Compliance of oral nutrition supplementation in elderly patients with hip fracture during perioperative period: a qualitative study

Compliance of oral nutrition supplementation in elderly patients with hip fracture during perioperative period: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Compliance of oral nutrition supplementation in elderly patients with hip fracture during perioperative period: a qualitative study Xujuan Chen, Li Zhang, Yan Wu, Xinyue Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8952056/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objective To explore the obstacle factors of oral nutrition supplementation compliance in elderly patients with hip fracture during perioperative period, and to provide theoretical basis for the development of targeted nursing intervention strategies. Methods A purposive sampling method was used to select 20 elderly patients with hip fracture admitted to a hospital in Shanghai from July to February 2026 to conduct semi-structured interviews. The interview data were sorted out and summarized by Colaizzi ’s seven-step analysis method. Results The compliance rate of oral nutrition supplementation in elderly patients with hip fracture during perioperative period was 20%. A total of 5 themes and 8 sub-themes were extracted from the relevant factors: postoperative physiological reaction leading to loss of appetite, insufficient nutrition cognition and lack of education, insufficient supervision mechanism and care support, insufficient economic burden and family support, and poor taste of nutrition preparations. Conclusion The compliance of oral nutrition supplementation in elderly patients with hip fracture is affected by many factors such as physiology, cognition and support system. Comprehensive intervention strategies should be developed from multiple levels to improve compliance and promote rehabilitation. Hip fracture Elderly Oral nutrition supplement Compliance Qualitative study 1. Introduction Hip fracture is the most common type of fracture in the elderly population, and the incidence rate is increasing year by year with aging. It is predicted that by 2050, the global hip fracture cases will increase from 1.26 million in 1990 to 4.5 million. Surgery is currently the preferred treatment [ 2 ]. Perioperative malnutrition is one of the important risk factors for poor prognosis in elderly patients with hip fracture. A study [ 3 ] pointed out that hip fracture has the highest incidence of malnutrition risk among all fracture types, and a large proportion of elderly patients with hip fracture have long-term malnutrition before admission [ 4 ]. Perioperative malnutrition can lead to an increase in the risk of surgery and the incidence of postoperative complications [ 5 ], such as postoperative wound infection or poor healing [ 6 ], stress injury [ 7 ], delirium [ 8 ], etc., thereby prolonging hospital stay and recovery time, and also increasing the risk of death. In 2021, the European Society for Parenteral and Enteral Nutrition (ESPEN) recommended that patients should start taking oral nutritional supplements (ONS) after admission to reduce the incidence of complications and shorten the length of hospital stay [ 9 ]. ESPEN defines ONS as: in addition to normal food, supplementary oral intake of special medical use (formula) food [ 10 ]. The best evidence from the Joanna Briggs Institutions (JBI) also points out that medical staff should give oral protein drinks twice a day to elderly hip fracture patients during hospitalization[ 11 ]. However, a number of studies [ 12 – 15 ] have found that patients’ compliance with oral ONS is generally low. The existing research focuses on patients with gastrointestinal tumors, and it is difficult to grasp the subjective experience and complex influencing factors of patients with simple quantitative research. Therefore, this study intends to summarize the root causes of insufficient oral ONS compliance from the real experience and cognition of patients through qualitative research methods, so as to provide reference for medical staff to formulate scientific and feasible intervention measures. 2. Materials and methods 2.1 Study design This study is guided by the phenomenological method in qualitative research [ 16 ],.The research group consisted of one physician, one deputy director nurse, two supervisor nurses and two nurses. All of them had received systematic training in qualitative research methods and had rich experience in qualitative research. The research team combined with the research purpose, consulted the relevant literature at home and abroad, and preliminarily formulated the interview outline around the compliance status and influencing factors of oral nutrition supplementation in elderly patients with hip fracture, and invited orthopedic experts to review and modify it. Before the formal interview, 3 elderly patients with hip fracture were selected for pre-interview, and the outline was further revised according to the feedback results. After several rounds of discussion in the group, the interview outline was finally determined.(The detailed interview guide used in this study is provided in Supplementary File 1.) 2.2 Participants A purposive sampling method was used to select elderly patients with hip fractures admitted to the Department of Orthopaedics, a hospital in Shanghai from July to February 2026 as the study subjects. Inclusion criteria: (1) diagnosed as femoral neck fracture or intertrochanteric fracture by clinical symptoms, signs and imaging examination;(2) Age ≥ 60 years;(3) Be able to understand the content of this study and volunteer to participate. Exclusion criteria: (1) patients with dysphagia or unable to eat orally for other reasons;(2) Combined with severe cognitive impairment or speech communication disorder, the interviewer could not successfully complete the interview. The sample size is based on the saturation of data content and no new information appears. All patients who participated in this study have signed informed consent. 2.3 Data collection Before the formal interview, the researchers explained the purpose and significance of the study to the interviewees, and promised that the data were only used for scientific research and strictly confidential, and all information was replaced by numbers. After the consent of the interviewee, the written informed consent was signed and the recording permission was obtained. The interview site was selected in the orthopedic ward demonstration classroom of a hospital in Shanghai .Taking into account the tolerance of elderly patients and the amount of information, we will control each interview time in 20 ~ 30min, in a quiet and comfortable environment. During the interview, the researchers maintained a neutral attitude, listened carefully to the interviewees’ narration, did not give guidance or hints, and asked, repeated or clarified if necessary. At the same time, the tone, attitude and non-verbal behavior of the respondents were recorded to encourage them to fully express their true feelings and the underlying causes of compliance. A total of 20 patients were interviewed in this study and numbered by P1-P20. 2.4 Data analysis Within 24 hours after the end of the interview, the recordings and on-site records were collated and transcribed into text by two researchers ; another researcher checked the recordings and transcripts one by one to ensure that the data were accurate and complete. The collated text materials are returned to the interviewees for member verification to confirm that the content is true and reliable. Colaizzi ’s seven-step method was used for data analysis [ 17 ], The data analysis process was jointly participated by the research team and continued peer review and discussion, and the differences were discussed until agreement was reached, so as to ensure the scientificity and credibility of the analysis. 2.5 Ethical consideration The study conformed to the Declaration of Helsinki and was approved by the Luodian Hospital Ethics Committee(NO.LDYY-KY-2026-06). Participants received full information, gave written consent, and were assured confidentiality and the right to withdraw. 3. Results The general information of the respondents is shown in Table 1 .Through the integration and analysis of the interview data, five themes and eight sub-themes affecting compliance were finally summarized. Table 1 General information of respondents (n = 20) Characteristic Category n (%) Age group (years) 60–70 3 (15.0) 71–80 13(65.0) ≥ 81 4 (20.0) Sex Female 10 (50.0) Male 10 (50.0) Education level Illiterate 2 (10.0) Primary 7 (35.0) Senior-high 7 (35.0) Junior-high 3(15.0) College 1 (5.0) Diagnosis Femoral-neck fracture 12 (60.0) Inter-trochanteric fracture 8(40.0) Payment source Medical insurance 17 (85.0) Self-pay 3(15.0) Adherence to ONS Adherent 4 (20.0) Partially adherent 7(35.0) Refused 9 (45.0) 3.1 Theme 1: Postoperative loss of appetite 3.1.1 Physiological stress reaction causes digestive tract discomfort The side effects of anesthetic drugs and surgical trauma pain form a double physiological stress, which directly stimulates the gastrointestinal mucosa and interferes with the regulation of digestive function, resulting in nausea, nausea and other discomfort symptoms, and reducing the tolerance of food. P5:“Before the operation can eat a little nutrition powder, but after the operation is always nausea and nausea, really do not want to eat.”P18:“I want to eat, but now I want to vomit as soon as I eat, I can only wait for a better time to eat.”P12:“After the anesthetic strength has passed, it becomes more and more painful, and it hurts when it moves, and does not want to eat anything.” 3.1.2 Prolonged bed rest leads to slow bowel movement Fractures and surgery lead to prolonged bed rest, which leads to a sudden decrease in body activity and a significant decrease in intestinal peristalsis. Some patients are accompanied by abdominal distension, constipation and other problems .P4: “I had a bad appetite, and I lay down all the time after the operation, and I couldn 't eat the meal, and this nutritional powder couldn 't eat any more.”P7:“surgery has not been defecated, not much to eat. ” 3.2 Theme 2: Lack of nutrition cognition and lack of education 3.2.1 Lack of nutrition knowledge and cognitive bias Most patients have insufficient scientific understanding of nutritional support, and it is generally believed that daily diet can meet the needs of postoperative physical repair without additional supplements. P1:“Three meals are enough to eat, no need to eat any protein powder, but the doctor let me eat, I will eat.”.P9:“Why do I have to eat this ? Eating something else is just as nutritious, and I’m not malnourished”. Some patients also have knowledge confusion or misconceptions, such as equating nutritional powder with health food or milk powder, and even believe that infusion of albumin instead of oral supplementation is more effective. P16:“Eating protein powder is not as good as hanging albumin, isn 't the effect better.”P14:“I usually drink milk powder, similar to this”. 3.2.2 Lack of education and guidance In clinical nursing, nutrition-related education is often superficial. Due to the busy work, most of the medical staff briefly explained the method of taking at the first time, and lacked a systematic explanation of the purpose of nutritional support. One patient said P13:“The nurse just asked me whether to eat, did not say I must eat.”P11:“No one told me what was the benefit of eating this, I thought it didn 't matter, so I didn 't eat”. There are even patients who rely entirely on the doctor ’s attitude to decide whether to take it, P3:“the doctor did not say to eat protein powder, I will not eat it”. 3.3 Theme 3: Insufficient supervision mechanism and care support 3.3.1 Inadequate oversight and absence of processes Although some patients are willing to accept ONS, medical staff usually only simply inform the usage when ONS is issued for the first time, and do not carry out follow-up tracking and compliance assessment. In addition, memory loss is common in elderly patients, and the superposition of the two leads to frequent problems such as missed administration and improper frequency of administration. P13:“I eat, but often can not remember to eat. The nurse said once or twice a day, I can 't remember, anyway, it doesn 't matter to eat more and eat less.”P15:“The best nurse can remind us, otherwise I remember is not good, it is easy to forget. ” 3.3.2 Care dependence and inadequate support The postoperative activity of elderly patients with hip fracture is limited, and most of them need the help of family members or caregivers to adjust ONS. However, due to the uneven quality of care, it is easy to lead to missed or wrong clothes. P20:“I eat when my daughter takes care of me, but my son often forgets to eat”.P14:“The caregiver sometimes ate me several times a day, sometimes not once, and I was too embarrassed to remind her.”P10:“Today, my son went out, no one bubble protein powder for me to eat”. 3.4 Theme 4: Economic and family support factors 3.4.1 Heavy economic burden Economic pressure is an important external factor affecting patient compliance. At present, nutritional supplements such as whey protein powder commonly used in clinical practice have not been included in the scope of medical insurance reimbursement,. However, the cost of hip fracture surgery itself is high, which further aggravates the economic burden of the family. P11:“Doing an operation has cost a lot of money, this protein powder is so expensive, I don 't want to eat it.”P16:“This is not into health care, at their own expense, spend so much money, I eat something else is not good, if health care can be reimbursed, I will eat.”P17:“My son says this is useless and a waste of money. I see a doctor is to spend his money, he said don 't eat, don 't eat, surgery has spent a lot of money, can save a little save a little.”P19: “My daughter said that her stewed ribs soup is more nutritious than this protein powder. These money is enough to buy a lot of ribs. Usually my daughter takes care of me. I have to listen to her”. 3.5 Theme 5: Poor taste of nutritional preparations Poor taste is an important reason for patients to refuse or reduce the use of nutritional supplements. Some elderly patients have natural rejection of the taste of dairy products, or do not adapt to their flavor due to decreased taste function, which in turn affects compliance. P3:“I know that protein powder is nutritious, but I never eat this milk-like thing. I really don 't like the taste. I’d rather take medicine than this.”P2:“Although I am eating, I feel that the taste is very light, no taste, not tasty.”P13:“This taste I don 't like very much, it’s best to have other flavors to choose from.”P14:“protein powder has a smell, I can 't eat it.” . 4 Discussion In view of the above themes, the study suggests the following improvement measures. 4.1Optimize perioperative management, improve patient appetite and tolerance Hip fracture surgery is usually accompanied by large blood loss and significant protein loss. In addition to conventional intravenous rehydration, oral protein supplementation is also crucial for maintaining body balance and promoting wound healing [ 18 ]. Before surgery,too long preoperative fasting time will also increase the incidence of postoperative nausea and vomiting. Therefore, patients undergoing elective surgery can still drink clear liquid 2 hours before surgery[ 19 – 20 ]. This will not only increase the risk of aspiration, but also help to accelerate gastric emptying and reduce the incidence of postoperative nausea and vomiting. During the operation, too long operation time may increase the incidence of postoperative nausea and vomiting [ 21 ].Therefore, on the premise of ensuring the safety of the operation, the operation time should be shortened as much as possible. After surgery, aromatherapy, as an adjuvant therapy, can effectively relieve postoperative nausea and vomiting[ 22 ]. In view of the poor appetite caused by postoperative pain, patients often refuse to eat or reduce their intake, which further aggravates malnutrition. which causes local edema and aggravates pain symptoms[ 23 ]. Therefore, in view of the influence of pain on patients ' appetite and nutritional intake, multimodal analgesia management should be strengthened during perioperative period. In view of the weakening of gastrointestinal peristalsis during perioperative period, moderate increase of activity has a positive effect on the recovery of intestinal peristalsis. When patients cannot move autonomously before operation, abdominal massage can be used to assist intervention to help maintain the basic intestinal motility [ 24 ]. After the operation, patients should get out of bed as soon as possible after the medical staff 's assessment and confirmation of safety [ 24 ], so as to improve the appetite and improve the patient 's compliance with ONS. 4.2 Strengthen nutrition education, improve the cognitive level of patients and their families This study shows that most patients are more inclined to rely on daily diet to meet postoperative nutritional needs, and lack of awareness of the necessity and effectiveness of oral ONS. Medical staff should clearly convey the value of ONS in improving nutritional status, reducing complications and shortening hospitalization time, rather than just staying at the guidance level of taking methods. At the same time, the education should not only be limited to patients, but also cover the main caregivers to help them understand the importance of nutritional support, so as to provide more stable external support. The forms of education can be diversified, such as bedside one-on-one explanation, peer education, printed promotional materials, video teaching and distance education, forming a multi-channel and continuous health education network. 4.3 Establish a supervision mechanism to improve the continuity of compliance management Although some patients are willing to accept oral nutritional supplements, in the actual implementation process, there are still many reasons for missed or irregular use of oral nutritional supplements. [ 13 ] Common causes include decreased memory in patients, easy to forget to take or confuse the frequency of taking ; the supervision of caregivers is insufficient, and there is no effective reminder and handover. It shows that relying solely on the patient ”s personal initiative is not enough to ensure compliance, and it needs the support of external supervision mechanisms. Therefore, medical staff should make repeated confirmation after the initial guidance to ensure that patients and their families can master the correct method of taking, and continue to follow up throughout the hospitalization period. Incorporating the supervision and guidance of nutritional supplements into the routine nursing process. At the same time, some simple measures can be used to strengthen reminders and supervision, such as hanging prompt cards at the bedside of patients, establishing a daily compliance record table, or using electronic reminders to help patients and caregivers form regular habits. 4.4 Reduce the economic burden, promote policy support and strengthen family participation This study found that economic pressure is an important reason for patients to refuse oral nutritional supplements. At present, most nutritional supplements have not been included in the scope of medical insurance reimbursement, which requires patients to bear at their own expense, increasing the economic burden of perioperative treatment. Therefore, it is of great significance to promote the inclusion of commonly used clinical nutritional supplements into the scope of medical insurance to improve the acceptance and compliance of patients. At the same time, the hospital nutrition department can make self-made low-cost oral nutrient solution, which not only reduces the cost, but also improves the convenience of taking. 4.5 Improve the taste of the preparation and enhance the patient’s experience The taste of food is one of the key driving forces that affect patients’ dietary choices and compliance[ 26 ].The taste and olfactory function of the elderly gradually decreases, the sweetness threshold is about 1.3 times higher than that of young people, and the sensitivity to food flavor is significantly reduced[ 27 ]. In European and American countries, nutritional supplements are more diversified in flavor and dosage forms, which can provide patients with more choices and thus improve compliance[ 12 ]. In contrast, the clinical use of ONS in China is relatively simple and lacks diversity, which is difficult to meet the differentiated needs of elderly patients. In view of this problem, the clinical can be improved from two aspects: First, the hospital nutrition department should actively introduce or develop a variety of flavors and formulations of nutrition preparations to provide personalized choices for patients ; second, nursing staff can guide patients to improve their taste through reasonable other food matching to enhance acceptability. However, attention should be paid to avoid mixing with acidic drinks such as fruit juice, so as to prevent precipitation or clots from affecting nutrient absorption. 5. limitations This study employed a purposive sampling strategy with a small sample size from a single center in Shanghai, which may limit the generalizability of our findings. The short recruitment period (February to August 2026) may introduce seasonal bias, as hip fracture incidence varies seasonally. The study only collected data from the perspective of patients, without involving family caregivers, medical staff, or other stakeholders, which may lead to insufficient evidence from multiple perspectives. 6. Conclusion Clinical medical staff should attach great importance to the nutritional management of elderly patients with hip fracture.. Through comprehensive intervention in many aspects, patients ” compliance with oral nutritional supplements can be improved, their nutritional status can be improved, postoperative rehabilitation can be promoted and complications can be reduced. Declarations Funding: This research received the support of Scientific Research Program Fund of the Baoshan District Science and Technology Commission(24-E-48) 、（25-E-16）and the Nursing Branch Fund of the Shanghai Medical Ethics Society ( SYLLKPY-24). The funding source had no involvement in study design, data collection, analysis, or manuscript preparation. Ethics Statement: This study was approved by the Ethics Committee of Luodian Hospital, Baoshan District, Shanghai, Batch No.: LDYY-KY-2026-06, adhering to the principles of the “Declaration of Helsinki”. Participants were required to engage in the study voluntarily and provide written informed consent. Data Availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare no conflicts of interest. Author contributions X.C, L.Z., and Y.W. conceptualized the study; X.C. and X,H. conducted the focus group discussions and analyzed the data; Y.W, X.H.supervised the project; X.C., X.H.and L.Z. wrote the main manuscript text. All authors reviewed the manuscript. Acknowledgements We would like to thank all the participants who took part in this study and provided valuable insights through their responses. 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Curr Stud Hematol Blood Transfus. 1986;5336–52. 10.1159/000413163 . Sarkies MN, Testa L, Carrigan A, et al. Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis. Age Ageing. 2023;52(8):afad154. 10.1093/ageing/afad154 . Costa M, Spencer NJ, Brookes SJH. The role of enteric inhibitory neurons in intestinal motility. Auton Neurosci. 2021;235:102854. 10.1016/j.autneu.2021.102854 . MOLLER SORENSENLB. Effect of sensory perception of foods on appetite and food intake: a review of studies on humans. Int J Obes Relat Metab Disord. 2003;27(10):1152–66. 10.1038/sj.ijo.0802391 . Mojet J, Christ-Hazelhof E, Heidema J. Taste perception with age: generic or specific losses in threshold sensitivity to the five basic tastes? Chem Senses. 2001;26(7):845–60. 10.1093/chemse/26.7.845 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1interviewguide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 30 Mar, 2026 Editor invited by journal 09 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 09 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8952056","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":617372060,"identity":"817d3c99-8b16-43cd-aeef-0331c711f3d6","order_by":0,"name":"Xujuan Chen","email":"","orcid":"","institution":"Luodian Hospital Nursing Department,Baoshan District,Shanghai,China","correspondingAuthor":false,"prefix":"","firstName":"Xujuan","middleName":"","lastName":"Chen","suffix":""},{"id":617372061,"identity":"744056b7-d876-4d8a-8bb6-e9355d4bf074","order_by":1,"name":"Li Zhang","email":"","orcid":"","institution":"Luodian Hospital Nursing Department,Baoshan District,Shanghai,China","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Zhang","suffix":""},{"id":617372062,"identity":"59e537cb-2efa-4792-9b5f-e23235975853","order_by":2,"name":"Yan Wu","email":"","orcid":"","institution":"Luodian Hospital Nursing Department,Baoshan District,Shanghai,China","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Wu","suffix":""},{"id":617372063,"identity":"a9816b1e-253b-4012-8a08-3414c29c84cd","order_by":3,"name":"Xinyue Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBAC++P9Hw5I/rHhYWxvIFbPmQOGDywb0uSYew4Qq+VGgrFBZcNhY/YZCUTqYOw5kCZxc0daYu/MxxtvMNTYRBPUwszecExy5hmbxJmz04otGI6l5TYQ0sLGc7BNWoItLXHj7BwzCcaGw4S18Egks0n/YTucuP/mGSK1SEikMRtIth02ZpzBQ6QWA54zjA8kzqTJMfYA/ZJAjF8M2HsYDkhUgKLy8MYbH2psCGtB0S6RQIpyiBZSdYyCUTAKRsHIAACmyUPNm3P52AAAAABJRU5ErkJggg==","orcid":"","institution":"Luodian Hospital Nursing Department,Baoshan District,Shanghai,China","correspondingAuthor":true,"prefix":"","firstName":"Xinyue","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2026-02-24 03:10:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8952056/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8952056/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106403023,"identity":"ef2fccb4-ad40-42c1-985a-b6feadbfe2b8","added_by":"auto","created_at":"2026-04-08 09:13:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":993821,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8952056/v1/38617f30-d4a4-4e2f-ba98-e67a0e0e5a83.pdf"},{"id":106216722,"identity":"37c58d42-d355-4ded-b64a-9b81bde211e7","added_by":"auto","created_at":"2026-04-06 08:52:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":11406,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1interviewguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8952056/v1/6915a3db5af71e56e9e00814.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCompliance of oral nutrition supplementation in elderly patients with hip fracture during perioperative period: a qualitative study\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHip fracture is the most common type of fracture in the elderly population, and the incidence rate is increasing year by year with aging. It is predicted that by 2050, the global hip fracture cases will increase from 1.26\u0026nbsp;million in 1990 to 4.5\u0026nbsp;million. Surgery is currently the preferred treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Perioperative malnutrition is one of the important risk factors for poor prognosis in elderly patients with hip fracture. A study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] pointed out that hip fracture has the highest incidence of malnutrition risk among all fracture types, and a large proportion of elderly patients with hip fracture have long-term malnutrition before admission [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Perioperative malnutrition can lead to an increase in the risk of surgery and the incidence of postoperative complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], such as postoperative wound infection or poor healing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], stress injury [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], delirium [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], etc., thereby prolonging hospital stay and recovery time, and also increasing the risk of death. In 2021, the European Society for Parenteral and Enteral Nutrition (ESPEN) recommended that patients should start taking oral nutritional supplements (ONS) after admission to reduce the incidence of complications and shorten the length of hospital stay [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. ESPEN defines ONS as: in addition to normal food, supplementary oral intake of special medical use (formula) food [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The best evidence from the Joanna Briggs Institutions (JBI) also points out that medical staff should give oral protein drinks twice a day to elderly hip fracture patients during hospitalization[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, a number of studies [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] have found that patients\u0026rsquo; compliance with oral ONS is generally low. The existing research focuses on patients with gastrointestinal tumors, and it is difficult to grasp the subjective experience and complex influencing factors of patients with simple quantitative research. Therefore, this study intends to summarize the root causes of insufficient oral ONS compliance from the real experience and cognition of patients through qualitative research methods, so as to provide reference for medical staff to formulate scientific and feasible intervention measures.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis study is guided by the phenomenological method in qualitative research [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e],.The research group consisted of one physician, one deputy director nurse, two supervisor nurses and two nurses. All of them had received systematic training in qualitative research methods and had rich experience in qualitative research. The research team combined with the research purpose, consulted the relevant literature at home and abroad, and preliminarily formulated the interview outline around the compliance status and influencing factors of oral nutrition supplementation in elderly patients with hip fracture, and invited orthopedic experts to review and modify it. Before the formal interview, 3 elderly patients with hip fracture were selected for pre-interview, and the outline was further revised according to the feedback results. After several rounds of discussion in the group, the interview outline was finally determined.(The detailed interview guide used in this study is provided in Supplementary File 1.)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003eA purposive sampling method was used to select elderly patients with hip fractures admitted to the Department of Orthopaedics, a hospital in Shanghai from July to February 2026 as the study subjects. Inclusion criteria: (1) diagnosed as femoral neck fracture or intertrochanteric fracture by clinical symptoms, signs and imaging examination;(2) Age\u0026thinsp;\u0026ge;\u0026thinsp;60 years;(3) Be able to understand the content of this study and volunteer to participate. Exclusion criteria: (1) patients with dysphagia or unable to eat orally for other reasons;(2) Combined with severe cognitive impairment or speech communication disorder, the interviewer could not successfully complete the interview. The sample size is based on the saturation of data content and no new information appears. All patients who participated in this study have signed informed consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eBefore the formal interview, the researchers explained the purpose and significance of the study to the interviewees, and promised that the data were only used for scientific research and strictly confidential, and all information was replaced by numbers. After the consent of the interviewee, the written informed consent was signed and the recording permission was obtained. The interview site was selected in the orthopedic ward demonstration classroom of a hospital in Shanghai .Taking into account the tolerance of elderly patients and the amount of information, we will control each interview time in 20\u0026thinsp;~\u0026thinsp;30min, in a quiet and comfortable environment. During the interview, the researchers maintained a neutral attitude, listened carefully to the interviewees\u0026rsquo; narration, did not give guidance or hints, and asked, repeated or clarified if necessary. At the same time, the tone, attitude and non-verbal behavior of the respondents were recorded to encourage them to fully express their true feelings and the underlying causes of compliance. A total of 20 patients were interviewed in this study and numbered by P1-P20.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e\n \u003cp\u003eWithin 24 hours after the end of the interview, the recordings and on-site records were collated and transcribed into text by two researchers ; another researcher checked the recordings and transcripts one by one to ensure that the data were accurate and complete. The collated text materials are returned to the interviewees for member verification to confirm that the content is true and reliable. Colaizzi \u0026rsquo;s seven-step method was used for data analysis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], The data analysis process was jointly participated by the research team and continued peer review and discussion, and the differences were discussed until agreement was reached, so as to ensure the scientificity and credibility of the analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Ethical consideration\u003c/h2\u003e\n \u003cp\u003eThe study conformed to the Declaration of Helsinki and was approved by the Luodian Hospital Ethics Committee(NO.LDYY-KY-2026-06). Participants received full information, gave written consent, and were assured confidentiality and the right to withdraw.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe general information of the respondents is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.Through the integration and analysis of the interview data, five themes and eight sub-themes affecting compliance were finally summarized.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information of respondents (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13(65.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior-high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior-high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemoral-neck fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInter-trochanteric fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePayment source\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (85.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdherence to ONS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdherent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartially adherent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7(35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefused\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (45.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Theme 1: Postoperative loss of appetite\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Physiological stress reaction causes digestive tract discomfort\u003c/h2\u003e \u003cp\u003eThe side effects of anesthetic drugs and surgical trauma pain form a double physiological stress, which directly stimulates the gastrointestinal mucosa and interferes with the regulation of digestive function, resulting in nausea, nausea and other discomfort symptoms, and reducing the tolerance of food. P5:\u0026ldquo;Before the operation can eat a little nutrition powder, but after the operation is always nausea and nausea, really do not want to eat.\u0026rdquo;P18:\u0026ldquo;I want to eat, but now I want to vomit as soon as I eat, I can only wait for a better time to eat.\u0026rdquo;P12:\u0026ldquo;After the anesthetic strength has passed, it becomes more and more painful, and it hurts when it moves, and does not want to eat anything.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Prolonged bed rest leads to slow bowel movement\u003c/h2\u003e \u003cp\u003eFractures and surgery lead to prolonged bed rest, which leads to a sudden decrease in body activity and a significant decrease in intestinal peristalsis. Some patients are accompanied by abdominal distension, constipation and other problems .P4: \u0026ldquo;I had a bad appetite, and I lay down all the time after the operation, and I couldn 't eat the meal, and this nutritional powder couldn 't eat any more.\u0026rdquo;P7:\u0026ldquo;surgery has not been defecated, not much to eat. \u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Theme 2: Lack of nutrition cognition and lack of education\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Lack of nutrition knowledge and cognitive bias\u003c/h2\u003e \u003cp\u003eMost patients have insufficient scientific understanding of nutritional support, and it is generally believed that daily diet can meet the needs of postoperative physical repair without additional supplements. P1:\u0026ldquo;Three meals are enough to eat, no need to eat any protein powder, but the doctor let me eat, I will eat.\u0026rdquo;.P9:\u0026ldquo;Why do I have to eat this ? Eating something else is just as nutritious, and I\u0026rsquo;m not malnourished\u0026rdquo;. Some patients also have knowledge confusion or misconceptions, such as equating nutritional powder with health food or milk powder, and even believe that infusion of albumin instead of oral supplementation is more effective. P16:\u0026ldquo;Eating protein powder is not as good as hanging albumin, isn 't the effect better.\u0026rdquo;P14:\u0026ldquo;I usually drink milk powder, similar to this\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Lack of education and guidance\u003c/h2\u003e \u003cp\u003eIn clinical nursing, nutrition-related education is often superficial. Due to the busy work, most of the medical staff briefly explained the method of taking at the first time, and lacked a systematic explanation of the purpose of nutritional support. One patient said P13:\u0026ldquo;The nurse just asked me whether to eat, did not say I must eat.\u0026rdquo;P11:\u0026ldquo;No one told me what was the benefit of eating this, I thought it didn 't matter, so I didn 't eat\u0026rdquo;. There are even patients who rely entirely on the doctor \u0026rsquo;s attitude to decide whether to take it, P3:\u0026ldquo;the doctor did not say to eat protein powder, I will not eat it\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Theme 3: Insufficient supervision mechanism and care support\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Inadequate oversight and absence of processes\u003c/h2\u003e \u003cp\u003eAlthough some patients are willing to accept ONS, medical staff usually only simply inform the usage when ONS is issued for the first time, and do not carry out follow-up tracking and compliance assessment. In addition, memory loss is common in elderly patients, and the superposition of the two leads to frequent problems such as missed administration and improper frequency of administration. P13:\u0026ldquo;I eat, but often can not remember to eat. The nurse said once or twice a day, I can 't remember, anyway, it doesn 't matter to eat more and eat less.\u0026rdquo;P15:\u0026ldquo;The best nurse can remind us, otherwise I remember is not good, it is easy to forget. \u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Care dependence and inadequate support\u003c/h2\u003e \u003cp\u003eThe postoperative activity of elderly patients with hip fracture is limited, and most of them need the help of family members or caregivers to adjust ONS. However, due to the uneven quality of care, it is easy to lead to missed or wrong clothes. P20:\u0026ldquo;I eat when my daughter takes care of me, but my son often forgets to eat\u0026rdquo;.P14:\u0026ldquo;The caregiver sometimes ate me several times a day, sometimes not once, and I was too embarrassed to remind her.\u0026rdquo;P10:\u0026ldquo;Today, my son went out, no one bubble protein powder for me to eat\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Theme 4: Economic and family support factors\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Heavy economic burden\u003c/h2\u003e \u003cp\u003eEconomic pressure is an important external factor affecting patient compliance. At present, nutritional supplements such as whey protein powder commonly used in clinical practice have not been included in the scope of medical insurance reimbursement,. However, the cost of hip fracture surgery itself is high, which further aggravates the economic burden of the family. P11:\u0026ldquo;Doing an operation has cost a lot of money, this protein powder is so expensive, I don 't want to eat it.\u0026rdquo;P16:\u0026ldquo;This is not into health care, at their own expense, spend so much money, I eat something else is not good, if health care can be reimbursed, I will eat.\u0026rdquo;P17:\u0026ldquo;My son says this is useless and a waste of money. I see a doctor is to spend his money, he said don 't eat, don 't eat, surgery has spent a lot of money, can save a little save a little.\u0026rdquo;P19: \u0026ldquo;My daughter said that her stewed ribs soup is more nutritious than this protein powder. These money is enough to buy a lot of ribs. Usually my daughter takes care of me. I have to listen to her\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Theme 5: Poor taste of nutritional preparations\u003c/h2\u003e \u003cp\u003ePoor taste is an important reason for patients to refuse or reduce the use of nutritional supplements. Some elderly patients have natural rejection of the taste of dairy products, or do not adapt to their flavor due to decreased taste function, which in turn affects compliance. P3:\u0026ldquo;I know that protein powder is nutritious, but I never eat this milk-like thing. I really don 't like the taste. I\u0026rsquo;d rather take medicine than this.\u0026rdquo;P2:\u0026ldquo;Although I am eating, I feel that the taste is very light, no taste, not tasty.\u0026rdquo;P13:\u0026ldquo;This taste I don 't like very much, it\u0026rsquo;s best to have other flavors to choose from.\u0026rdquo;P14:\u0026ldquo;protein powder has a smell, I can 't eat it.\u0026rdquo; .\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn view of the above themes, the study suggests the following improvement measures.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1Optimize perioperative management, improve patient appetite and tolerance\u003c/h2\u003e \u003cp\u003eHip fracture surgery is usually accompanied by large blood loss and significant protein loss. In addition to conventional intravenous rehydration, oral protein supplementation is also crucial for maintaining body balance and promoting wound healing [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Before surgery,too long preoperative fasting time will also increase the incidence of postoperative nausea and vomiting. Therefore, patients undergoing elective surgery can still drink clear liquid 2 hours before surgery[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This will not only increase the risk of aspiration, but also help to accelerate gastric emptying and reduce the incidence of postoperative nausea and vomiting. During the operation, too long operation time may increase the incidence of postoperative nausea and vomiting [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].Therefore, on the premise of ensuring the safety of the operation, the operation time should be shortened as much as possible. After surgery, aromatherapy, as an adjuvant therapy, can effectively relieve postoperative nausea and vomiting[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In view of the poor appetite caused by postoperative pain, patients often refuse to eat or reduce their intake, which further aggravates malnutrition. which causes local edema and aggravates pain symptoms[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, in view of the influence of pain on patients ' appetite and nutritional intake, multimodal analgesia management should be strengthened during perioperative period.\u003c/p\u003e \u003cp\u003eIn view of the weakening of gastrointestinal peristalsis during perioperative period, moderate increase of activity has a positive effect on the recovery of intestinal peristalsis. When patients cannot move autonomously before operation, abdominal massage can be used to assist intervention to help maintain the basic intestinal motility [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. After the operation, patients should get out of bed as soon as possible after the medical staff 's assessment and confirmation of safety [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], so as to improve the appetite and improve the patient 's compliance with ONS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Strengthen nutrition education, improve the cognitive level of patients and their families\u003c/h2\u003e \u003cp\u003e This study shows that most patients are more inclined to rely on daily diet to meet postoperative nutritional needs, and lack of awareness of the necessity and effectiveness of oral ONS. Medical staff should clearly convey the value of ONS in improving nutritional status, reducing complications and shortening hospitalization time, rather than just staying at the guidance level of taking methods. At the same time, the education should not only be limited to patients, but also cover the main caregivers to help them understand the importance of nutritional support, so as to provide more stable external support. The forms of education can be diversified, such as bedside one-on-one explanation, peer education, printed promotional materials, video teaching and distance education, forming a multi-channel and continuous health education network.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Establish a supervision mechanism to improve the continuity of compliance management\u003c/h2\u003e \u003cp\u003eAlthough some patients are willing to accept oral nutritional supplements, in the actual implementation process, there are still many reasons for missed or irregular use of oral nutritional supplements. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Common causes include decreased memory in patients, easy to forget to take or confuse the frequency of taking ; the supervision of caregivers is insufficient, and there is no effective reminder and handover. It shows that relying solely on the patient \u0026rdquo;s personal initiative is not enough to ensure compliance, and it needs the support of external supervision mechanisms. Therefore, medical staff should make repeated confirmation after the initial guidance to ensure that patients and their families can master the correct method of taking, and continue to follow up throughout the hospitalization period. Incorporating the supervision and guidance of nutritional supplements into the routine nursing process. At the same time, some simple measures can be used to strengthen reminders and supervision, such as hanging prompt cards at the bedside of patients, establishing a daily compliance record table, or using electronic reminders to help patients and caregivers form regular habits.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Reduce the economic burden, promote policy support and strengthen family participation\u003c/h2\u003e \u003cp\u003eThis study found that economic pressure is an important reason for patients to refuse oral nutritional supplements. At present, most nutritional supplements have not been included in the scope of medical insurance reimbursement, which requires patients to bear at their own expense, increasing the economic burden of perioperative treatment. Therefore, it is of great significance to promote the inclusion of commonly used clinical nutritional supplements into the scope of medical insurance to improve the acceptance and compliance of patients. At the same time, the hospital nutrition department can make self-made low-cost oral nutrient solution, which not only reduces the cost, but also improves the convenience of taking.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Improve the taste of the preparation and enhance the patient\u0026rsquo;s experience\u003c/h2\u003e \u003cp\u003eThe taste of food is one of the key driving forces that affect patients\u0026rsquo; dietary choices and compliance[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].The taste and olfactory function of the elderly gradually decreases, the sweetness threshold is about 1.3 times higher than that of young people, and the sensitivity to food flavor is significantly reduced[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In European and American countries, nutritional supplements are more diversified in flavor and dosage forms, which can provide patients with more choices and thus improve compliance[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In contrast, the clinical use of ONS in China is relatively simple and lacks diversity, which is difficult to meet the differentiated needs of elderly patients. In view of this problem, the clinical can be improved from two aspects: First, the hospital nutrition department should actively introduce or develop a variety of flavors and formulations of nutrition preparations to provide personalized choices for patients ; second, nursing staff can guide patients to improve their taste through reasonable other food matching to enhance acceptability. However, attention should be paid to avoid mixing with acidic drinks such as fruit juice, so as to prevent precipitation or clots from affecting nutrient absorption.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. limitations","content":"\u003cp\u003eThis study employed a purposive sampling strategy with a small sample size from a single center in Shanghai, which may limit the generalizability of our findings. The short recruitment period (February to August 2026) may introduce seasonal bias, as hip fracture incidence varies seasonally. The study only collected data from the perspective of patients, without involving family caregivers, medical staff, or other stakeholders, which may lead to insufficient evidence from multiple perspectives.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eClinical medical staff should attach great importance to the nutritional management of elderly patients with hip fracture.. Through comprehensive intervention in many aspects, patients \u0026rdquo; compliance with oral nutritional supplements can be improved, their nutritional status can be improved, postoperative rehabilitation can be promoted and complications can be reduced.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThis research received the support of Scientific Research Program Fund of the Baoshan District Science and Technology Commission(24-E-48) 、（25-E-16）and the Nursing Branch Fund of the Shanghai Medical Ethics Society ( SYLLKPY-24). The funding source had no involvement in study design, data collection, analysis, or manuscript preparation.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics Statement:\u003c/strong\u003eThis study was approved by the Ethics Committee of Luodian Hospital, Baoshan District, Shanghai, Batch No.: LDYY-KY-2026-06, adhering to the principles of the \u0026ldquo;Declaration of Helsinki\u0026rdquo;. Participants were required to engage in the study voluntarily and provide written informed consent.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare no conflicts of interest. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eX.C, L.Z., and Y.W. conceptualized the study; X.C. and X,H. conducted the focus group discussions and analyzed the data; Y.W, X.H.supervised the project; X.C., X.H.and L.Z. wrote the main manuscript text. All authors reviewed the manuscript.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants who took part in this study and provided valuable insights through their responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the Ethics Committee of Luodian Hospital, Baoshan District, Shanghai, Batch No.: LDYY-KY-2026-06).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants before participation. Participants were provided with comprehensive information regarding the study\u0026rdquo;s objectives, procedures, potential risks, and benefits, as well as their right to withdraw at any time without repercussions. Confidentiality and anonymity of the data were maintained throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was obtained from all participants involved in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSing CW, Lin TC, Bartholomew S, et al. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. J Bone Min Res. 2023;38(8):1064\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jbmr.4821\u003c/span\u003e\u003cspan address=\"10.1002/jbmr.4821\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRidha M, Al-Jabri T, Stelzhammer T, et al. 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Chem Senses. 2001;26(7):845\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/chemse/26.7.845\u003c/span\u003e\u003cspan address=\"10.1093/chemse/26.7.845\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hip fracture, Elderly, Oral nutrition supplement, Compliance, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-8952056/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8952056/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo explore the obstacle factors of oral nutrition supplementation compliance in elderly patients with hip fracture during perioperative period, and to provide theoretical basis for the development of targeted nursing intervention strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA purposive sampling method was used to select 20 elderly patients with hip fracture admitted to a hospital in Shanghai from July to February 2026 to conduct semi-structured interviews. The interview data were sorted out and summarized by Colaizzi \u0026rsquo;s seven-step analysis method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe compliance rate of oral nutrition supplementation in elderly patients with hip fracture during perioperative period was 20%. A total of 5 themes and 8 sub-themes were extracted from the relevant factors: postoperative physiological reaction leading to loss of appetite, insufficient nutrition cognition and lack of education, insufficient supervision mechanism and care support, insufficient economic burden and family support, and poor taste of nutrition preparations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe compliance of oral nutrition supplementation in elderly patients with hip fracture is affected by many factors such as physiology, cognition and support system. Comprehensive intervention strategies should be developed from multiple levels to improve compliance and promote rehabilitation.\u003c/p\u003e","manuscriptTitle":"Compliance of oral nutrition supplementation in elderly patients with hip fracture during perioperative period: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 08:52:35","doi":"10.21203/rs.3.rs-8952056/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-01T15:02:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T08:22:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-09T12:59:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T09:28:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2026-03-09T09:07:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ebdd8691-f200-46dd-a54c-99c8f388e542","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T08:52:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 08:52:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8952056","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8952056","identity":"rs-8952056","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}