Effect of extended nursing based on self-efficacy theory on the anxiety of patients with intertrochanteric fracture

Abstract

BACKGROUND

Extended care based on self-efficacy theory to elderly patients with intertrochanteric fractures will provide data reference to optimize the care plan of these patients, reduce patients’ concurrent mental diseases, and improve prognosis.

AIM

To analyze the value of extended nursing based on the self-efficacy theory in older patients with intertrochanteric fractures.

METHODS

Older patients with intertrochanteric fractures (n = 88) admitted to our hospital between January 2021 and December 2024 were randomly divided into two groups - the control group (n = 44, routine nursing) and the observation group (n = 44, extended nursing) - via balloting and treated for 12 weeks. The mental state, pain severity, limb function, and self-nursing ability of all patients before and after nursing were analyzed.

RESULTS

After nursing, the Hamilton Anxiety Scale and General Self-Efficacy Scale scores of patients in the two groups improved. Notably, Hamilton Anxiety Scale and General Self-Efficacy Scale scores in the observation group were lower and higher, respectively, than those in the control group (P < 0.05). The pain severity in the observation group (2.64 ± 0.22) was lower than that in the control group (2.85 ± 0.41) (P < 0.05). The recovery rate of limb function was higher in the observation group than in the control group (P < 0.05). In addition, the self-nursing ability scores of the patients in both groups increased, with a significantly higher score in the observation group (P < 0.05).

CONCLUSION

Extended nursing based on the self-efficacy theory can significantly improve mental state, relieve pain, and promote the recovery of limb function and self-nursing ability in older patients with intertrochanteric fractures.

Key Words: Self-efficacy theory; Extended nursing; Intertrochanteric fractures; Mental health; Clinic

Core Tip: Extended nursing founded on self-efficacy theory holds immense significance in improving the mental health of fracture patients. Especially for those with intertrochanteric fractures who have received surgical treatment, it is of paramount importance. This approach can offer personalized and targeted support and care, addressing their specific needs and concerns. By enhancing their self-efficacy, patients are more likely to actively participate in their recovery process, leading to better outcomes and an improved sense of well-being.

INTRODUCTION

Fear, anxiety, and tension due to pain, dysfunction, economic burden, and other factors are common concerns during postoperative recovery in older patients with intertrochanteric fractures. These factors complicate postoperative recovery, increase the psychological burden on patients, and have a negative impact on families[1]. Therefore, improving the poor mental state of older patients with intertrochanteric fractures, reducing the influence of negative emotions, and helping them achieve functional recovery have emerged as important focal points in clinical research. An intertrochanteric fracture of the femur, a type of hip joint fracture that is prone to occur in older individuals, is usually associated with factors such as sudden torsion of the lower limb, strong adduction or abduction when falling, or direct external force impact[2]. After trauma, patients mainly present with local swelling, pain, tenderness, and significant dysfunction, along with visible subcutaneous congestion on the lateral side of the hip in some patients. Notably, patients develop fear because of these symptoms. Simultaneously, limited limb activity following injury and not being able to stand or walk also affect the mental state of the patients[3]. However, nursing care can considerably influence the mental state of patients. Reasonable and efficient nursing plans can improve the mental state of patients during postoperative recovery and strengthen their self-protection consciousness[4]. Patients with hip fractures experience a significant decrease in driving frequency and other activities, an increase in depressive symptoms, and a decrease in active participation in activities in the first year after the fracture[5]. Meanwhile, compared with their peers, hip fracture survivors experience an inferiority complex, anxiety, and other adverse emotions due to the significant decline in limb function in the first year after hip fracture. Notably, negative emotions after surgery in most patients with hip fractures significantly affect postoperative recovery. As China enters an aging society, the proportion of older people is relatively high, and their manifestations are more significant in some diseases that are prone to occur in older patients. Many clinical studies have been conducted to improve mental function in older patients with intertrochanteric fractures and optimize postoperative limb recovery. However, the outcomes may vary with different intervention methods, and corresponding guidelines and standards in this regard remain lacking. Self-efficacy, proposed by American psychologist Albert Bandura, refers to the degree of individual confidence in whether they have the skill to complete a job[6]. Self-efficacy affects an individual’s behavior and effort, as well as their thinking and emotional response. Self-efficacy, as a dynamic concept, gradually changes with access to new information. High self-efficacy can promote applying enough effort to achieve success, and low self-efficacy can hamper applying efforts in advance or taking the initiative, thereby weakening competency expectations[7]. Extended nursing is designed as a series of actions to ensure that patients receive collaborative and continuous care within the same and in different healthcare places. Many factors lead to the poor mental state of patients, and a single nursing intervention often lacks systematicity, integrity, and pertinence. Therefore, extended nursing based on the self-efficacy theory can resolve nursing implementation issues. Further, targeted nursing measures formulated according to the mental state of patients as guidance may improve negative emotions in patients, thereby improving the effect of postoperative care. In this study, we analyzed the application value of extended nursing based on self-efficacy theory in older patients with intertrochanteric fractures admitted to our hospital.

MATERIALS AND METHODS

General data

A total of 88 older patients with intertrochanteric fractures admitted to Affiliated Hospital of Nantong University who met the diagnostic criteria for femoral trochanteric fractures[8] were selected for this study. The inclusion criteria were as follows: (1) Patients aged ≥ 60 years; (2) Patients who could undergo surgical treatment; (3) Patients without mental disorders; (4) Patients with normal self-nursing ability before the fracture; and (5) Patients or their families who provided informed consent. The exclusion criteria were as follows: (1) Poor compliance; (2) Patients with multiple or combined injuries based on the fracture examination; (3) Patients insensitive to sedative drugs or had a history of long-term use of sedative drugs; (4) Patients with language communication disorder or hearing impairment; and (5) Patients from other places or who could not be followed up after discharge. The general data of the two groups were balanced and comparable (P > 0.05) (Table 1).

Table 1 Comparison of general data.

General data	Observation group (n = 44)	Control group (n = 44)	t/χ2	P value
Mean age (years)	68.80 ± 4.11	68.70 ± 5.00	0.102	0.919
Sex			0.185	0.667
Male	24	26
Female	20	18
Injury type			0.229	0.892
Traffic injury	16	15
High falling injury	17	16
Impact injury	11	13
Mean body mass index (kg/m2)	23.44 ± 3.14	23.22 ± 3.28	0.321	0.749
Education			0.792	0.673
Middle school and below	11	13
High school	15	17
Junior college and above	18	14

Patient intervention and methods

The control group was provided routine nursing care. Before discharge, nursing staff evaluated the vital signs of the patients, including heart rate, blood pressure, limb function exercise, and degree of wound recovery, to guide patients to eat scientifically, fast raw cold and greasy foods, urge patients to get out of bed as soon as possible, and urge patients to undergo regular reexamination. The observation group was provided extended nursing care based on self-efficacy theory on the basis of routine nursing. An extended nursing group, including orthopedists, rehabilitation physicians, psychologists, head nurses, and several nursing staff members, was established. Prior to the study, all members learned about self-efficacy theory and extended nursing content.

Condition evaluation

During hospitalization, the actual situation of the patients was evaluated, which included the effect of surgery, postoperative limb function, mental state, and self-nursing ability. A day before discharge, nursing needs were understood through a questionnaire, such as timely medical consultation and providing skill guidance. Based on the condition assessment and actual needs of patients, a reasonable self-efficacy theory of extended nursing programs and health guidance was formulated.

Mental state

Before discharge, professional psychologists evaluated the mental state of patients and grouped them according to their evaluation results (mild, moderate, and severe). Through active communication with the patients, we could understand the reasons for their poor mental states. For patients worried about the treatment effect, nursing staff could speak more encouraging words to provide mental support and enhance their confidence in the rehabilitation treatment. Based on their professional knowledge and skills, they explained the possible effects of surgery to patients to help them strengthen their self-efficacy. The nursing staff also helped patients actively participate in self-intervention and treatment. Patients who were anxious about their limb function recovery and the decline of their quality of life were encouraged to undergo walking training and perform routine activities with the help of a walker. Further, the patients were told about the cases with good recovery to make them understand the importance and necessity of standardized functional exercise postoperatively, thereby enhancing their confidence in recovery and promoting them to actively participate in functional exercises. For the patients with poor psychology due to a lack of security or economic burden, the nursing staff guided the family members to improve communication with the patients, provide full support and understanding to reduce the psychological burden, and improve the mood of the patient.

Follow-up

The patients and their family members were taught the correct methods of limb function exercises. Nursing staff guided patients to perform functional exercises according to the rehabilitation knowledge guidance manual at regular intervals via online guidance. The intensity and time of training were adjusted based on the actual recovery status of the patient, and the daily completed limb functional exercises were recorded in the registration form. Light exercise was recommended daily, which was adjusted according to the patient’s situation and fixed at 3 times/week. The patients were followed up twice a month through phone or WeChat to understand their problems and provide guidance.

Outcome indicators

Mental state: The Hamilton Anxiety Scale (HAMA) and General Self-Efficacy Scale (GSES) were used for assessments before and after nursing. The HAMA consists of 14 items reflecting anxiety symptoms, mainly involving two major factors: Somatic anxiety and mental anxiety. Each item is assessed based on a score of 0-4, where 0 = asymptomatic, 1 = mild, 2 = moderate, 3 = severe, and 4 = extremely severe. The higher the score, the more serious the anxiety symptoms. The GSES consists of 10 items mainly related to patients’ self-confidence when facing difficulties or setbacks. Each item is assessed based on a score of 1-4, where 1 = incorrect, 2 = slightly correct, 3 = mostly correct, and 4 = completely correct. The total score ranges from 10 to 40 points. Higher scores indicate stronger self-efficacy.

Pain intensity: Before and after nursing, a straight line was equally divided into 10 segments using the numerical rating scale, and pain severity was assessed on a scale of 0-10. Notably, the most severe pain sensation in the past 24 hours was described, and the “√” was drawn on the figure. Accordingly, 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, and 10 = extreme pain[6].

Limb function: The joint function of the patients was assessed before and after nursing using the Harris Hip Functional Standard (Harris) score. The total score is 100, where ≥ 85 points = excellent joint function, 70-85 points = good joint function, 60-70 points = average joint function, and < 60 points = poor joint function. The joint function recovery rate was calculated as (excellent cases + good cases)/total cases × 100%.

Self-nursing ability: The Barthel Index Scale was used to assess the self-nursing ability of patients before and after nursing. This scale includes 10 items, and each item was rated as 0, 5, or 10, where 0 represented complete inability to take care of oneself, 5 represented the need for assistance from others, and 10 represented complete independence, with a total score of 100. The patient’s daily living ability was positively correlated with the scores.

Statistical analysis

The data collected in this study were analyzed using SPSS 26.0 (SPSS Inc., Chicago, IL, United States) and GraphPad Prism 8.0 software (GraphPad Software, La Jolla, CA, United States). Before conducting parametric tests, the normality of the measurement data was assessed with appropriate statistical tests, such as the Shapiro-Wilk test or the Kolmogorov-Smirnov test. Data that were normally distributed were expressed as mean ± SD, while non-normally distributed data were presented using median and interquartile range. For normally distributed data, comparisons between groups were performed using independent sample t-tests, and comparisons within groups were made using paired sample t-tests. Count data, rate (%), and categorical variables were assessed using the χ² test. A P value less than 0.05 indicated statistical significance.

RESULTS

Mental state

Compared with those before nursing, The HAMA and GSES scores of the patients decreased and increased, respectively, after nursing in both groups. Notably, more significant changes were observed in the observation group than in the control group (P < 0.05) (Table 2).

Table 2 Mental state score (mean ± SD, points).

Group	HAMA		t	P value	GSES		t	P value
	Pre-nursing	Post-nursing			Pre-nursing	Post-nursing
Observation group (n = 44)	36.44 ± 3.42	20.53 ± 1.84	27.175	0.000	28.75 ± 4.12	36.58 ± 6.22	6.209	0.000
Control group (n = 44)	36.39 ± 3.30	21.61 ± 2.13	24.961	0.000	28.75 ± 4.22	31.25 ± 4.78	2.148	0.036
t	0.070	2.545			0.000	3.823
P value	0.945	0.013			1.000	0.000

HAMA: Hamilton Anxiety Scale; GSES: General Self-Efficacy Scale.

Pain intensity

No significant difference was found in the degree of pain between the two groups before nursing (P > 0.05). After nursing, the pain severity of the patients was relieved in both groups, and it was lower in the observation group than in the control group (P < 0.05). Notably, a significant difference was observed in the degree of pain before and after nursing within the groups (P < 0.05) (Table 3; Figures 1 and 2).

Figure 1 Comparison degree of pain between the two groups before and after nursing. A: Comparison degree of pain between the two groups before nursing; B: Comparison degree of pain between the two groups after nursing.

Figure 2 Observation group degree and control group degree of pain before and after nursing. A: Observation group degree of pain before and after nursing; B: Control group degree of pain before and after nursing.

Table 3 Pain scores (mean ± SD, points).

Group	Pain		t	P value
	Pre-nursing	Post-nursing
Observation group (n = 44)	6.33 ± 0.62	2.64 ± 0.22	37.306	0.000
Control group (n = 44)	6.39 ± 0.71	2.85 ± 0.41	28.640	0.000
t	0.422	3.136
P value	0.674	0.002

Limb function

The recovery rate of limb function was higher in the patients in the observation group than in the control group (P < 0.05) (Table 4).

Table 4 Degree of functional recovery of limbs, n (%).

Degree of functional recovery of limbs	Observation group (n = 44)	Control group (n = 44)	χ2	P value
Excellent	24 (54.55)	16 (36.36)
Good	11 (25.00)	10 (22.72)
Average	8 (18.18)	8 (18.18)
Poor	1 (2.27)	9 (20.45)
Recovery rate			4.328	0.038

Self-nursing ability

No difference was observed in the self-nursing ability of the patients between the two groups before nursing (P > 0.05). After nursing, the self-nursing ability was higher in the patients in the observation group than in the control group. Notably, compared with that before nursing, the self-nursing ability of patients in both groups was significantly improved after nursing (P < 0.05) (Table 5).

Table 5 Self-nursing ability score (mean ± SD, points).

Group	Self-nursing ability score		t	P value
	Pre-nursing	Post-nursing
Observation group (n = 44)	40.33 ± 5.62	74.63 ± 5.22	29.663	0.000
Control group (n = 44)	40.39 ± 5.71	70.67 ± 6.33	23.561	0.000
t	0.050	3.202
P value	0.960	0.002

DISCUSSION

Older patients with intertrochanteric fractures lose the ability to perform activities of daily living because of impaired function due to the injury. According to a report[9] by the China Scientific Research Center for Aging and Social Science Academic Press, as of 2015, there were over 40 million older people with disabilities in China, accounting for 18.3% of the older population. Older patients with impaired function due to fractures cannot perform basic personal care activities and are also more prone to adverse mental states such as anxiety and depression due to pain, limited limb activity, economic pressure, and other factors. Limb dysfunction, deformity, and long-term bed rest restrictions further affect the mental state of older patients with intertrochanteric fractures and aggravate the development of negative emotions. Nursing measures are important to improve negative emotions in these patients. Self-efficacy is an individual’s ability to engage in certain behaviors and achieve expected results in a specific situation. To a large extent, this refers to an individual’s assessment of self-related abilities. Self-efficacy also refers to an individual’s confidence or belief in their ability to achieve behavioral goals in a specific field. Notably, an individual’s physiological and psychological behavior is influenced by a variety of stimuli, along with external environmental factors, which may promote behavioral motivations[10]. Extended nursing emphasizes the continuity of patient information, medical care services, and the nurse-patient relationship and provides patients with high-quality care through “three parties”, including providing out-of-hospital health guidance to discharged patients, professional and technical support to nursing staff, and health maintenance knowledge to patients’ families[11]. Therefore, we adopted extended nursing based on the self-efficacy theory, in which the mental state of patients is considered for guiding nursing implementation and the corresponding nursing interventions are performed according to the actual situation to improve the overall quality of nursing.

This study found that, compared with that before nursing, the HAMA score decreased, whereas the GSES score increased in the patients after nursing, and the improvement was more significant in the observation group than in the control group. These results indicated that extended nursing based on the self-efficacy theory for older patients with intertrochanteric fractures had a positive effect on improving their mental state. Currently, research on extended nursing measures guided by self-efficacy in older patients in clinical practice remains limited. Fu et al[12] in their study on postoperative fear, compliance, and self-efficacy in older patients with hip fractures, revealed that evidence-based interventions can improve the mental state of patients and enhance the overall nursing effect, thereby confirming the feasibility and applicability of our study. Previous literature on the use of extended nursing for older patients with intertrochanteric fractures has revealed that extended nursing can improve the postoperative recovery of these patients to a certain extent but cannot improve their negative emotions[13]. Therefore, through discharge condition evaluation, we can understand the mental problems of patients, identify the specific factors leading to their negative emotions by strengthening communication with patients, and formulate corresponding nursing measures to improve the level of nursing intervention.

As one of the main manifestations of intertrochanteric fractures in older patients, timely pain relief after surgery can reduce the patients’ resistance to limb activities, thereby promoting postoperative limb functional recovery. The Harris hip score system is a curative effect evaluation index applicable to various hip joint diseases that emphasizes the importance of pain and function in the recovery process. The Harris score includes pain, function, deformity, and joint range of motion. The Harris index is overall a good predictor, emphasizing postoperative pain and changes in joint function. The Harris score can appropriately reflect the limb function recovery of patients[14]. In this study, after nursing, the pain severity of patients in the observation group significantly decreased and the Harris hip joint score significantly increased compared with those in the patients in the control group. Notably, patients were made aware of the importance of mental state to limb function recovery through extended nursing based on self-efficacy theory, health guidance manuals prepared by the nursing staff, organizing group learning, seminars, and live demonstrations, which weakened the patient’s resistance to the limb function training, thereby significantly promoting recovery in patients.

The assessment of self-nursing ability can help nursing staff understand the current self-nursing situation of older patients with intertrochanteric fractures and determine whether they need further rehabilitation training or adjustments in their rehabilitation plans. Simultaneously, the evaluation results can provide a reference for the medical team to formulate personalized care content. Therefore, the level of self-nursing ability of the patients has direct feedback value for the implementation of the nursing plan[15]. After nursing, the self-nursing ability of the patients in the observation group was higher than that in the control group, and compared with that before nursing, the self-nursing ability of patients in both groups improved significantly. Following this analysis, in the extended nursing intervention, the patients and their families were guided about the appropriate limb function training methods. Further, through online and offline methods, the patients were regularly guided to perform function training according to the rehabilitation knowledge guidance manual, and the families were asked to record the daily completed limb function training in the registration form to help enhance the patients’ initiative in limb activities, thereby promoting postoperative recovery.

This study explored the clinical treatment effect of extended care of self-efficacy for older patients with intertrochanteric fractures by using a randomized controlled study, and improved the reliability of the findings while effectively controlling confounders. However, this study has some limitations. The sample size of 88 participants may limit the generalizability of the findings. The clusion of a larger and more diverse sample could enhance the external validity of the findings and enhance its applicability to a wider population. Furthermore, although this study demonstrated positive outcomes associated with extended care, the potential cost impact of implementing such interventions were not addressed, so further research targeting cost-effectiveness analysis is needed to provide healthcare decision makers with valuable information about the feasibility and resource allocation of integrating these interventions into clinical practice.

CONCLUSION

Extended nursing based on self-efficacy for older patients with intertrochanteric fractures plays a significant role in improving their poor mental state and relieving pain, and promotes the recovery of limb function and self-nursing ability of patients.