip fracture: a qualitative study. Patient Prefer Adher 2015;9:57-64. 58 59 60
26 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 36
1 2 3 4
661 58. Jensen CM, Smith AC, Overgaard S, et al. “If only had I known”: a qualitative study investigating a BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 662 treatment of patients with a hip fracture with short time stay in hospital. Int J Qual Stud Health Well- 6 663 being 2017;12(1):1307061. 7 664 59. Asif M, Cadel L, Kuluski K, et al. Patient and caregiver experiences on care transitions for adults with a 8 9 665 hip fracture: a scoping review. Disabil Rehabil 2019:1-10. 10 666 60. Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care 11 667 for Persons with Continuous Complex Care Needs. J Am Geriatr Soc 2003;51(4):549-55. 12 668 61. Lockwood KJ, Harding KE, Boyd JN, et al. Predischarge home visits after hip fracture: a randomized 13 669 controlled trial. Clin Rehabil 2019;33(4):681-92. 14 670 62. Stark S, Keglovits M, Arbesman M, et al. Effect of Home Modification Interventions on the Participation 15 671 of Community-Dwelling Adults With Health Conditions: A Systematic Review. Am J Occup Ther 16 672 2017;71(2):1-11A. 17 673 18 674 For peer review only 19 675 Figure legends 20 676 Figure 1 Research circle process with overall topics discussed 21 22 677 Figure 2 Analysis process: abstraction of subcategory to generic category 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
27 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 36 BMJ Open
1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 Reflection Reflection Reflection RC I RC II RC I RC II RC I RC II RC I + RC II Develop final 7 1. meeting: 1. meeting: 2. meeting: 2. meeting: 3. meeting: 3. meeting: 4. meeting: rehabilitation 8 Rehabilitation Rehabilitation Rehabilitation Rehabilitation Rehabilitation Rehabilitation A joint programme at at transition to transition to in the in the proposal for a including 9 hospitalization hospitalization municipality municipality municipality municipality rehabilitation expert 10 programme assessment Reflection Reflection Reflection Final analysis 11 12 13 RC I, Research circle with older adults with hip fracture; RC II, Research circle with healthcare professionals 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 36
1 2 3 4
BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 5 6 7 Sub-category Generic category 8
9 • Learn to be oneself as quick
10 as possible
11 • Urge and follow-up goal-oriented Challenge with goal-oriented 12 performance of daily tasks ADL tasks 13 • Surroundings here and there 14
15 16 17 • Short time to learn 18 • Apron and nightlightFor peer review only 19 • Movement restrictions – maybe? Strategies to enhance 20 • Deliver, instruct and follow-up on independent and safe 21 assistive devices performance of ADL tasks 22 23 24 25 26 • Information and active involvement 27 in rehabilitation plan 28 • 29 Clarification of network Communicate the important 30 • Confusion about transitional hip information to the target 31 fracture rehabilitation group and across sectors 32 • Need for coherent support 33 34 35 36
37 http://bmjopen.bmj.com/
38
39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 31 of 36 BMJ Open
1 2 3 4 - 5 6 7 8 9 · 10 11 12 For peer review· only 13 · - 14 15 16 17 http://bmjopen.bmj.com/ 18 - · 19 · - - 20 21 22 23 24 · on October 1, 2021 by guest. Protected copyright. - 25 - - 26 27 · - - 28 29 30 · 31 32 · 33 34 · - - 35 36 - 37 38 39 40 41 42 43 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 32 of 36
1 The TIDieR (Template for Intervention Description and Replication) Checklist*: 2 3 Information to include when describing an intervention and the location of the information 4 5 Item Item Where located ** 6 number Primary paper Other † (details) 7 8 (page or appendix 9 number) 10 11 12 BRIEF NAME For peer review only 13 1. Provide the name or a phrase that describes the intervention. P. 5, l. 122-126 ______14 15 WHY 16
2. Describe any rationale, theory, or goal of the elements essential to the intervention. http://bmjopen.bmj.com/ P. 5, l. 122-128, ______17 18 P. 6, l. 137-143 19 WHAT 20 21 3. Materials: Describe any physical or informational materials used in the intervention, including those P. 17, L. 389- ______22 23 provided to participants or used in intervention delivery or in training of intervention providers. 400 + table 3 + 24
Provide information on where the materials can be accessed (e.g. online appendix, URL). on October 1, 2021 by guest. Protected copyright. figure 3 25 26 (supplementary 27 file 1) and table 28 29 4 30 31 32 4. Procedures: Describe each of the procedures, activities, and/or processes used in the intervention, P. 16-17, L. 376- ______33 34 including any enabling or support activities. 387 + table 3 + 35 table 4 36 37 38 39 40 WHO PROVIDED 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
Page 33 of 36 BMJ Open
1 5. For each category of intervention provider (e.g. psychologist, nursing assistant), describe their P. 16, L. 377- ______2 expertise, background and any specific training given. 378 3 4 HOW 5 6 6. Describe the modes of delivery (e.g. face-to-face or by some other mechanism, such as internet or P. 16, L. 377- ______7 telephone) of the intervention and whether it was provided individually or in a group. 378 8 9 10 WHERE 11 12 7. Describe the type(s) of location(s)For where the peer intervention occurred, review including any necessary only P. 16, L. 377- ______13 infrastructure or relevant features. 387 14 15 16 WHEN and HOW MUCH 17 http://bmjopen.bmj.com/ 18 8. Describe the number of times the intervention was delivered and over what period of time including P. 16-17, L. 377- ______19 the number of sessions, their schedule, and their duration, intensity or dose. 387 + table 4 20 21 TAILORING 22 9. If the intervention was planned to be personalised, titrated or adapted, then describe what, why, P. 16, L. 364 + ______23 24 when, and how. 397 25 on October 1, 2021 by guest. Protected copyright. 26 MODIFICATIONS 27 10.ǂ If the intervention was modified during the course of the study, describe the changes (what, why, N/A ______28 29 when, and how). 30 HOW WELL 31 32 11. Planned: If intervention adherence or fidelity was assessed, describe how and by whom, and if any N/A ______33 34 strategies were used to maintain or improve fidelity, describe them. 35 12.ǂ Actual: If intervention adherence or fidelity was assessed, describe the extent to which the N/A ______36 37 intervention was delivered as planned. 38 39 ** Authors - use N/A if an item is not applicable for the intervention being described. Reviewers – use ‘?’ if information about the element is not reported/not 40 41 sufficiently reported. 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from
BMJ Open Page 34 of 36
1 † If the information is not provided in the primary paper, give details of where this information is available. This may include locations such as a published protocol 2 or other published papers (provide citation details) or a website (provide the URL). 3 ǂ If completing the TIDieR checklist for a protocol, these items are not relevant to the protocol and cannot be described until the study is complete. 4 5 * We strongly recommend using this checklist in conjunction with the TIDieR guide (see BMJ 2014;348:g1687) which contains an explanation and elaboration for each item. 6 7 * The focus of TIDieR is on reporting details of the intervention elements (and where relevant, comparison elements) of a study. Other elements and methodological features of 8 9 studies are covered by other reporting statements and checklists and have not been duplicated as part of the TIDieR checklist. When a randomised trial is being reported, the 10 TIDieR checklist should be used in conjunction with the CONSORT statement (see www.consort-statement.org) as an extension of Item 5 of the CONSORT 2010 Statement. 11 When a clinical trial protocol is being reported, the TIDieR checklist should be used in conjunction with the SPIRIT statement as an extension of Item 11 of the SPIRIT 2013 12 Statement (see www.spirit-statement.org). ForFor alternate study peer designs, TIDieR can review be used in conjunction with only the appropriate checklist for that study design (see 13 www.equator-network.org). 14 15 16 17 http://bmjopen.bmj.com/ 18 19 20 21 22 23 24 25 on October 1, 2021 by guest. Protected copyright. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 TIDieR checklist For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 35 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 Standards for Reporting Qualitative Research (SRQR)* 2 http://www.equator-network.org/reporting-guidelines/srqr/ 3 4 Page/line no(s). 5 Title and abstract 6 7 Title - Concise description of the nature and topic of the study Identifying the 8 study as qualitative or indicating the approach (e.g., ethnography, grounded 9 theory) or data collection methods (e.g., interview, focus group) is recommended 10 3 11 Abstract - Summary of key elements of the study using the abstract format of the 12 intended publication; typically includes background, purpose, methods, results, 13 14 and conclusions 3 15 16 Introduction For peer review only 17 18 19 Problem formulation - Description and significance of the problem/phenomenon P. 6-7 / l. 144- 20 studied; review of relevant theory and empirical work; problem statement 163 21 Purpose or research question - Purpose of the study and specific objectives or 22 questions P. 5 / l. 122-128 23 24 25 Methods 26 27 28 Qualitative approach and research paradigm - Qualitative approach (e.g., 29 ethnography, grounded theory, case study, phenomenology, narrative research) 30 and guiding theory if appropriate; identifying the research paradigm (e.g., 31 postpositivist, constructivist/ interpretivist) is also recommended; rationale** P. 8 / l. 182-193 32
33 http://bmjopen.bmj.com/ 34 Researcher characteristics and reflexivity - Researchers’ characteristics that may 35 influence the research, including personal attributes, qualifications/experience, 36 37 relationship with participants, assumptions, and/or presuppositions; potential or 38 actual interaction between researchers’ characteristics and the research P. 8-9 / l. 195- 39 questions, approach, methods, results, and/or transferability 210 + table 1 40 P. 8-9 / l. 195- 41 Context - Setting/site and salient contextual factors; rationale** 210 on October 1, 2021 by guest. Protected copyright. 42 43 Sampling strategy - How and why research participants, documents, or events 44 were selected; criteria for deciding when no further sampling was necessary (e.g., P. 8-9 / l. 195- 45 sampling saturation); rationale** 210 46 Ethical issues pertaining to human subjects - Documentation of approval by an 47 48 appropriate ethics review board and participant consent, or explanation for lack P. 23 / l. 513- 49 thereof; other confidentiality and data security issues 518 50 Data collection methods - Types of data collected; details of data collection 51 52 procedures including (as appropriate) start and stop dates of data collection and 53 analysis, iterative process, triangulation of sources/methods, and modification of P. 9-10 / l. 213- 54 procedures in response to evolving study findings; rationale** 232 + figure 1 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 36 BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 2 Data collection instruments and technologies - Description of instruments (e.g., 3 interview guides, questionnaires) and devices (e.g., audio recorders) used for data P. 10-11 / l. 234- 4 collection; if/how the instrument(s) changed over the course of the study 249 5 6 7 Units of study - Number and relevant characteristics of participants, documents, P. 11 / l. 261-264 8 or events included in the study; level of participation (could be reported in results) + table 2 9 Data processing - Methods for processing data prior to and during analysis, 10 11 including transcription, data entry, data management and security, verification of P. 9-10 / l. 212- 12 data integrity, data coding, and anonymization/de-identification of excerpts 232 + figure 2 13 Data analysis - Process by which inferences, themes, etc., were identified and 14 developed, including the researchers involved in data analysis; usually references a P. 10-11 / l. 233- 15 specific paradigm or approach; rationale** 249 + figure 2 16 For peer review only 17 Techniques to enhance trustworthiness - Techniques to enhance trustworthiness P. 15 / l. 355-360 18 and credibility of data analysis (e.g., member checking, audit trail, triangulation); + p. 17 / l. 401- 19 rationale** 408 20 21 22 Results/findings 23 Synthesis and interpretation - Main findings (e.g., interpretations, inferences, and 24 25 themes); might include development of a theory or model, or integration with P. 11-15 / l- 260- 26 prior research or theory 345 27 Links to empirical data - Evidence (e.g., quotes, field notes, text excerpts, P. 12-15 / l. 287- 28 photographs) to substantiate analytic findings 345 29 30 31 Discussion 32
33 Integration with prior work, implications, transferability, and contribution(s) to http://bmjopen.bmj.com/ 34 the field - Short summary of main findings; explanation of how findings and 35 conclusions connect to, support, elaborate on, or challenge conclusions of earlier 36 scholarship; discussion of scope of application/generalizability; identification of P. 20-22/ l. 427- 37 unique contribution(s) to scholarship in a discipline or field 481 38 P. 22-23 / l. 482- 39 Limitations - Trustworthiness and limitations of findings 499 40
41 on October 1, 2021 by guest. Protected copyright. 42 Other 43 Conflicts of interest - Potential sources of influence or perceived influence on 44 study conduct and conclusions; how these were managed P. 24 / l. 522 45 46 Funding - Sources of funding and other support; role of funders in data collection, 47 interpretation, and reporting P. 24 / l. 523-527 48 49 50 *The authors created the SRQR by searching the literature to identify guidelines, reporting 51 standards, and critical appraisal criteria for qualitative research; reviewing the reference 52 lists of retrieved sources; and contacting experts to gain feedback. The SRQR aims to 53 improve the transparency of all aspects of qualitative research by providing clear standards 54 for reporting qualitative research. 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 36 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-044539 on 18 June 2021. Downloaded from 1 **The rationale should briefly discuss the justification for choosing that theory, approach, 2 method, or technique rather than other options available, the assumptions and limitations 3 4 implicit in those choices, and how those choices influence study conclusions and 5 transferability. As appropriate, the rationale for several items might be discussed together. 6 7 Reference: 8 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative 9 research: a synthesis of recommendations. Academic Medicine, Vol. 89, No. 9 / Sept 2014 10 DOI: 10.1097/ACM.0000000000000388 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40
41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml