Hip Surgery Route Shapes Nurses’ Perceived Workload, Study Finds

Nurses caring for older adults after hip replacement surgery report feeling substantially more workload when the operation is performed through the back of the hip rather than the front, even though the actual time they spend on tasks is nearly identical, according to a prospective observational cohort study conducted at a single Chinese hospital. The study, published in Nursing Open, followed 65 patients with femoral neck fractures who underwent hip arthroplasty through either a direct anterior approach or a posterolateral approach, and tracked the workload of the 27 orthopaedic nurses who cared for them from the day before surgery until discharge.

The research team, based at Beijing Tsinghua Changgung Hospital, enrolled patients admitted between February 11, 2025 and July 31, 2025. Thirty patients received the direct anterior approach, in which the surgeon reaches the hip joint from the front of the body, while 35 received the traditional posterolateral approach, which enters from behind. All patients were at least 60 years old, and the researchers deliberately excluded people with cognitive impairment, cerebrovascular sequelae affecting walking, severe pulmonary complications, lower extremity deep vein thrombosis or pathological fractures, because those conditions independently inflate nursing care demands and would have muddied the comparison the investigators wanted to make.

What makes the study unusual is its vantage point. Most surgical comparisons weigh complications, operative time or patient-reported function. This one asked a question that is rarely measured: how much work does a given operation create for the nurses who staff the ward? The investigators argue that the answer matters because workload, both the objective tasks and the subjective sense of burden, is tied to care quality. Prior research in intensive care settings has linked excessive nursing workload to missed interventions, heightened stress and adverse patient outcomes including falls and medication errors. Until now, no study had systematically examined whether the choice of hip arthroplasty approach changes that burden.

To capture it, the researchers measured two distinct things. Actual workload was recorded with an adapted Orthopaedic Nurse Work Responsibilities scale, a time-and-motion instrument in which every task, from measuring vital signs and administering medications to transferring patients, assisting with toileting and providing emotional support, is logged in minutes; the total score is simply the sum of those times, so a higher number means more hours of hands-on care. Perceived workload was measured with the Chinese version of the NASA Task Load Index, a six-item questionnaire covering mental demand, physical demand, temporal demand, performance, effort and frustration, each rated on a 21-point scale. After every nurse-patient interaction at five time points, preoperative day 1, postoperative days 1, 2 and 3, and the day of discharge, the nurse completed both instruments. The unit of analysis was each interaction, and 325 records were completed with no missing data.

The statistical approach accounted for the fact that the same patients and the same nurses appear repeatedly in the data. Linear mixed-effects models treated surgical approach, time and their interaction as fixed effects, with random intercepts for nurse and patient identity, and Bonferroni corrections for the pairwise comparisons. On the objective side, the results were strikingly flat. Actual nursing workload averaged 205.41 minutes in the direct anterior group versus 215.43 minutes in the posterolateral group, a difference that was not statistically significant, and none of the day-by-day comparisons reached significance either. Measured in minutes of direct care, the two operations cost the ward essentially the same.

Perceived workload told a different story. Overall, the main effect of surgical approach was not significant, but the group-by-time interaction revealed two clear divergences. On postoperative day 3, nurses caring for posterolateral patients reported significantly higher perceived workload than those caring for anterior-approach patients, with a difference of 1.364 points on the 0-to-20 scale. On discharge day the gap persisted, at 1.406 points. Both differences survived Bonferroni correction, with p-values of 0.003 and 0.002 respectively. In both cases the direction favoured the anterior approach: nurses felt less burdened when their patients had been operated on from the front.

The authors attribute this pattern to the mobilization schedules embedded in their institution’s care protocols. Under their nursing pathway, direct anterior patients are encouraged to begin walking with a walker as early as the first postoperative day, owing to the minimal soft tissue disruption and better early stability associated with that approach. Posterolateral patients typically take their first mobilization on the third postoperative day, under direct supervision from both physicians and nurses. That first attempt at getting out of bed is a high-risk moment: the authors note that patients remain at considerable risk for falls and hip dislocation at this stage, events that demand close monitoring and heightened vigilance. The discharge process added a further layer, because posterolateral patients often required more comprehensive education about hip precautions, assistive device use and home mobility management before they could safely go home.

The discrepancy between the two measures is, for the authors, the study’s central lesson. Time-and-task instruments counted the minutes of vital signs checks, medication administration and wound care and found them comparable, yet nurses consistently reported higher subjective burden around the first mobilization and discharge of posterolateral patients. The researchers argue that these high-risk junctures demand intense attention, risk anticipation and decision-making responsibility, an invisible burden of sustained vigilance and anxiety over potential serious complications that conventional workload metrics, which prioritize countable tasks and time allocation, largely fail to capture. In other words, the qualitative intensity of care may be a real and measurable component of nursing workload even when the stopwatch sees nothing.

The study also generated an exploratory observation about experience. Descriptive analyses of workload trends across nurse grades suggested that senior nurses at level 3 reported lower perceived and actual workload than their level 2 and level 1 colleagues. Because nurse competency level was not formally tested in the mixed-effects models, the authors are careful to frame this as hypothesis-generating rather than confirmatory, and they note that the proposed mechanisms, such as greater proficiency in patient monitoring, early complication recognition and task prioritization, remain speculative. Still, they suggest that nursing management might benefit from blending expertise across seniority levels when structuring shifts and patient assignments, distributing cognitive load and creating mentorship opportunities, though they stress that such recommendations are preliminary.

The investigators are equally candid about the limits of what their design can show. This was a single-centre study whose results may reflect the organizational structure, staffing patterns and clinical workflow of one department rather than the surgical approach alone. The sample size was set by feasibility rather than a formal power calculation and was relatively small, which limited statistical power and precluded subgroup analyses. The strict inclusion criteria produced a narrow patient population with limited representativeness. The perceived workload questionnaire has not been extensively validated as a gold-standard instrument. Most importantly, the choice of surgical approach was decided through discussion between the surgeon and the patient rather than by randomization, so potential confounders including procedure type, patient characteristics, nurse experience, nurse-to-patient ratios, operative time, blood loss and mobilization timing could not be adjusted for. The two groups did differ significantly in intraoperative blood loss and operative time, which the authors attribute to inherent differences between the surgical methods. Because the design is observational, the findings can only suggest associations and cannot establish causality. The authors call for larger multi-centre studies with more diverse patient populations to confirm whether the perceived-workload gap persists across different hospital settings, and whether tailoring staffing and training to specific surgical approaches merits formal evaluation.

Subject of Research: Nursing workload differences between direct anterior and posterolateral approaches for hip arthroplasty in femoral neck fractures

Article Title: Comparison of Nursing Workload Between Direct Anterior Approach Versus Posterolateral Approach for Hip Arthroplasty in Femoral Neck Fractures: A Prospective Cohort Study

Article References: Xu, P., Gao, F., Zhang, H., Zhao, B., Yang, K., Huang, J., Chen, L., Pan, Y., & Cao, H. (2026). Comparison of Nursing Workload Between Direct Anterior Approach Versus Posterolateral Approach for Hip Arthroplasty in Femoral Neck Fractures: A Prospective Cohort Study. Nursing Open, 13(11), Article e70805. https://doi.org/10.1002/nop2.70805

Image Credits: AI Generated

DOI: 10.1002/nop2.70805

Keywords: nursing workload, hip arthroplasty, femoral neck fracture, direct anterior approach, posterolateral approach, NASA Task Load Index, perceived workload, orthopaedic nursing, prospective cohort study, mobilization, nurse staffing, Comparison