Journal of Orthopaedic Nursing (2008) 12, 181–186

www.elsevier.com/joon

Journal ofOrthopaedic Nursing

Nursing contributions to mobilizing older adultsfollowing total hip replacement in Ireland

Mary O’Sullivan MSc, RGN, RNT (Lecturer) *, Eileen Savage PhD (SeniorLecturer)

School of Nursing and Midwifery, Brookfield Health Sciences, University College, Cork, Ireland

13do

KEYWORDSNursing;Mobility;Older adults;Total hip replacement;Mobility rehabilitation

61-3111/$ - see front mattei:10.1016/j.joon.2008.07.00

* Corresponding author. Tel.E-mail address: m.p.osulli

r �c 2004

: +353 2van@ucc

Summary Little is known on the nursing contributions to the mobilising of olderadults following hip replacement surgery. This paper presents the findings from astudy on nurses’ views of the contributions they make to the mobilising of olderpatients recovering from total hip replacement. A specific focus was laid on painmanagement and interpersonal care. The results show that Irish nurses reject mech-anistic models of care in favour of contemporary approaches. The work of otherauthors is discussed extensively.

�c 2008 Published by Elsevier Ltd.

Editor’s commentThis study explores nurses’ perceptions related to mobilising patients. How we view patients dramatically affects the care weprovide. PD

Introduction

Patterns of increased longevity contribute to thechanging demographic trends of the Irish popula-tion. The Central Statistics Office (2004) reportedthat the projected life expectancy will increaseby 7.4% for Irish males and 6.6% for Irish femalesbetween 2002 and 2036. Chronic pain, loss ofmobility and function are the consequences ofdegenerative musculoskeletal conditions prevalentin the older population. Hip replacement surgerycan be performed safely on adults over 65 years

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1 4901488..ie (M. O’Sullivan).

old, providing excellent pain relief and improvedfunctional outcome (Cuttfield (2002), O’Brien,2003). Nursing priorities for patients recoveringfrom hip replacement surgery are the managementof pain and discomfort, impaired mobility and anx-iety relating to knowledge deficit of the rehabilita-tion process (Schoen, 2000).

Previous research has been focussed on theexperiences of the patients in relation to the phys-ical elements such as pain management and com-fort promotion and interpersonal elements suchas professional characteristics and relationalcapacity. A third category comprised a combina-tion of the above, relating to nurses’ competen-cies, patient monitoring, patient safety, holisticcare and ward environment. Nurses contribute to

182 M. O’Sullivan, E. Savage

meeting such needs through pain management,comfort promotion, professional interpersonalrelations, competent and holistic practice, patientmonitoring and safety promotion. However, little isknown about nurses’ perceptions of their contribu-tion to mobility rehabilitation of the patients fol-lowing total hip replacement.

Pain was reported to be more intense than ex-pected by patients following hip replacement sur-gery (Montin et al., 2002). Patients’ willingness tobecome active following THR surgery is believedto be dependent upon their pain tolerance(Nussenzveig, 1999). While effective therapeuticpain management is essential for early mobiliza-tion, nurses perceive that physical outcomes canalso be gained by non-therapeutic methods. Non-therapeutic methods are closely aligned to inter-personal care. However, interpersonal issues asso-ciated with the rehabilitation of mobility ofpatients following THR receive little attention inthe literature. Insights into interpersonal issuesmay be gleaned from patients’ accounts of theirexperiences of undergoing total hip replacementsurgery. Findings from a qualitative study by Mon-tin et al. (2002) suggested that it was positiveinterpersonal relationships, professional character-istics and nurses attentiveness to patient safetythat most enhanced the rehabilitative milieu ofpatients recovering after hip replacement surgery.

The presence of an ‘engaged’ nurse was por-trayed as a positive experience by the patientsrecovering after hip replacement surgery in a phe-nomenological study by Kralik et al. (1997). Thequalities/characteristics of an ‘engaged’ nurse areacknowledgement of the physical, emotional, spiri-tual and environmental dimensions of the individ-ual; uses confident, firm and supportive physicaltouch; displays an understanding of the patients’situation and preserves patients’ dignity. The ‘en-gaged’ nurse was perceived as authentic and en-gaged in the patient’s humanness. Patients,therefore, gained psychological comfort from beingcared for by nurses with such characteristics.Relationships that allowed for the exposure of‘humanness’ of both patients and nurses wereacknowledged by patients. Authentic demeanourand capacity to display happiness and cheerfulnessinfluences not only the nurse–patient relationshipbut also that of family members. Consulting withpatients about the planned nursing care providedthe patient with a sense of control. Informing thepatients of the plan of care for the day was impor-tant because they were eager to understand whatwas expected of them. Female patients felt partic-ularly vulnerable when feeling unwell and unsafewhen mobilizing alone. Close monitoring by nurses

therefore comforted patients. Nursing care arisestherefore from biophysical and interpersonal needsof the patient. The studies highlight how the rela-tional capacity of the nurse plays a major role inpromoting the well-being of patients. Despite thelimitations of the small sample size (n = 9) the stud-ies reviewed support DeSouza (2002) contentionthat the concept of nursing care must be describedwith a focus on the patient as a whole person.

However, a question arises as to whether nursesvalue the contribution of physical and interper-sonal care to patients and whether they perceivesuch aspects of care as enabling patients’ mobilityfollowing total hip replacement. Further researchwas needed therefore on nurses’ perceptions oftheir contribution to the rehabilitation of mobilityof patients following total hip replacement.

Methods

The aim of this study was to describe nurses’ per-ceptions of their contribution to the mobilising ofolder adults following surgery for total hip replace-ment. The research questions were (a) what arenurses’ perceptions of their contribution to thephysical care of patients concerning pain manage-ment with respect to mobility following total hipreplacement surgery; (b) what are nurses’ percep-tions of their contribution to the interpersonal careof patients following total hip replacement with re-spect to mobility.

A quantitative approach employing a non-exper-imental descriptive design was carried out. A con-venience sample of registered nurses (n = 30)were selected from the entire population of 140nurses employed at an orthopaedic hospital in thesouth of Ireland.

The inclusion criteria for participants were reg-istered general nurses working on wards where pa-tients are nursed following total hip replacementsurgery and who had at least one month’s experi-ence as an employee at the hospital at the timeof the study. Student nurses were excluded fromthe study because they did not meet the sampledefinition. Access to the population was obtainedwith the permission of the Director of Nursing andthe Ethics Committee.

A two-part multi-item instrument consisting ofnine questions including nurses views on rehabilita-tion, pain management and nursing contributions tophysical, interpersonal and combined aspects ofnursing care was developed by the researcher.Question formats included forced choice, Likertscale, checklist, and ranked order. To improve thecontent validity of the instrument it was pilot-

Nursing contributions to mobilizing older adults following total hip replacement in Ireland 183

tested by five nurses who shared the same charac-teristics as the main sample. A nurse academic withexperience in orthopaedic nursing also confirmedcontent validity through review of the questions.

Results

Twenty-three nurses responded representing a re-sponse rate of 77%. Over half of the nurses (n = 13)regarded rehabilitation as focussing on the mainte-nance of existing abilities and roles, the promotionof health, the prevention of further impairment,the reduction of disability, the restoration of func-tion and roles and the minimisation of handicap.Less than half (n = 10) of the nurses considered thatrehabilitation emphasised the contribution ofphysical, social and psychological well-being. Whilenurses perceived that nursing contributions aregreatest with respect to physical care 65.2%(n = 15) their contribution to the patient’s interper-sonal care emerged as significant also.

Findings reflecting nurses’ assumptions on painmanagement portray that over ninety percent ofthe nurses (n = 21) agreed with the statement‘there is more to patient comfort than administer-ing analgesics. Furthermore, 65.2% (n = 15) respon-dents agreed that nurses rely mostly on thepatients to let them know of their need for analge-sia. Over half of the nurses (n = 13) agreed thatnurses are sometimes inattentive to patients needsfor analgesics’ and furthermore 34.8% (n = 8) ofrespondents consider that nurses are indeed ‘inat-tentive to patients’ analgesia requirements. Over69% (n = 16) of nurses perceive that patients’ will-ingness to engage in physical activity is dependenton their pain tolerance, yet 17.4% (n = 4) disagreeand 13.0% (n = 3) were unsure.

Problems of a physical nature contribute to thepatient’s complications following hip replacementsurgery and may delay mobilization and discharge.Nurses were asked to rate the degree to which nurs-ing contributed to a patient’s mobilisation. Nursingcontributions were reported as follows: pressurearea care (78.3%), management of patients’ pain(69.6%), toileting and personal care needs (69.6%)and the prevention of wound infection (65.2%), pre-vention of deep venous thrombosis (47.8%) and dis-location of the hip (47.8%). Nursing contributionswere perceived lowest with regard to the preven-tion of neurovascular impairment (26.1%) and withthe delivery of physical exercises (17.4%).

With respect to interpersonal care nurses identi-fied the following areas as those where the nursingcontribution was greatest in the mobilising of pa-tients’ following hip surgery: acknowledgement of

the physical, psychological, emotional and spiritualneeds of patients (56.5%), keeping a patient in-formed of the daily care plan (43.5%). Of the com-bined physical and interpersonal elements nursesidentified the following as contributing greatest:nurses’ competence (73.9%) monitoring of patients(73.9%), continuity of patient care (43.5%). How-ever, an environment conducive to rest (39.1%),involving the patient in goal setting (31.8%), posi-tive interactions with professionals (30.4%) andcreation of informal networks (17.4%) were re-ported as contributing least.

Discussion

Contemporary models of rehabilitation emphasisethe contribution of physical, social and psychologi-cal well-being as well as the interaction of the pa-tient with the environment. Irish nurses’ views onthe mobilising of THR patients were found to rejectmechanistic models in favour of contemporary ap-proaches to rehabilitation. The nurses’ perceptionmay have been influenced by the fact that themajority of patients commence full weight bearingon the operated leg by the second post-operativeday (Lucas, 2004). Therefore, in the absence of col-laborative problems improvement in the individ-ual’s ambulatory, recreational and occupationalfunction can be anticipated from an early stage(Orbell et al., 1998). Young et al. (1999) contendedthat the concept of rehabilitation must reflect notjust the function of a body part alone but of thewhole person, set in the context of their personalcircumstances. Furthermore, Young et al. (1999)pointed out that an important distinction betweenrehabilitation and other health interventions is thatpatients are not passive recipients. Reducing thegap between the person’s disability and capabilitythrough rehabilitation requires varying degrees ofenergy and is determined by the patient’s tolerance.

Rehabilitation of orthopaedic patients takesplace from the first point of contact (Davis,2000). In the absence of pre-admission clinics inthe hospital for this study, admission for surgeryis the first opportunity that nurses have to assessthe patient’s needs and potential post-operativeproblems. Lucas (2004) considered that nurses arewell placed to undertake patient assessment sothat any unrealistic expectations held by patientsmay be avoided. A conclusion that can be drawnfrom the findings is that Irish nurses respect thehealth potential of individual patients who undergojoint replacement surgery irrespective of thepatients’ age. Such a philosophy is complimen-tary to that of the RCN (2000) with regard to

184 M. O’Sullivan, E. Savage

rehabilitating older people. Nurses, however, rec-ognise that the rehabilitation of mobility is a com-plex process that is dependent upon the physical,psychological and social functioning of the individ-ual patient relative to their set of circumstances.

Nurses perceived that their greatest contribu-tion to mobilising older patients following totalhip replacement was in the provision of physicaland interpersonal care. Waters and Luker (1996),however, found that nurses were not perceivedby themselves or by other professionals as makinga major contribution to the rehabilitation processof hospitalised elderly people. Long et al. (2002)identified assessment, co-ordination and communi-cation, technical and physical care, therapy inte-gration and therapy carry-on, emotional supportand involving the family as core nursing roles inrehabilitation. The findings in this study make ex-plicit the potential contribution that nursing makesto the rehabilitation of patients mobility followinghip replacement surgery by attempting to disentan-gle the complex components of this process. Thefindings are generalisable only to the settings withsimilar characteristics. In order, therefore, to fur-ther clarify the nurse’s role in rehabilitation fur-ther study from the perspective of patients andtheir families is recommended.

Montin et al. (2002) found that patients reportedof post-operative pain following hip replacementsurgery more intense than expected, yet they werehappy with pain management. While pain mademobility difficult, patients considered it importantto do the exercises in accordance with the physio-therapy regime. Adequate pain control followingjoint replacement surgery is considered crucialfor early mobility and for the prevention of compli-cations (Nussenzveig, 1999). The majority of nurses(69.6%) perceived that they played a major role inthe management of post-operative pain. Sixty-fivepercent of nurses agreed that they rely on patientsto let them know of the need for analgesia. Fur-thermore, 35% of nurses perceive that nurses aresometimes inattentive to patients’ need for anal-gesia. The assessment and management of painwas categorised by Santy (2001) as the second mostimportant area in comfort enhancement for ortho-paedic nurses.

The majority of nurses (69.6%) in this study per-ceived that the patients’ willingness to engage inphysical activity is dependent on their pain toler-ance. Nurses also differentiated between comfortand pain relief. Ninety-one percent of nurses per-ceived that comfort is more than the outcomesgained from the administration of analgesics. Santy(2001) described the ‘comfort enhancer’ role as acore category in orthopaedic nursing. Comfort

enhancement involves activities such as meetingpatients’ physiological needs, positioning, skilfulhandling of patients in bed as well as the assess-ment and management of pain. Tutton and Seers(2003) contended, however, that comfort is a partof caring rather than an outcome of caring actions.

Mobilising patients following hip replacementsurgery is a positive and forward-looking processfor patients. The unique intimacy of the nurse–pa-tient relationship provides an opportunity fornurses to act as enablers to patients with regardto mobility. Evidence from the qualitative extractssuggests that nurses perceive that they provideencouragement, praise or motivation to patientsin relation to mobility. Young et al. (1999) sug-gested that the encouraging/facilitating role dif-fers from the caring/doing role and is thereforecomplimentary to rehabilitation. Furthermore,Santy (2001) considered that in this respect nursesadopt the role of ‘guide’ thereby playing a vitalrole in reducing the gap that exists between pa-tients’ mobility needs and their capabilities.

The findings from this study suggest that a pa-tient’s pain during the post-operative period maybe poorly assessed and managed. This may reflectinadequacies in the nurse’s level of knowledge inrelation to the prescribed pharmacological agents.A possible consequence of this is that patients con-tinue to experience unnecessary levels of painpost-operatively. Consequently, progression withambulation and discharge could be delayed. There-fore, post-operative pain management remains amajor challenge in the care of patients followingtotal hip replacement surgery. The absence of anacute pain service, patient controlled analgesiaand the services of a pain nurse specialist may alsocontribute to inadequacies with post-operativepain management.

The risk of pressure ulceration remains high forpatients undergoing hip replacement surgery(Maylor, 2001). Frequent repositioning and reliefof pressure is advocated as the best preventionstrategy. Nurses perceived that they make a largecontribution with regard to patient mobility. Aconclusion can be made that the nurses in the studynot only understood the risks but also were com-mitted to the prevention of pressure ulcer forma-tion. Deep venous thrombosis and dislocation ofthe prosthetic hip component were areas wherethe nursing contribution was reported equally highat 47.8%. Such complications can have serious con-sequences for the restoration of a patient’s mobil-ity. Prevention requires not only vigilant nursingcare but also competence and skills with the move-ment and handling of patients throughout the peri-operative and post-operative periods.

Nursing contributions to mobilizing older adults following total hip replacement in Ireland 185

Characteristics of the rehabilitative milieu aresaid to positively influence the recovery and reha-bilitative process. Pryor (2000) suggested that ifattention is focused on preserving the ‘wholeness’of the person whose body is impaired or disabledrehabilitation will be facilitated. In qualitative re-sponses nurses referred to providing ‘holistic careas contributing to the patients’ psychologicalwell-being. Keeping a patient informed of the dailycare plan (43.5%) and positive interactions withprofessionals (30.4%) are areas where the nursingcontribution was also significant. Pryor and Smith(2002) contended that to contribute effectively tothe facilitation of rehabilitation, nurses must pos-sess a repertoire of interpersonal skills and tech-niques. Furthermore, the choice of specific skillsand techniques must be based on an assessmentof the patient in their context as their conditionprogresses.

Nurses perceived that competent nursing andpatient monitoring contributes most to mobilising.Competence is demonstrated by the ability to prac-tice safely and effectively, utilizing evidence,thinking critically and performing as part of themultidisciplinary team (An Bord Altranais, 2000).Montin et al. (2002) found that patients followingtotal hip replacement consider that competentnurses can not only anticipate but also understandthe patient’s needs. Competence, however, is notstatic but developmental and has many attributes.Developing competence in orthopaedic nursing re-quires practice based on adequate knowledge andunderstanding of the core practical and technicalelements of care. Communication, interpersonal,organisation and managerial skills are also essen-tial. The ability to think critically, utilise evidenceand adopt a problem solving approach as well asperform effectively as part of the multidisciplinaryteam are attributes important in rehabilitativenursing. Furthermore, maintaining competence re-quires nurses to engage regularly in continuing pro-fessional development to remain informed ofdevelopments in practice.

With regard to nurses monitoring patients Kraliket al. (1997) reported that patients were com-forted by the notion that they were closely moni-tored by the nurse. Montin et al. (2002) reportedthat patients recovering from total hip replace-ment surgery felt safe when nurses visited themfrequently. Aiken et al. (2003, p. 1617) suggestedthat nurses are ‘‘the surveillance system for theearly detection of complications’’ while Pryor andSmith (2002) considered observation, assessmentand interpretation as a core activity for rehabilita-tive care. The rehabilitative approach is consideredone of seven domains of rehabilitation nursing

practice and represents the ‘how’ of practice(Pryor and Smith, 2002). By adopting a rehabilita-tive approach nurses focus on the person’s abilitiesrather than their disabilities. Activities such asobservation, assessment and interpretation deter-mine the plan of care for patients following totalhip replacement surgery. This facilitates goal set-ting and discharge planning with the patient.

Over 50% of nurses perceived that continuity ofcare also contributes to mobilising patients. Montinet al. (2002) found that patients consider continuityof care important also. Pryor and Smith (2002) con-sidered that nurses assume the role of co-ordinatorof patient care at both individual and ward levelswith 24 h responsibility for patient safety andwell-being. Advocacy is considered an essential ele-ment of this role and represents another domain ofrehabilitative nursing practice. Forty-three percentof nurses perceived that the nurse’s friendlinesscontributed to the patient’s mobilising followingtotal hip replacement. Kralik et al. (1997) describedthat a nurse’s ability to be friendly and warm is acharacteristic of engagement. Hartrick (1997) con-sidered the relationship between the patient andnurse to be the foundation of nursing practice. Fur-thermore, the nurse’s relational capacity is deter-mined by their interpersonal skills. Patientsfollowing total hip replacement considered thatan ‘engaged’ nurse made the patient feel comfort-able in unfamiliar, clinical surroundings. Hartrick(1997) identified initiative, authenticity andresponsiveness, mutuality and synchrony as capaci-ties that foster a caring relationship. Constraints onnursing personnel resources result in the delivery ofmore mechanistic models of care. Persistence withconventional approaches to patient care is com-pounded by limited opportunities for continuingeducation as well as the absence of education pro-grammes for nurses dedicated to the managementof musculoskeletal conditions.

The creation of a friendly atmosphere helpedpatients to relax and promoted interaction withothers. Santy (2001) considered that orthopaedicnurses harmonize the ward environment by creat-ing agreement or concord between the hospitalenvironment and the community for the good ofthe patient. Waters and Luker (1986) attributedresponsibility to nurses for the prevailing atmo-sphere and environment of the ward.

Conclusion

Current demographic trends represent an increasein the older population in Ireland. Increasedlongevity influences expectations regarding the

186 M. O’Sullivan, E. Savage

quality of life. The increasing numbers of the olderadults undergoing joint replacement surgery is tes-timony to the prevalence of degenerative jointconditions among this population. However, a per-iod of adaptation follows surgery and is when thepatient’s physical, psychological and social func-tioning is restored. The adoption of an enablingperson-centered approach to rehabilitation is con-sistent with the philosophy of care of older adults.

Pain is reported by patients as one of the pre-dominant physical experiences associated with thepost-operative period following total hip replace-ment. Effective post-operative pain managementis crucial for early mobilization and for the preven-tion of complications such as pneumonia and throm-boembolic disease. The contribution of the nursingrole in pain management may be an important fac-tor in enhancing the physical outcomes for patientspost THR. While nurses perceive that pain manage-ment is fundamental to the patient’s comfort, nev-ertheless they view other aspects of the patientscomfort to be equally important. Contemporary ap-proaches in health care emphasize the preservationof the wholeness of the person. Characteristics ofthe rehabilitative milieu can influence the psycho-logical well-being of patients such as ward philoso-phy, model of care delivery, atmosphere,communication and the attitudes of professionals.Patients also consider nurse’s authentic demean-our, relational capacity and communication regard-ing their plan of care as important.

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