Abstract
There is little research on the experience of recovering from acute injury, with most first person accounts of illness about chronic ill health. Ankle fracture is a common, distressing injury with short- and long-term life-altering impacts. In this article, an autoethnographic approach is used to tell a story of ankle fracture, surgery, and subsequent early recovery. The story is told and examined from one person’s multiple perspectives – as a patient, healthcare worker, and healthcare educator – and thus reflects on both the delivery and organisation of healthcare, and the personal experience of receiving care. The impacts of ankle fracture and recovery are considered and related to other research on the experience. Common factors include pain, loss of independence, isolation, loneliness and depression, changed personal and social identities and engagement, and lack of understanding of the trajectory of recovery. Illness and injury narratives can provide valuable contributions to healthcare education and the delivery of care, as well as being used to support those living through similar experiences. This article argues that the combination of sociological thinking and patient experience has a valuable contribution to make to healthcare education.
Introduction and background
. . . Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place . . . (Sontag, 2002: 7)
Being unwell or injured can affect self-image, self-belief, autonomy, and independence (Jensen et al., 2022; Larkin, 2011). Illness narratives have been used by sociologists to write about their experiences of health and illness (e.g. Frank, 1995 and Riessman, 2015; comprehensively discussed by Pierret, 2003) but Rier (2001), in discussing the ‘missing voice of the critically ill’ (p. 68), notes that most narratives are about chronic illness experiences, often from the perspective of families and caregivers. The sociology of health and illness (particularly when taught to health professionals) has also focused on chronic ill health and its impact on individuals and society (Larkin, 2011). There are exceptions, notably Fracture (2007), in which Ann Oakley explored the life-changing impacts of fracture and recovery. The concept of ‘biographical disruption’ (Bury, 1982) usually refers to chronic illness, although acute illness/injury can bring similar challenges, including sudden changes in work, social engagement, and family life. These can be profound – because, as Oakley (2007) notes: the problem with bodies is that they’re both material objects and the site of human experience. (p. 15)
The importance of patient-centred healthcare is now well recognised (e.g. National Health Service (NHS) England, 2019). Underpinning the training and delivery of nursing care in the UK are the Code and Standards (see Nursing and Midwifery Council (NMC), 2022) grounded in the ‘six Cs’, 1 originally outlined in the strategy ‘Compassion in Practice’ (Baillie, 2017; Department of Health, 2012a). The ‘Future Doctor’ report identified being a patient advocate as an important characteristic for doctors, operating within a ‘person-centred, personalised approach’ (Health Education England (HEE), 2020: 11). The ‘Hello My Name Is’ campaign (#hello my name is, 2022) – instigated by Dr Kate Grainger following her own healthcare experiences while terminally ill – highlighted the need for personalised care in therapeutic relationships. Illness narratives/patient experiences are also recognised as important in research, healthcare staff training, and service improvement (Health Research Authority (HRA), 2022a; National Association for Patient Participation (NAPP), 2021; National Institute for Health and Care Excellence (NICE), 2022).
Ankle fractures are a common reason for hospital admission (Jennison and Brinsden, 2019), sometimes seen as a ‘lesser injury’ (McPhail et al., 2012: 1). Despite this, they have varying rates of recovery and can cause long-term pain and impaired ability to carry out everyday activities, like walking or climbing stairs (McPhail et al., 2012). They primarily affect young men and older women, contributing significantly to rising healthcare costs (McKeown et al., 2020). Three qualitative studies have explored the profound impacts of ankle fracture (McKeown et al., 2020; McPhail et al., 2012; Jensen et al., 2022). Additional insights can also be gained from personal accounts in blogs and magazines, for example, Morgan (2015) and Chamberlain (2016).
I have extensive experience of healthcare, with hospital admissions from childhood to early adulthood. I have worked in clinical and non-clinical roles, for over 21 years, taught nurses, midwives, and allied health professionals for 11 years and now work in a medical school, primarily teaching qualified doctors. I am an HRA Research Ethics Committee (REC) member (HRA, 2022b). I know a lot about evidence-based practice (EBP – the principle of basing care on the best, most up-to-date evidence) and healthcare and research ethics. I am very used to being around healthcare professionals and hospitals.
This article reflects on my experience of injury (bimalleolar ankle fracture
2
), hospitalisation, and early recovery. To echo Riessman, . . . I had entered the hospital with my core identities intact . . . a competent and self-sufficient individual . . . I left the hospital . . . disabled, dependent, unable to walk down the street . . . (2015: 1058)
I have used this writing to help with my recovery, emotionally and psychologically; breaking my ankle (for the second time, but more seriously than the first) has been depressing and an ongoing challenge. I draw on my related experiences of being a patient, working in healthcare and health professional education, and my sociological reading and thinking. I thus contribute both to the body of work on illness/patient narratives and also, potentially, to healthcare professional training.
After discussion of methods used, the article is divided into three sections. First, I tell the story of my injury. I then reflect on and discuss my experience: both as a patient (drawing on my experiences and knowledge of healthcare) and considering more specifically the experience of ankle fracture and recovery. Throughout, the discussion situates my experience in relation to knowledge about ankle fracture and experiences of recovery, and to a range of other relevant literature.
Methods
Centralising one’s own experience has long been a form of social inquiry, sometimes called autoethnography (early examples: Bochner, 1997; Ellis, 1995; Sparkes, 1996), although the use of the personal in sociology has been debated. Brennan and Letherby (2017) outline a continuum, framed as auto/biography to auto/biography, in which the focus is more (or less) on the self or on the other. My writing here is along this continuum: both about my experience and reflecting on the actions of others: [The] . . . use of ‘continuum’ acknowledges that concentration on the self OR on the other is not clear cut . . . (Brennan and Letherby, 2017: 157)
In autoethnography, elements of storytelling/autobiography are used, alongside other methods of description and analysis, framed as either ‘evocative’ or ‘analytical’ (Ellis et al., 2011), often with a reliance on memory: Autoethnography offers a way of giving voice to personal experience for the purpose of extending sociological understanding. (Wall, 2008: 39)
There is a recognition that within a range of possible methods, there is no ‘correct’ way to proceed; variable criteria are used to assess rigour and validity. Wall provides a good summary of these issues (with examples), concluding that . . . there remains considerable creative latitude in the production of an autoethnographic text . . . (Wall, 2008: 40)
later exploring She later explores a range of related concerns, including the polarisation of methodological approaches and the interchangeability of terms used (Stahlke Wall, 2016).
Here, I have used autobiographical writing and reflection, framing this as an autoethnography. I have considered my work in relation to Bochner’s (2000) six criteria for autoethnography. In particular, I have thought about his criteria of ‘emotional integrity’ and ‘ethical awareness’. Emotional integrity is demonstrated through a faithful representation of my story and my emotional response to it, using as much detail as is possible within a restricted word count. I have also thought about the tensions inherent in this kind of work, how I have represented myself and others, and how vulnerable this makes me feel (discussed by Tedlock (2000), cited by Wall (2008: 42) in the context of feminist issues in autoethnography). I have considered how others are represented, ensuring that only one is identifiable and they have given their consent. Ellis et al. (2011) point out the many challenges; I have tried to be aware of these.
Methods used to discuss experiences of illness/recovery include photography (Bell, 2002; Radley and Taylor, 2003), contemporaneous notebooks (Rier, 2001), and journals (Riessman, 2015). These contribute to the wider endeavour of including patient voices in healthcare planning and delivery, noted above, also including reflections on professional practice (Denshire, 2014). More recently, accounts of illness and care have been seen in the media/popular writing. These include Steve Hewlett’s ‘Cancer Journey’, discussed by Brennan (2022); A.A Gill’s writing about his cancer treatment; and Henry Marsh (2022) and Kalanithi (2017), both also writing about cancer. Those from the UK act as critiques of NHS care, and discuss how the involvement of the author-patient affected their experience. Some have used their ‘insider’ perspective to illuminate the doctor–patient relationship (Marsh, Kalanithi); others have used their position (as journalist or writer) to document their care and illness journey (Hewlett, Gill).
I have chosen to both tell my story, by outlining my recent experience, and discuss it through thematic analysis. I use my ‘sociological imagination’ (Mills, 1959), alongside my professional knowledge, to think through my experiences of ankle fracture/early recovery and relate this personal story to wider issues in healthcare, relevant theory, and literature. Letherby has drawn on Mills’ work, reflecting on how her (and Mills’) sociological ‘journey’ was shaped by autobiography (Letherby, 2015). Writing about oneself can be . . . rewarding . . . in ways that tell us much about the elision and entanglement of our own personal and professional identities and our own place in the world . . . (Brennan and Letherby, 2017: 164)
Thus, I see this as more than (but also) having a ‘therapeutic function’ – one of the criticisms of this sort of work (Oakley, 2007: 22).
My thoughts, reflections, and observations (mostly written in the sixth week post-injury) are treated as data; I revisited and reread them, assigning thematic labels (Braun and Clarke, 2013). Two areas are discussed – ‘Being a patient’ and ‘Experiencing recovery from fracture’. Within the first, there are three themes; in the second, four. Where words quoted are mine, this is indicated. Broadly, analysis of the first area is more influenced by my knowledge of healthcare and healthcare education than the second. Rier has written about intensive care/therapy unit (ICU/ITU) experience from multiple viewpoints: patient, parent, grandparent, and researcher (Rier, 2014). We all see and interpret the world from different perspectives; these are mine.
Telling the story – Broken (again)
. . . I tell this story knowing that my voice, reality, and meaning of the experience are not any more exceptional, unique, or significant than others . . . (Sells, 2013: 172)
It’s a sunny Friday afternoon in February. I am sat in a friend’s garden with the women in my knitting group. It’s cold, but being outside in the sun feels like a sensible Covid measure. We drink tea, eat cake and chat, about knitting, elderly parents, our lives. It starts to feel more chilly; after all, being inside might be ok. I pick up my bag, knitting and cup and get up the step into the house. My balance has never been good, and since fracturing my ankle nine years before I’ve been cautious about steps and uneven ground, worried that I’ll fall again. I’m over the step and inside the room and I trip; I don’t know what happens, I try to stop myself from falling, I drop the cup, the knitting and the bag, and one leg seems to be twisted behind the other. As I fall I hear or feel (I’m not sure which) a crack and I know, in that moment, that I have broken my ankle again. I feel a terrible pain and a wooziness. I lie on the floor. I am broken. Again.
My knitting friends are wonderful. They look after me. There’s a long wait for an ambulance so we ring my partner and he comes and drives me to the Emergency Department (ED). We are there for over thirteen hours, all night. He goes home to eat and see our teenagers and returns to be with me. We are surrounded by people who seem to have limb injuries and one elderly man with a bleeding head, all waiting patiently. For most of the thirteen hours my foot is down, my ankle becoming more and more swollen. My partner asks a few times if my foot should be elevated and is told they have nothing suitable. We see nurses, doctors and radiographers, and doctors again. I leave knowing that I have fractured my ankle in two places, and will need surgery. My leg is in a plaster cast. I must return the next day to the fracture clinic. We arrive home, exhausted, at 7 am and sleep all morning. I am in pain. This is a far more serious injury than the previous fracture. I am shocked and feel numb.
We return to the fracture clinic on Sunday morning. The doctor thinks there is too much swelling. The cast is removed. My foot and ankle are indeed very swollen and covered in large blisters. They are worried about this and say that I need to be admitted so that my foot can be properly elevated to prepare for surgery. They cannot operate while the skin is so tight from swelling, and there is a risk of infection from the blisters. My partner goes home to pack a bag for me. I’m left on an examination couch for several hours until an inpatient bed becomes available. They forget I’m there; a nurse comes in and is noticeably surprised to see me. I ask a healthcare assistant to help me to the toilet. She says ‘Can’t you walk?’, ‘Can’t your husband help you?’
I am in hospital for eleven days; surgery takes place on day ten. For nine of the eleven days I am without visitors; the ward is closed for Covid reasons. I have the procedure known as ORIF 3 with metal pins to the outside of my ankle and a metal plate to the other. During this time I have the plaster removed and the blisters inspected three more times. My ankle is x-rayed to check the alignment. I learn more (by lying in my hospital bed and Googling) about ‘fracture blisters’: they are quite rare 4 and are caused by swelling following fractures. I have both fluid filled and haemorrhagic blisters. My ankle was not elevated, and was swelling, for thirteen hours in the ED. My partner and I talk about this a lot. In retrospect I should have just raised my ankle on a chair, but we were tired, shocked and didn’t think clearly. One day when they remove the plaster they also manually manipulate my ankle as the bones are not well aligned. Some of the blisters burst during this procedure.
After I leave hospital I have out-patient appointments in the fracture clinic, at weeks 2, 3 and 4 after surgery (at these visits there is some anxiety about the recovery of my skin, after the blistering). Each time my cast is removed; at week 2 the sutures are taken out (three on one side and nineteen on the other). At every visit the dressings are renewed and I have a new plaster cast. The staff in the fracture clinic are lovely. At each of the first few visits the doctor tells me that I had a ‘very serious injury’. Initially I am told to put no weight at all on my ankle; by week 4 I am put in a walking boot 5 rather than a cast and told to do ‘a little’ weight bearing. At this point everything becomes more painful again and I feel quite low; the reality of the long road to recovery hits me.
I leave hospital on codeine, paracetamol and morphine. I’m initially in a lot of pain; when my medication runs out I have to argue with my GP practice to prescribe more as they think this should be the role of the fracture clinic. The fracture clinic say otherwise. Whilst in hospital I’m injected daily with enoxaparin, 6 to prevent blood clots. I carry on doing this for four weeks at home; by the end my stomach is covered in bruises and puncture marks. I gradually need fewer painkillers until the cast is removed and I’m in the walking boot. Pain levels increase a lot again and I’m advised to start taking more codeine and paracetamol. This time my GP is happy to prescribe (although I later discover that I’ve only been given a short supply; I feel that I have to keep arguing for adequate pain relief).
By weeks 7/8 I am much more fed up. Recovery is slow. The more I move, the more it hurts. I can’t imagine it not hurting, or walking not being difficult. I am sleeping badly. The walking boot is very heavy and I need to wear it at night, I can’t get comfortable. I’m tired all the time. I go downstairs more but it’s hard getting back up and sometimes I don’t feel like it. I get better at using the crutches and don’t feel as scared of falling over again as I did at first. I go out a bit, using a hired wheelchair –to hear my daughter play in two concerts, to the opera, to a restaurant. I learn about access arrangements and how some are better than others. I have no idea how long this phase of my life will last.
The remainder of my story is interwoven into the following discussion, using excerpts from the written observations and reflections which form the basis of my analysis.
Being a patient
Doctors and nurses – ‘Hello, my name is . . .’ versus ‘We need to leave it in just in case’
In hospital, I was cared for by qualified and unqualified nurses. The care was good – sometimes, excellent – but everyone was clearly very busy; during this period, the NHS in England was widely acknowledged to be in crisis due to Covid-19 (Ibbetson, 2022). I also met many doctors; all introduced themselves to me, usually by name and role. Most nursing staff did not introduce themselves. Although there is guidance for NHS staff in England on uniforms and name badges (NHS England and NHS Improvement, 2020), many did not wear name/role identifiers. Signifiers such as colour of scrubs are knowledge which is gradually acquired as a patient (if at all). Having people come in and out of your room, carry out procedures, and support with intimate and personal acts of care without introducing themselves or their role can be a strange experience.
Aspects of the NHS are unlike other healthcare systems in the world. Originating – and, largely, operating – as a paternalistic organisation and hierarchical system, the patient is usually among those at the bottom: With doctors among the most powerful and trusted professionals . . . interactions between doctors and their patients characterised by deference and order . . . [with patients rarely] . . . explicitly questioning, let along overtly challenging . . . doctors face to face . . . (Brown et al., 2015: 165)
Despite moves towards patient involvement (‘no decision about me, without me’ – Coulter and Collins, 2011; Department of Health, 2012a) and more transparency (both in relation to organisational issues, like waiting lists, and care decisions), many of these are still challenges for the NHS, exacerbated both by Brexit and Covid.
Like many academics, I use ‘Dr’ in everyday life; this sometimes confuses. Most doctors asked whether I was a medic – leading to interesting discussions, as I now work in a medical school (one had undertaken the programme that I teach on). They related to me respectfully when I asked questions or discussed my care. The nurses did not ask whether I was a doctor, as they knew I had previously taught nurses in a local university. Some were very interested in this experience. Others appeared to find it threatening: One nurse, on learning that I used to work in the Nursing and Midwifery Department, asks ‘Are you checking to make sure I’m doing it right?’ – I’m not sure if she’s joking, I don’t think so. [SD]
Some nurses did not seem willing/happy to discuss things with me, not wanting decisions questioned: Early one morning a nurse comes into my room and says I need to have a cannula inserted and a saline drip ‘in case you go to theatre’. I don’t go to theatre and it takes until lunchtime for them to decide that surgery is not happening that day, probably not for about five days. I ask to have the cannula removed. Nurse: ‘We need to leave it in just in case’. Me: ‘In case of what?’. Nurse: ‘In case you feel sick?’. Me: ‘Why would I feel sick? I’ve been here five days and not felt sick!’. Nurse: ‘You never know’. Me: ‘Please can you remove it, it’s getting in my way and I don’t feel it’s necessary’. Nurse, without speaking further (but sighing), removes it, I bleed quite a bit, the blood is roughly blotted away. Nurse leaves the room. [SD]
Some seemed concerned about ‘what was allowed’, at times to the detriment of person-centred care: Every day a healthcare assistant complains about the fact that I’m using a wheeled chair to transfer between the bed and the toilet/sink. This chair came with me from the fracture clinic – it’s comfortable because there are footrests (my broken ankle is very painful, hanging down). She insists that it’s ‘not allowed’ and that I should be moved on a plastic chair without footrests, referred to as a ‘shower chair’. She removes the original chair and subsequent people have to use the shower chair in order to assist me. The next time she is on duty she says ‘I expect that’s been much better, using that chair’. I reply ‘No, it’s much more uncomfortable as there’s nowhere to rest my feet’. She doesn’t say anything more. [SD]
There was also a reluctance to accept my need for independence. I needed help to transfer from bed to toilet or sink, but once there, I wanted to manage myself. Some healthcare assistants wanted to wash me, expressing surprise that I could (and wanted to) do this for myself. Perhaps this is because the majority of their experience is in caring for those older and more infirm – but it also could be another example of failing to think in a person-centred way. Backhouse et al. (2020) conducted an ethnography of acute orthopaedic hospital wards, particularly focusing on ‘body work’ (Twigg et al., 2011). They note how this can lead to objectification and less personalised care, often carried out by the staff members with the least training, and little power.
I also experienced being talked to using childish language (‘number 1s or number 2s?’) and overheard other patients being talked to in an impatient/unkind manner. It is hard for nurses and patients to challenge poor care and inappropriate behaviour: Although I feel able to challenge some of what is happening to me when it doesn’t feel right, overall this is hard and I can feel myself wanting to be ‘a good patient’. I try not to ‘bother’ the nurses unless I really need to. I try to be ‘nice’ and ‘friendly’. I make conversation with them when they are in my room and try to relate to them. [SD]
Much of the behaviour I observed was a surprise; I know that nurses are taught to be compassionate and person-centred and can only speculate about what happens to prevent this once they are working in busy and stressful clinical environments.
Routines – ‘Just changing your water’
My experience of being a patient, healthcare worker, and educator ranges from 1965 to present. I have witnessed a wide range of practices and changing beliefs. During my personal and professional life, ideas about person-centred and evidence-based care have become more prominent; I thought aspects of ward routine I witnessed as a child/young adult/novice nurse would no longer take place. However, there were times when these still seem to take precedent over individualised care: For three mornings in a row someone enters my room, waking me, at 5am. ‘Just changing your water’, they say, walking round the bed, putting down a fresh jug of water and taking the old one away. [SD]
Another example includes the waking up of all patients early in the day, even those in side rooms and for whom there are no planned early interventions or investigations.
EBP involves not only just looking for the best/most current evidence on an issue but also thinking about the experiences of healthcare workers and patients [Dowling and Williams, 2018]. The example of the nurse and the cannula seems to not follow these principles. There were others too: I am woken at 1.15 am by the lights being switched on with no warning and two people entering the room. Them: ‘We’ve come to take you for an x-ray’. Me, struggling to wake up and understand what’s happening: ‘What, now?’. ‘Oh, ok, we’ll come back in the morning’, they answer – and leave. [SD]
Inpatients surrender personal privacy as well as autonomy – walking unannounced into someone’s bedroom like this in any other setting would be unacceptable. In hospital environments, many things happen and people seem to stop noticing how odd they are; patients very quickly become institutionalised and cease questioning.
Consent – ‘I don’t feel up to arguing’
In my professional roles, consent is something frequently considered. The presumption of consent was striking. It was as if, through admission to hospital, I had given blanket consent to anything felt to be in my best interests – and that, as a result, explanation or consent-seeking was not needed for every intervention: A phlebotomist comes up to my bed (I assume that’s what she is as she doesn’t introduce herself). Phlebotomist: ‘I’ve come to take some blood’. Me: ‘What are you taking it for?’. Phlebotomist: ‘It’s just routine’. She proceeds to take blood. This doesn’t feel like I am giving informed consent but I don’t feel up to arguing. [SD]
Rier (2000) noted something similar, discussing what he calls a ‘delusion of partnership’ in relation to various aspects of his care (p. 77). I found myself often questioning whether someone had actually tried to obtain my consent, and concluding that they had not, for example, ‘We’re going to manipulate your ankle as it’s out of alignment. You can have some gas and air for the pain’. Am I consenting to this? I don’t feel like I have a choice. Or that what is going to happen is properly explained to me so I know what to expect. Lots of people round the bed, horrible wooziness from the gas and air. The worst pain I can remember experiencing, which feels like it will never end. I dissociate slightly in order to cope. I hear myself moaning. [SD]
I wonder what this is like for those who are not able to question what is going on, for reasons of understanding, ability to verbalise questions or power relations.
Experiencing recovery from fracture
In hospital – ‘the days become very same-y’
Initially I surprise myself how much I accept all this. I just ‘get on with it’. It’s painful and uncomfortable. Unpleasant and undignified things happen. I can’t have any visitors. I have never been away from my children for so long. I miss them and my partner. The days pass. [SD]
I was in hospital for a total of 11 days. The plaster was removed, ankle swelling and blisters inspected several times, and dressings and plaster reapplied. I was ‘nil by mouth’ twice before being told I was not having surgery that day. Finally, it happened on day 10 and I was discharged the next day. For all but one of the first 10 days, I could not have visitors; as noted above, When I am in hospital my partner brings me clothes, chocolate and fruit. He is not allowed on the ward and leaves these things at the door for me. This feels very strange and isolating. [SD]
The days were very long. I was in pain but did not feel ill: The days become very same-y. I watch a lot of catch-up TV on my laptop. After I finish a series I have very little memory of what I’ve watched. I find it hard to read. I listen to podcasts. I do a little work, of questionable quality. [SD]
I felt lucky, except for one night I was in a side room with my own bathroom. The hospital is very new with large wards, with four-bedded bays and single rooms. Hospitals are always noisy places, despite being in a side room: Almost all the time there is the sound of patient call-buzzers. It’s loud and very irritating. It makes me anxious about pressing mine as it contributes to the cacophony. One of the nurses tells me that she hears the constant noise when she goes home; another that she has stopped hearing it. The first night I am in hospital I can’t sleep, it’s so noisy. [SD]
Once my buzzer was left out of reach, I felt very panicky and had to shout before anyone came. Communication was often not good and this was brought home to me on the final day: In the evening of the day I have surgery, someone asks me how I feel about moving out of ‘my’ room. It’s the first I’ve heard of it. I’m (unreasonably) outraged, as I realise how much being in this single room has affected my experience of the past ten days. Later, I’m moved into a four-bedded bay. One of the other women is elderly and confused and shouts all night. Lights are left on in the corridor outside the (glass paned) door, they are too bright; the nurses talk loudly out there too. For that final night in hospital I get no sleep. I am amazed at the contrast in the experience (why am I amazed? – I’ve been in hospital many times, I know what it’s like) and wonder what sort of state I would have been in if I’d been in that bay all the time. I also think that this is quite a selfish perspective. [SD]
McKeown et al. (2020) also noted that . . . Those who required an inpatient stay for their injury described these experiences as lonely or difficult, usually due to other patients in the ward with them . . . (p. 7).
Being in hospital can be very challenging – often the most worst aspects of this are environmental and psychological, as much as physical.
Being at home (‘I wish I was back in hospital’) and being dependent (‘I drop things a lot . . . where I can’t reach them’)
I’m home, I can sleep in my bedroom. But it is up two flights of stairs and I can’t weight-bear. It’s easier to stay up and not try to come downstairs. For a few days I wish I was back in hospital. Being home is hard work and fairly lonely. [SD]
Managing activities of daily living with an ankle fracture leads to an immediate altered relationship with one’s body, not just with the affected part: I have become a person who needs aids to live my everyday life. I very quickly get used to it. We have a toilet riser delivered (arranged by the hospital occupational therapist) along with something called a ‘perching stool’ (we can’t think how it will be helpful and it’s put away). A friend lends me a swivelling shower seat, which is a godsend. She also sends a ‘grabber’. I have a sleeve to put over my cast so I can sit on the stool, swivel, and have a shower. I have a walking frame and my partner hires a wheelchair from the Red Cross. [SD]
Negotiating being at home for those with an ankle fracture is challenging: . . . Having two ankles that work is what keeps you stable and allows independence. Being without one is suddenly so limiting that I see doors closing all around me as I tot up all the things I won’t be able to do . . . (Morgan, 2015) . . . the most terrifying aspect of all [was] – how to get up and down stairs . . . (Chamberlain, 2016).
Loss of independence is often an issue identified for those recovering from ankle fracture. People report feeling like a ‘burden to friends and family’ (McPhail et al, 2012: 9); others talk about being reliant as a ‘cause of low mood’ (McKeown et al., 2020: 4), although some adjusted. Feeling dependent is related to feeling frustrated: . . . The worst part was not being able to do things when I wanted how I wanted that was the worst definitely (McKeown et al., 2020: 4) . . . I can do hardly anything for myself if I can’t reach what’s needed from my bed or chair. I drop things a lot, usually under the chair where I can’t reach them with the grabber. [SD]
Not being able to do basic self-care tasks is very difficult, particularly at first: Once I am home he becomes very proficient at caring for me, finding my clothes and putting them near me while I’m drying from the shower. I balance on my one good leg and he dries the bits of me that would make me fall over if I tried to dry myself. [SD]
Jensen et al.’s (2022) participants talked about feeling uncomfortably dependent, with one group (who had surgical treatment (ST)) more dependent at 6 weeks than the other (conservative treatment (CT)): . . . the ST group was still in pain and had attempted limited weight-bearing. Thus, they were still dependant, which bothered them . . . (p. 4)
Recovery: time, pain, and psychological impacts – ‘It’s getting harder to stay positive’
Jensen et al. (2022) were able to contrast those who had ankle fractures needing ST and those who had CT (usually a plaster cast or boot), with the CT group mobilising sooner. I have experience of both ST and CT so could compare: The enormity of what has happened hits me around week six. I thought by now I would be in less pain, be more mobile – I remember what it was like last time. I think ahead to things that are happening and are planned. I am no longer sure I will be doing some of these; begin to realise that I’ll be doing them in a much more limited way. I start to think about how long it took me to recover from the previous, much less serious fracture. I feel daunted and depressed. It’s getting harder to stay positive. [SD]
As time went on, I became more unhappy and found things more difficult: I am very, very fed up. It’s gone on too long. I am fed up with being dependent, with seeing so little of my own home, with rarely leaving the house. I don’t like being so limited in what I can do. [SD]
Jensen et al. (2022) also found, in the group of people they interviewed, that . . . most patients had a pragmatic and predominantly positive attitude towards their treatment plans . . . after six weeks expectations had been significantly adjusted. Patients had realised that the rehabilitation period . . . was going to be longer than hoped or first expected . . . (pp. 3–4)
In the literature, impacts and rates of recovery are discussed in relation to both physical and psychological aspects. Ankle injuries result in significant pain and physical discomfort initially, following surgery and during recovery and rehabilitation. It is common to experience pain and swelling, stiffness, altered sensation, and difficulty with walking (McPhail et al., 2012), affecting mobilisation and activities of daily living (Jensen et al., 2022). For me, the pain was very bad at first, a little better after the suture removal and with a lighter cast, and significantly worse again once I had started mobilising. This has also been the experience of others: . . . by the six-week interview pain was perceived as more intrusive in their everyday lives than initially expected . . . (Jensen et al., 2022: 4) . . . Pain was the number one problem . . . (McPhail et al., 2012: 7)
Pain puts limits on activity and recovery; many report frustration at not being able to do previously regular activities (McPhail et al., 2012). I experienced altered sensation under the heel and on the top of my foot; this was also an issue discussed by both patients and clinicians in McPhail et al.’s (2012) study and reflected on by Oakley (2007). Small things become milestones. Chamberlain (2016) noted this (also my experience): . . . The daily injections cease – good, because I’m running out of places around my belly button to push the needles in – and it’s onto the next phase . . . I begin to count and celebrate small victories . . .
Perhaps not surprisingly, McPhail et al. (2012) found that health professionals were most concerned with the physical recovery, not so much with psychological/social consequences, some reporting unrealistic expectations about recovery time. I was given no information about what to expect, either short or long term. Participants in Jensen et al.’s study, however, felt that they were very well informed; despite this, they were not able to recall having specific information about recovery, including pain and mobility: . . . What have I been told today? Actually not really anything if I have to be completely honest! . . . nor did I ask . . . (Jensen et al., 2022: 5) . . . I do not know much about it [plan for the future] and it was perhaps one of the things I would like to know more about . . . how bad may it hurt, how long may it hurt . . . can I do anything wrong? . . . (Jensen et al., 2022: 5)
Although I am a health professional and am quite assertive, I sometimes found it difficult to ask questions and hard to remember what I’d been told.
The psychological impacts identified with ankle fracture include depression and anxiety, feeling tired, and worried (Jensen et al., 2022; McKeown et al., 2020; McPhail et al., 2012). Other issues, some of which I can relate to, included weight gain, body image (including specific issues like clothing and footwear, or not being able to shave legs), sleep disturbance, financial impacts, and feeling old/thinking more about aging.
I moved from heavy to lighter plaster to walking boot, being able to use crutches instead of the walking frame, sometimes being able to use one crutch, standing up to clean my teeth, feeling confident enough to shower on my own. At the time of writing, I have not been able to make a cup of tea and carry it (carrying anything requires a backpack). This is a common problem and limits participation in household activities (McKeown et al., 2020; Morgan, 2015). The wide range of physical and psychological issues experienced by those with ankle fractures seems to indicate the need for a more person-centred and holistic approach to supporting recovery (McKeown et al., 2020).
Social and family life, work, sleep – ‘We get more grumpy with each other’
Injuries such as ankle fracture impact all areas of life; for me, sleep was a big issue in the early days. Being unable to fully participate in family life or paid work affects self-esteem (as well as contributing to loneliness and isolation). Relationships are put under strain as family members have to do the work of the injured person: As the weeks go on he gets tired, managing the household alone, and sometimes forgets to leave me things in reach. We get more grumpy with each other. We are both short of sleep as I disturb us both, being so uncomfortable at night. [SD]
For the first few weeks, I felt particularly distanced from my family whose lives were continuing without me. The rest of my family are two floors down much of the time although they are kind and bring me meals and drinks and come and talk to me. It’s very strange. I don’t see my kitchen from the morning before the accident until four weeks later. I can’t get comfortable at night and I can’t get comfortable in the day. [SD]
Once I was able to come downstairs, it was still challenging; I found standing, walking, or sitting without my leg elevated too painful and so participation was very limited. Being unable to join in family activities, including meal preparation and social times, was also identified as an issue by the participants in McKeown et al. (2020).
Goffman’s work, both on presentation of self and in relation to stigma, has been important in thinking about the impact of illness and injury on how people see themselves, and are seen by others (Goffman, 1956, 1963). In her chapter ‘Old Bones’, Oakley (2007: 95–113) reflected on being an older woman (a group which experiences fractures more than others) within a medical system and culture which sees aging women and their bodies in particular ways. There is not space to think more about this here, apart from to note that acquiring a disabling injury shortly before a milestone birthday, as I did, made me feel old, older, aging, and to have depressing thoughts about my future years as an older person (noted above as also found in the published literature).
Conclusion
Week eight after the injury, six weeks post-surgery. It hurts. I can’t walk far and not at all without crutches. My heel and the top of my foot are still numb; my toes feel odd. I can’t drive and have no idea when I will. I’m more independent in the house but still rely on others for many things. I’m still working from home. I’m sleeping badly. I’ve been out a bit more, for meals and to the theatre, but still feel quite isolated. Week ten. I can walk a bit without crutches, balance is getting better. I can shower and dress without help. I cook a meal although standing is still hard; my ankle hurts quite a lot and swells if it’s not elevated. I’m bothered about the numb feeling in my heel and foot. I haven’t walked outside with crutches yet; we are still using the wheelchair. I feel vulnerable.
I have covered many issues relating to my experience of ankle fracture and reflected on this through a number of different lenses: as a person experiencing a second ankle fracture who has been in hospital many times, a health professional, educator, and academic. The importance of person-centred, ethical care has been highlighted and the need to understand the meaning of ongoing consent. Although well recognised in the literature, there are many aspects of being in hospital that are humiliating and institutionalising – that these continue should not be seen as inevitable and challenged wherever possible.
A number of ankle fracture-specific issues have been raised; these may be useful in healthcare training and subsequent care delivery. My experience echoes that reported in the existing qualitative work in this area and other personal accounts. Knowing about and having personalised treatment/recovery plans is important, as well as specific information about what to expect in normal recovery, recognising variation in life experiences and activities. Acknowledgement of the devastating impacts of ankle injury on self-image, home and social life, work, and independence seems to be absent in interactions with healthcare professionals although highlighted in published research and personal accounts.
In preparing this article, I have read many accounts of illness, recovery, and ankle fracture. I have taken comfort particularly in the latter, and in seeing aspects of my own experience (often isolated and lonely) reflected – and normalised – by those of others. Sharing this information with patients would be valuable. Although everyone’s experience will be different knowing, for example, that many find it frustrating and painful, 6 weeks can be a low point or experiencing dependency as challenging is common, could be helpful. No one, at any point during my interactions with healthcare professionals, talked to me about what to expect, how my injury might impact my life – or how I felt.
Limitations include that this article is based on a very personal account. I have tried to ground this in relevant literature, where appropriate, and to consider wider issues than my own. It is an account of a very recent – and ongoing – experience, which could be seen as problematic; I have not been able to reflect on the later aspects of my recovery. Writing has been, however, an important part of the experience for me – doing this once I had recuperated and regained full mobility would have presented a different story: one both relying more on recall and influenced by hindsight. I present my story as a contribution to thinking about experience of illness and recovery, healthcare delivery, and ethics – and to add to the small body of work on ankle fracture.
Footnotes
Acknowledgements
None.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.