What Are Orthopaedic Healthcare Professionals’ Attitudes Toward Addressing Patient Psychosocial Factors? A Mixed-Methods Investigation

Abstract

Background

Integrating psychosocial resources into orthopaedic clinics can reduce psychological distress and opioid use after injury, enhance functional outcomes, and increase patient satisfaction with care. Establishing referral pathways for connecting orthopaedic patients with psychosocial resources requires the active collaboration and buy-in of orthopaedic healthcare professionals. Designing and disseminating psychosocial training materials for orthopaedic healthcare professionals requires a nuanced understanding of orthopaedic healthcare professionals’ current attitudes toward addressing psychosocial factors, including any stigma and misconceptions about mental health that exist.

Questions/purposes

(1) What are orthopaedic healthcare professionals’ attitudes toward addressing patient psychosocial factors, and how are they related? (2) How do orthopaedic healthcare professionals’ beliefs, reasonings, and experiences help to explain these attitudes? (3) How do attitudes differ between physicians and nonphysician healthcare professionals?

Methods

In this multisite, mixed-methods study (that is, a study collecting both quantitative and qualitative data), our team of psychology researchers conducted qualitative focus groups over secure live video with 79 orthopaedic healthcare professionals at three geographically diverse Level I trauma centers. We approached all orthopaedic healthcare professionals within the three trauma centers to participate in the study to collect as many diverse perspectives as possible. Eighty-four percent (79 of 94) of the professionals we approached participated in qualitative data collection (the group of professionals comprised 20 attending surgeons; 28 residents; 10 nurse practitioners, registered nurses, and physician assistants; 13 medical assistants; five physical therapists and social workers; and three research fellows). We also asked participants to complete self-report items that assessed their attitudes toward addressing patients’ psychosocial factors (research question 1). The different attitudes identified through the quantitative measurement served as a priori defined themes within which our two independent coders organized the qualitative data and identified beliefs and experiences that explained attitudes (research question 2). We used both quantitative and qualitative data to assess differences between surgeons and residents and nonphysician healthcare professionals (research question 3).

Results

We quantitatively identified six underlying attitudes toward addressing psychosocial factors: professional confidence, perceived resource availability, fear of offending patients, fear of negative patient reactions, blame toward patients, and professional role resistance. We observed a strong quantitative correlation between the attitudes of professional confidence and perceived resource availability, and qualitative data revealed how healthcare professionals’ willingness to discuss psychosocial issues with patients is shaped by their perception of psychosocial resources available for orthopaedic patients, as well as their perception of their own skills and tools to navigate these conversations. Quantitative data suggested that surgeons and residents endorse higher blame toward patients for psychosocial factors (medium effect size; p = 0.04), which is a stigmatizing attitude that serves as a barrier to integrating psychosocial resources into orthopaedic settings.

Conclusion

The varying levels of confidence orthopaedic healthcare professionals reported with respect to the topic of discussing psychosocial factors and the misconceptions they endorse regarding psychosocial factors (such as blame toward patients) highlight the need for more specific education for orthopaedic healthcare professionals to help equip them with skills to raise and discuss psychosocial factors with patients in an empathic and destigmatizing manner.

Clinical Relevance

The strong relationship observed between the attitudes of professional confidence and perceived resource availability suggests that expanding the provision of psychosocial resources in orthopaedic settings and establishing specific, efficient referral processes to connect patients with psychosocial resources will in turn increase orthopaedic healthcare professionals’ confidence discussing psychosocial issues with patients.

Introduction

Acute orthopaedic injuries represent a major public health burden because they are a leading cause of hospitalizations and disability [14, 24, 26]. After orthopaedic injuries like fractures, soft tissue lacerations, and dislocations, patients must undergo a strenuous recovery, and 50% of patients develop persistent pain and disability [9, 24, 30]. Mounting evidence indicates that psychosocial factors (factors related to patients’ mental, behavioral, and social health) are important to recovery from orthopaedic injuries [5]. Depression, posttraumatic stress, anxiety about pain, and catastrophic thinking about pain are among the strongest predictors of persistent pain and disability after orthopaedic injuries [16, 18, 28, 29, 32, 33]. Psychosocial resiliency factors such as positive coping skills and social support help patients with orthopaedic conditions recover well and return to regular, pleasurable activities [19, 27]. In line with evidence-based biopsychosocial models of care [1, 10], it is crucial to address psychosocial factors among patients with orthopaedic injuries to promote recovery and prevent chronic pain and disability after traumatic injuries.

Despite the relevance of psychosocial factors for recovery, patients’ engagement in psychosocial care is low [32, 37]. In a large prospective study, 50% of patients experienced psychological distress 3 months after an acute orthopaedic injury, and 42% stated they were distressed 2 years later [23]. However, only 12% had received mental health care 3 months postinjury, and only 22% had received this type of care 2 years later [23]. These low proportions of mental health care after injury are concerning and are likely related to the limited psychosocial resources in orthopaedic settings [3, 18, 34]. Although many systemic barriers contribute to this low provision of psychosocial care, including organizational resources and limited time in fast-paced clinic flows [37], integrated behavioral health models may be a promising solution. In other medical settings such as primary care clinics, embedded behavioral health providers have helped to promote patient health outcomes and decrease healthcare costs [17, 20].

Integrating psychosocial resources in orthopaedic clinics requires the support of orthopaedic physicians and other healthcare professionals. Given the importance of multidisciplinary support, it is essential to understand orthopaedic healthcare professionals’ perspectives toward psychosocial factors. These professionals have varying degrees of training and familiarity with mental health and psychosocial factors [13, 35, 37]. In a survey of 350 orthopaedic surgeons, only 60% reported they are “somewhat likely” or “very likely” to refer patients in distress for psychosocial care [35]. They identified that major barriers to referrals include lack of time, stigma associated with mental health, and uncertainty regarding how to refer patients for support [35]. However, further research regarding orthopaedic healthcare professionals’ attitudes about psychosocial factors is scant, and the perspectives of nonphysicians have not been considered. An in-depth investigation of orthopaedic healthcare professionals’ attitudes toward addressing psychosocial factors, including any differences among physicians (surgeons and residents) and nonphysicians (nurses, medical assistants, and physical therapists), could provide valuable information to facilitate multidisciplinary collaboration and ultimately improve functional and psychosocial outcomes for patients who sustain trauma.

A mixed-method study design integrating quantitative and qualitative approaches is well-suited to explore orthopaedic healthcare professionals’ attitudes toward addressing psychosocial factors and generate nuanced information on the beliefs, reasonings, and experiences underlying these attitudes. Mixed-method approaches are valuable for investigating complex phenomena by offering complementary insights [12, 25]. Although quantitative data can reveal trends in individuals’ attitudes and generalize to our broader population of interest (orthopaedic trauma healthcare professionals from diverse regions of the United States), qualitative data can help us understand why individuals hold certain attitudes and can yield more fine-grained insights into the thoughts, feelings, and institutional or cultural factors associated with them [4].

In this study, we asked: (1) What are orthopaedic healthcare professionals’ attitudes toward addressing patient psychosocial factors, and how are they related? (2) How do orthopaedic healthcare professionals’ beliefs, reasonings, and experiences help to explain these attitudes? (3) How do attitudes differ between physicians and nonphysician healthcare professionals?

Patients and Methods

Study Design and Setting

Our study used a cross-sectional, multisite, mixed-methods design (that is, a study combining quantitative and qualitative data). We conducted thematic qualitative focus groups with exit interviews over secure live video with orthopaedic healthcare professionals at three geographically diverse Level I trauma centers in academic medical centers. We also asked participants to complete self-report items that assessed their attitudes toward addressing patient psychosocial factors, distributed electronically. Sites A, B, and C (anonymized) are in Austin, TX, USA; Lexington, KY, USA; and Boston, MA, USA, respectively.

Participants

We recruited participants from October 2020 to November 2020. Participants were orthopaedic healthcare professionals across Sites A, B, and C, including attending surgeons, residents, physician assistants, nurse practitioners, registered nurses, and medical assistants (n = 79). Eligible participants were those who work in Level 1 trauma centers at any of the sites, provide direct outpatient care to adults with acute orthopaedic injuries, and provided implied consent. We partnered with “surgeon champions” (study ambassadors identified at each site) to present our study to each orthopaedic department, and then emailed a survey to all potential participants through Research Electronic Data Capture [15] to determine eligibility and provide information about the study. Survey completion constituted implied consent for focus group participation. We aimed to include all healthcare professionals within the three orthopaedic trauma centers to collect as many diverse perspectives as possible.

Our screening survey was distributed to 94 orthopaedic healthcare professionals (the total number within the three trauma centers), 94% (88 of 94) of whom completed the survey and consented to focus group participation. Of those who consented, 90% (79 of 88) participated in qualitative data collection (20 attending surgeons; 28 residents; 10 nurse practitioners, registered nurses, and physician assistants; 13 medical assistants; five physical therapists and social workers; and three research fellows). Ten percent of people who consented to study participation (9 of 88) did not attend focus groups because of scheduling conflicts.

Participant Characteristics

Surgeons and residents were mostly men (92% [44 of 48]) (Table 1), and nonphysician healthcare professionals were mostly women (68% [21 of 31]). Participants were predominantly white (73% [35 of 48] of surgeons and residents; 71% [22 of 31] of nonphysician healthcare professionals). These demographics were similar to those reported in other studies of orthopaedic healthcare professionals [2, 34]. Approximately half of the participants in both groups reported prior mental health training (50% [24 of 48] of surgeons and residents; 52% [16 of 31] of nonphysician healthcare professionals).

Table 1.

Participants’ descriptive statistics

Variable	Surgeons and residents (n = 48)	Nonphysician healthcare professionals (n = 31)
Gender
Men	92 (44)	32 (10)
Women	6 (3)	68 (21)
Other	2 (1)	0 (0)
Age in years
25-39	67 (32)	65 (20)
40-55	27 (13)	32 (10)
56-65	4 (2)	3 (1)
66-75	2 (1)	0 (0)
Race
White	73 (35)	71 (22)
Black	8 (4)	10 (3)
Asian	13 (6)	0 (0)
Multiracial or other	6 (3)	19 (6)
Ethnicity
Hispanic or Latino	2 (1)	39 (12)
Non-Hispanic or Latino	98 (47)	61 (19)
Marital status
Single (never married)	31 (15)	39 (12)
Married	65 (31)	48 (15)
In a domestic partnership	2 (1)	0 (0)
Divorced	2 (1)	13 (4)
Household income in USD
20,001-50,000	0 (0)	29 (9)
50,001-100,000	44 (21)	23 (7)
100,001-200,000	17 (8)	39 (12)
200,001-300,000	4 (2)	6 (2)
300,001-400,000	0 (0)	0 (0)
400,001-500,000	4 (2)	0 (0)
500,001-750,000	25 (12)	3 (1)
< 750,000	6 (3)	0 (0)
Self-reported mental health training
Yes	50 (24)	52 (16)
No	50 (24)	48 (15)

Quantitative Data

Quantitative Data Collection

All participants completed self-reported questionnaires electronically through Research Electronic Data Capture before participating in the focus groups. To quantitatively assess healthcare professionals’ attitudes toward addressing patients’ psychosocial factors, we used modified items from an existing measure [36] and condensed the items into dimensions (that is, underlying constructs) using an exploratory factor analysis. Specifically, we identified 25 items from a validated measure that assesses healthcare providers’ attitudes toward addressing psychosocial concerns in patients who have experienced domestic violence [22]. Ten of these items were previously adapted to pertain to orthopaedic healthcare professionals’ perspectives about addressing psychosocial factors in their patients (for example, “I have strategies to encourage orthopaedic trauma patients to seek help for psychosocial problems” and “I have access to personnel to assist in the management of psychosocial issues related to recovery”) [36], which we used in the present study. We also adapted the remaining 15 items from the original domestic violence scale to pertain to orthopaedic healthcare professionals (for example, “Orthopaedic patients’ psychosocial complications are a function of their personality, which is not changeable”). All 25 items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Quantitative Analyses

We used SPSS version 26 (IBM Corp) to conduct quantitative analyses. We performed exploratory factor analyses, a statistical procedure that allowed us to determine how the 25 adapted items “group together” into factors or “constructs” that represent underlying dimensions of participants’ attitudes toward addressing psychosocial factors in orthopaedic patients. We excluded one item that did not contribute meaningfully to any of the constructs and grouped the remaining 24 items into six distinct dimensions using evidence-based approaches [6, 8, 21]. The index of reliability (Cronbach alpha) for these factors ranged from 0.75 to 0.91, indicating good to excellent reliability. We calculated scores for each dimension as the sum of associated items. We calculated bivariate correlations among the six dimensions for the entire sample to determine how factors are associated. Additionally, we conducted six independent t-test analyses to examine differences in each dimension between surgeons and residents (n = 48) and nonphysician healthcare professionals (n = 31).

Qualitative Data

Qualitative Data Collection

We conducted 18 focus groups with accompanying individual exit interviews over secure videoconferencing (Zoom) with 76 participants. We grouped orthopaedic healthcare professionals at each site by role to form focus groups with four to eight participants (seven, eight, and three groups for sites A, B, and C, respectively). In some instances, we combined healthcare professionals who had several roles (for example, nurse practitioners with physician assistants or physical therapists with social workers). Focus groups lasted 60 minutes. We also invited all participants to join optional 10-minute individual exit interviews to share any additional insights, which were conducted using the breakout room feature in Zoom at the end of focus groups. To prevent conflicts and/or group influence, surgeons functioning in the role of department chiefs were excluded from focus groups and invited to participate in 30-minute individual interviews instead (n = 3).

We created a semistructured qualitative script for the focus group (Table 2). We developed the script collaboratively as a multidisciplinary team of psychologists, orthopaedic surgeons, and an implementation science expert. We sought to understand orthopaedic healthcare professionals’ perspectives related to addressing the psychosocial needs of their patients. The script was designed to explore participants’ perspectives on psychosocial factors in patients with orthopaedic conditions, the role of orthopaedic healthcare professionals in addressing these factors, and barriers and facilitators to the provision of psychosocial care in orthopaedic settings. Focus groups were led by predoctoral and postdoctoral research fellows in psychology with training by the multidisciplinary team. The focus group facilitators included both male and female researchers who had no prior relationship with participants. Having two facilitators for each group allowed facilitators to keep track of field notes during groups. As data collection was ongoing, we conducted informal rapid data analyses in which focus group facilitators used a structured template to summarize and disseminate insights gained from each group with our broader research team. We continued data collection to include all orthopaedic trauma healthcare professionals who were willing to participate. Our rapid data analysis procedure facilitated our ongoing review of the insights gained from each group throughout data collection, which allowed us to recognize when we stopped generating new insights in response to questions for each topic of our focus group discussion. This allowed us to conclude that we reached thematic saturation (the point when new themes are no longer emerging) for all topics of our focus group discussion. Focus groups, exit interviews, and individual interviews were audio recorded and transcribed by research assistants.

Table 2.

Semistructured focus group script domains and questions

Domains	Questions
Perceptions of barriers or facilitators to patient recovery	What do you consider a “good outcome” for your patients?
	What are some patient factors that might impede recovery in your patients?
	What factors help your patients recover well?
Perceptions of the psychosocial needs of orthopaedic patients	What comes to mind when you think of the terms “psychological, mental health, or behavioral concerns”?
	How often do you notice psychological, mental health, or behavioral problems in your patients?
	Do you formally assess or screen patients for psychological problems?
	What do you think about the role of these factors in the recovery trajectory of your patients?
Comfort addressing psychosocial factors in patients with orthopaedic trauma	How do you address mental or behavioral health problems that you notice in your patients?
	Do you ever refer or initiate the connection of patients to mental or behavioral health services?
	What mental and behavioral health resources are you aware of that are potentially available to your patients?
	What would be an ideal scenario for addressing mental health factors for your patients?
Barriers and facilitators to psychosocial care integration in orthopaedic departments	How supportive are you of integrating psychosocial care within the orthopaedic practice?
	What do you see as the most significant barriers to the integration of psychosocial care within orthopaedic departments?
Individual exit interview (optional)	Is there anything that you would like to share that is relevant to the discussion from the focus group that you did not share in the focus group for any reason?
	How was your experience in the focus group today?

Qualitative Analyses

We designated the six dimensions representing orthopaedic healthcare professionals’ attitudes toward addressing psychosocial factors in patients identified through factor analysis as six a priori–defined themes for qualitative analysis (a deductive approach). Using NVivo software (QSR International), two members of the research team (MR, NF, or IS [the latter two are not authors on this paper]) independently coded all transcripts to organize qualitative data within these six a priori–defined themes. Coders met to discuss and resolve discrepancies. We then took a collaborative approach to data interpretation, in which three members of the research team (MR, VAG, JDD) examined the data coded in each theme and identified any findings emerging from the data that characterized providers’ attitudes toward addressing psychosocial factors in patients with orthopaedic injuries (an inductive approach). Given that this approach to qualitative data analysis was both deductive (that is, influenced by previously-defined constructs) and inductive (allowing for unexpected and original insights to emerge), it is characterized as a hybrid inductive-deductive approach [11]. During the discussions associated with both the data coding and interpretation processes, we kept an audit trail of collaborative decisions made to increase trustworthiness.

Ethical Approval

Ethical approval for this study was obtained from Mass General Brigham (number 2020P000095).

Results

Healthcare Professionals’ Attitudes Toward Addressing Psychosocial Factors

We identified six underlying dimensions that represented orthopaedic healthcare professionals’ attitudes toward addressing psychosocial factors: professional confidence, perceived resource availability, fear of offending patients, fear of negative patient reactions, blame toward patients, and professional role resistance (Table 3).

Table 3.

Loading matrix of the exploratory factor analysis

Statement	1	2	3	4	5	6
1. I have strategies to encourage orthopaedic trauma patients to seek help for psychosocial problems.	0.896
2. I have ways to ask patients about their psychosocial problems that will encourage them to take action.	0.867
3. I feel confident in making appropriate referrals for orthopaedic trauma patients with psychosocial problems.	0.713
4. I have strategies to help orthopaedic trauma patients change their psychosocial situation.	0.657
5. I have access to information to guide the management of psychosocial issues related to recovery.	0.602
6. I have strategies to encourage orthopaedic trauma patients to seek help for psychosocial problems.	0.509
7. I feel support personnel at my hospital can help manage psychosocial issues related to recovery.		0.979
8. I feel the mental health services at the hospital can meet the needs of orthopaedic trauma patients.		0.785
9. I have access to mental health services should my patients need referrals.		0.711
10. I have access to personnel to assist in the management of psychosocial issues related to recovery.		0.710
11. I am afraid of offending patients if I ask about their psychosocial problems.			0.969
12. It is demeaning to patients to question them about their psychosocial issues.			0.677
13. Asking patients about psychosocial complications is an invasion of their privacy.			0.674
14. If I ask orthopaedic patients about psychosocial issues, they will get very angry.			0.616
15. Patients lack acknowledgment and acceptance of the fact that healing is a lengthy process.				0.856
16. When challenged, patients with psychosocial problems frequently direct their anger toward healthcare providers.				0.710
17. It is not my place to interfere with how a patient chooses to resolve their psychosocial issues.				0.581
18. If patients do not reveal psychosocial problems to me, they feel it is none of my business.				0.471
19. Patients report psychosocial issues for secondary gains.					0.566
20. Patients choose to have psychosocial issues.					0.874
21. Patients often do something to bring about psychosocial complications.					0.827
22. Patients’ psychosocial complications are a function of their personality, which is not changeable.					0.651
23. I feel there are ways of asking about the psychosocial complications of my patients without placing myself at risk for complaints.						-0.864
24. I think that investigating the underlying cause of patients’ psychosocial complications is not part of medical care.						0.465

These self-report items assess participants’ attitudes on addressing psychosocial factors in orthopaedic patients, and they are grouped into six underlying constructs through exploratory factor analyses; the group of all six items (items 1 through 6) represent the underlying construct of “professional confidence”; the grouping of items 7 through 10 represent “perceived resource availability”; the grouping of items 11 through 14 represent “fear of offending patients”; the grouping of items 15 through 18 represent “fear of negative patient reactions”; the grouping of items 19 through 22 represent “blame toward patients”; finally, the grouping of items 23 and 24 represent “professional role resistance.” The factor loadings displayed in this table represent the correlation between each item and its underlying construct: 1 = professional confidence; 2 = perceived resource availability; 3 = fear of offending patients; 4 = fear of negative patient reactions; 5 = blame toward patients; and 6 = professional role resistance.

We observed that professional confidence increased substantially as perceived resource availability increased (r = 0.627; p < 0.001). Professional confidence modestly decreased as blame toward patients (r = -0.245; p = 0.03) and professional role resistance increased (r = -0.269; p = 0.02). Fear of offending patients modestly increased as fear of negative patient reactions (r = 0.528; p < 0.001), blame toward patients (r = 0.437; p < 0.001), and professional role resistance increased (r = 0.348; p = 0.002). Blame toward patients modestly increased as fear of negative patient reactions (r = 0.315; p = 0.005) and professional role resistance increased (r = 0.264; p = 0.02).

How Healthcare Professionals’ Beliefs and Experiences Help Explain Attitudes

Qualitative data illustrates the beliefs, reasonings, and experiences that help to explain physicians’ and nonphysician healthcare professionals’ attitudes toward addressing psychosocial factors in their patients (Table 4).

Table 4.

Illustrative quotations of attitudes towards addressing psychosocial factors

Surgeons and residents	Nonphysician healthcare professionals
Provider confidence
It’s not something that was traditionally part of people’s training, and so I think people will just come at it from different perspectives … there will be significant variation in people’s comfort level even addressing the topic to begin with. (Resident) I try to tell people that if they have a problem or complication, I’m not going to abandon them …. But that’s, like, a flea landing on a rhino for a lot of these people. They have so many problems a lot of times … so many levels of abuse in their life, and sometimes self-inflicted, sometimes outside-inflicted … You try to be a good listener in, you know, the 10 minutes you have with them, but, really, how much of a difference can you really make? (Surgeon) To be honest, I have no idea where to direct the patient if they were sounding suicidal, or depressed, or anxious, or what-have-you. I don’t feel like I know where to send that person, and as a result, I don’t necessarily ask more questions. (Resident)	We’re definitely comfortable speaking with each other and especially about patients. It’s a high priority to us …we do those questionnaires for anxiety and depression, you know, even if those look normal and I just get a weird vibe with maybe a patient mentioned something concerning, I have no problem bringing it up to the provider. (Medical assistant) I think that we get those expressions a lot, and I’ve taken those to the surgeon before … “Hey, just, before you go in, Susie Q has, you know, concerns.” But they don’t tend to act on it … They’ll walk out and be like “I just reassured her.” And they think that that’s what they need is just reassurance, which, yes, for some patients, they just need reassurance. But for others, this is their cry for help. (Research personnel) I think for me I would just need to learn how to speak to patients about that, just because everything I know is ortho … I want to make sure I have the right words. (Medical assistant) We’re definitely very comfortable, you know, either mentioning something to patients or even to the provider … Our providers are very open and listening to everyone. There’s not a hierarchy there … maybe a patient mentioned something concerning, I have no problem bringing it up to the provider. (Medical assistant)
Perceived resource availability
It’s hard to get people in in a timely manner … We refer patients, and they get appointments 1 to 3 months out. That’s really not helpful. (Surgeon) We don’t even really have psychologists here … and psychiatry services are only available to patients with acute stress disorder that self-refer …. The only option we have currently is that we hand the patient a list of phone numbers. (Surgeon) It’s been my experience in our behavioral health colleagues here, it’s like we’re referring and they’re like, “What the hell you want us to do?”… so I think maybe because of the shortage of personnel in our current system—at least that’s what I perceive—maybe they’re kind of shrugging off consults for the people that really need this. (Surgeon) We need a treatment pathway or algorithm: “Hey, you fall into these criteria. Here’s somebody that we have that can help you. Here’s their contact information, we’ll get you get set up.” (Resident)	It’s incredibly challenging for us to refer patients to psych … We don’t have a direct pathway. I can’t tell you how many hours I’ve spent trying to facilitate a patient who expresses any kind of mental health need. It is this incredibly complex system to navigate .… We need more resources in place. (Nurse) If it’s something [surgeons] can’t handle, they’ll send our office manager .… She is great at talking to patients .… I can say about 80% of the time the patient does leave feeling better. (Medical assistant) It would be wonderful if we had a psych team that was designated just for trauma that we could call … and they’re specialized in patients who have the mental health history, and then, on top of that, now they’re experiencing a traumatic injury, and, just, too, for the person who doesn’t have the psych history and experiences a trauma …. I know that would benefit our providers, our patients, their outcomes, patient satisfaction—all of it—provider satisfaction, it would just be huge. (Nurse) We don’t have a wealth of … people to pull from to help us manage those things that could see them in a timely fashion. Sure, they can get them in in 3 months, but in 3 months, they are … moved on. (Nurse)
Fear of offending patients
Sometimes referring somebody to something like this can feel like you’re, you know, diagnosing or accusing them. (Resident) I’ve had patients that have had known diagnosed mental health issues … and say, “Hey, how is the treatment going for this?”… but sometimes that’s hard. You don’t want to come across as, “Oh, the reason you’re having struggles with your femur fracture is really your schizophrenia.” You don’t want them to get defensive … But I think you can appraise it and talk to them in an upfront way that is empathetic to their whole medical picture. (Surgeon) I felt like the best way to, kind of, bring up a conversation with somebody that did not have a prior diagnosis was to phrase things a little … less medical. So, you know, I think most patients won’t get offended if you say, “Hey, you know you’ve had this big injury … that is really stressful. You might feel down.” And if you phrase it, kind of, in that way, I think … they are much more open. (Surgeon)	I think for us a lot of times it’s mostly getting the patient to accept mental help … They hear the words “social worker,” or “depression,” and they kind of get scared or don’t want to talk about it. It’s such a taboo issue some people feel, and some people have said … “I’m here for my shoulder pain—I’m not here to talk about my feelings.” (Medical assistant) It seems like a better format to say, “This is what we do for all patients”… Instead of singling someone out, or giving them something that says … “This is a psych eval.” No, it’s more trying to understand how you’re feeling, and recommend you might want to talk to someone just in case. These options are available to you. (Medical assistant) I think that the more we can have buy-in from the provider—the more they sell it … like “Hey, I really think this is going to help you … this is about managing pain and …. Helping them realize this is a legitimate treatment option and not a—not in lieu of a treatment option. (Nurse)
Fear of negative patient reactions
In their mindset, it’s this wrist fracture I had is the reason I’m having all these issues, it’s not the fact that I have, you know, pre-existing anxiety … So, when you come in—you come in with another thing, and say, “Hey, it’s actually not bad, it’s because you have XYZ going on. Here are some coping strategies.” I almost think that may have an adverse reaction. (Resident)	I think people, when they see the words “anxiety” and “depression”… they get scared and think “Oh you’re getting too private now.” (Medical assistant) I’ve been in practice a long time and the one thing that pisses patients off most is them thinking that you’re saying it’s all in their head … “Use meditation, you’ll be fine.” They hate that. (Nurse)
Blame toward patients
These patients are dealing with a lot … feeling depressed and not motivated. They aren’t necessarily going to comply with their PT … with taking their medications. They might over-exaggerate pain …. They are more difficult to treat. (Resident) There is a certain amount of patients that we have here that just lack a certain mental fortitude or grit or kind of mental toughness. (Surgeon) We come in with biases … and it’s hard to change and so we put them on to patients … “Suck it up, it’s not that bad, you’ll be fine, you’re hyper-somaticizing … we’ve seen a bunch of people get through it, why should you be different?” (Surgeon)	Sometimes we can kind of tell that they don’t want to go back to work, and so they kind of aren’.t motivated to put in the work to get better .… They try and string it along as long as possible …. “Oh, hey I could milk this and get disability, right?” And then it’s a lifelong issue. (Medical assistant) I think something that I’ve kind of noticed is the patients that believe that they can get better tend to do better …. If they feel like there’s no way they’re going to get better, like they don’t have any hope that they’re going to get better, than their health tends to do a little bit worse, just because they’re, like, psychologically coming in with this mindset that their injury is so severe. (Research personnel) It’s hard sometimes to be as sympathetic for people when they don’t want to get better because they’re choosing to not get better. (Medical Assistant)
Professional role resistance
Fortunately, I live in a world where I can usually send that somewhere else and frankly it’s not our training or experience to deal with it very well and it shouldn’t be … If you can remove the majority of real physical worries, we can help a great deal of people … you can repair a lot of the mechanical things and make the mechanical side a lot better. (Surgeon) I do think that it’s also a responsibility for us to at least know how to address it …. We are physicians, we need to know how to treat basic stuff …. Not everyone who’s experiencing psychosocial distress is going to experience it to the point where they need like a separate resource, right? …. We should have in our toolkit, you know … ways to kind of reassure and help address, you know, maybe more minor or mild cases of psychosocial distress. (Resident) I do make a note in my own note that I deferred to the PCP for assistance with something I think is psychological in nature, whether it be depression or anxiety, and then I do follow up with it … and some patients have gone to their PCPs or been referred to a psychiatrist …. They will explain to me that they’ve been put on different medication and how they’re feeling, but that’s the extent of my conversation with them. You know, I have very rudimentary knowledge of psychiatry from medical school. (Surgeon)	It depends on the doctor and how compassionate that physician is once we’re relaying the message because some doctors are going to go in, find out what’s wrong with the patient, and look a little deeper into it. With some doctors, they are just like, “It’s not part of my job.” (Medical assistant) Like a few weeks ago we had a patient come …. When I brought him back to the room, the first thing that he started telling me was all his mental disabilities that he had, and how he needed to be handicapped and have disability. He was somehow attributing all that to the injury that he had. And so that’s frustrating that a patient doesn’t understand, look we don’t treat that. We treat what’s broken, then once you’re better, and that’s fixed, we send you on your way. (Medical assistant) Our healthcare system is so fragmented, so I think, as a specialty practice … I think we have this view—it’s like, “Well, we’re orthopaedics, we’re just treating that fracture, or that injury,” and if the patient does have psych needs, it’s, you know, often kind of a culture of “Well, that’s for the PCP to, sort of, deal with, or that’s for the psychologist, or the psychiatrist.” And that’s not because we don’t want to, or we don’t want to recognize that the need is there, but I think we need more resources. (Nurse)

Professional Confidence

Surgeons and residents described varying levels of confidence in their ability to discuss psychosocial issues with patients. They identified several barriers to engaging in conversations about psychosocial concerns, including limited time, tools, and training and uncertainty regarding available psychosocial resources. As one resident said, “I can talk to them about … their fracture healing and range of motion all I want, but I don’t have many tools to actually improve the situation with their mental health, and so, I don’t get into that subject.” Surgeons and residents tended to believe that psychosocial issues are too difficult to modify to be worth raising in the orthopaedic setting. As one surgeon said, “There are some people, you know, if you pick the scab, there’s going to be a whole flow of stuff that you don’t have the resources or the time or the ability to deal with.” Alternatively, some surgeons and residents felt confident assessing patients’ psychosocial needs, and described the importance of expressing empathy, normalizing distress after injury, and tailoring postoperative regimens to overcome psychosocial barriers. A few providers even felt confident initiating referrals to psychiatry. Surgeons and residents with higher confidence tended to have training in psychology or have learned from mentors who addressed psychosocial factors in patient care.

Nonphysician healthcare professionals (including nurses, medical assistants, and physical therapists) noted that they spend more time with patients than physicians, and they expressed higher confidence identifying, discussing, and understanding patients’ psychosocial needs. Nonphysician healthcare professionals also expressed confidence in alerting attending physicians to patient distress; however, some reported frustration that physicians brush off their concerns or refrain from initiating referrals because of lack of time or perceived resources.

Perceived Resource Availability

Surgeons, residents, and other healthcare professionals similarly perceived very limited psychosocial resources for orthopaedic patients. Orthopaedic healthcare professionals noted a lack of mental health services accessible in a timely fashion, mental health professionals with specialized training in the needs of orthopaedic patients, and standardized screening and referral processes for connecting patients to psychosocial care. Orthopaedic healthcare professionals were also concerned that psychosocial providers appear unable to provide services to their patients. As one nurse said, “Our psych team will not—if you called them to try to see a patient for depression, they’re like ‘No.’ You can barely get them to see anyone when they try to kill themselves, so to get them to like try to set up any kind of outpatient therapy or anything like that is like impossible.” The support resources that most orthopaedic healthcare professionals used (including chaplains, patient advocates, and office managers) were not adequate or specialized enough to manage complex psychosocial comorbidities.

Fear of Offending Patients

Surgeons, residents, and other healthcare professionals expressed fear of offending patients when discussing psychosocial factors given stigma and the perception that patients expected to receive strictly medical care within orthopaedic settings. As one nurse explained, “We still live in a world where, unfortunately, psychosocial issues are still considered taboo, and so I would say that when you start to say anything … they assume you mean that you think they’re crazy.” Participants recommended standardizing a procedure to screen all patients for psychosocial issues and using normalizing language to avoid making patients feel singled out. Nonphysician healthcare professionals recommended that physicians raise the subject with patients to underscore its importance.

Fear of Negative Patient Reactions

Surgeons, residents, and other healthcare professionals all expressed reluctance to raise psychosocial concerns with patients because of fear of patients reacting defensively (by closing off or withholding important communication). Surgeons and residents specifically raised the concern that patients who felt invalidated may be dissatisfied with their care and react in ways that could be detrimental to their practices (such as by issuing complaints). As one resident expressed, “From the provider’s standpoint, I think they’re worried about getting that Yelp review.”

Blame Toward Patients

Many surgeons, residents, and other healthcare professionals expressed the belief that psychosocial factors and their impact on recovery are under patients’ conscious control. Several surgeons and residents expressed the belief that emotional distress was a result of lack of “mental toughness,” which they understood as difficult—if not impossible—to modify. As one surgeon said, “I’ve got a guy that I saw today, and he was just—he’s just a sad sack of ‘taters every time I see him, and he’s got a beautiful healed distal femur fracture and he just can’t you know—it’s just he’s got a case of the woe-is-me.” Some nonphysician healthcare professionals raised the opinion that patients may lack motivation to recover because of a desire to maximize access to resources (such as qualifying for disability or workers compensation). At the same time, other participants acknowledged that their own biases regarding psychosocial factors might interfere with their ability to empathize and provide adequate support to patients.

Professional Role Resistance

Surgeons, residents, and other healthcare professionals expressed reluctance regarding the appropriateness of addressing psychosocial factors within orthopaedic settings. Surgeons and residents tended to cite their lack of expertise, explaining that they are responsible for the mechanical side of injuries and it would be inappropriate to discuss psychosocial issues in-depth. Surgeons and residents also noted that given the longstanding and complex nature of psychosocial issues, it would not be feasible to address them in the fast-paced and specialized orthopaedic setting. As one surgeon mentioned, “You want the truth? We can’t change it. It doesn’t mean the rest can’t, but we can’t change it. And it’s also a much, much deeper problem than one psychological event. It’s often a major social problem—things in the past, family issues. It’s much, much deeper than a social, personal reaction to the injury or illness.” At the same time, most surgeons and residents did perceive that it is within the scope of their role to initiate referrals to primary care or mental health professionals.

Nonphysician healthcare professionals who were resistant to addressing psychosocial factors in orthopaedic settings tended to believe that psychosocial issues were not relevant to orthopaedic recovery. As one medical assistant said, “They come in saying ‘Oh well I have depression, I have PTSD, I have a disability, I have all these other things that are wrong with me.’ But those things don’t pertain to the injury that they have, but they’re trying to say somehow, it’s all connected.”

Differences in Attitudes Between Physicians and Nonphysician Healthcare Professionals

There were no differences observed quantitatively between surgeons and residents compared with nonphysician healthcare professionals on professional confidence, perceived resource availability, fear of offending patients, fear of negative reactions, and professional role resistance (Table 5). However, surgeons and residents had higher blame toward patients for psychosocial complications (mean scores of 9 ± 2) than nonphysician healthcare professionals (mean scores of 8 ± 3; mean difference 1.26 [95% CI 0.04 to 2.47]; p = 0.04).

Table 5.

Means, SDs, and standardized scores of each dimension of attitudes and beliefs toward addressing patient psychosocial factors for surgeons (n = 48) and nonphysician healthcare professionals (n = 31)

Factor	Role group	Mean ± SD	Normalized score
Professional confidence	Surgeons and residents	18 ± 4	0.50
	Nonphysician healthcare professionals	18 ± 6	0.50
Perceived resource availability	Surgeons and residents	13 ± 4	0.57
	Nonphysician healthcare professionals	13 ± 4	0.58
Fear of offending patients	Surgeons and residents	8 ± 2	0.41
	Nonphysician healthcare professionals	8 ± 3	0.44
Fear of negative patient reactions	Surgeons and residents	11 ± 2	0.45
	Nonphysician healthcare professionals	11 ± 3	0.48
Blame toward patients	Surgeons and residents	9 ± 2	0.45
	Nonphysician healthcare professionals	8 ± 3	0.33
Professional role resistance	Surgeons and residents	4 ± 1	0.48
	Nonphysician healthcare professionals	4 ± 1	0.40

The scale for each dimension differs depending on the number of corresponding items (range = 6-30 for professional confidence; range = 4-20 for perceived resource availability, fear of offending patients, fear of negative patient reactions, and blame toward patients; range = 2-10 for professional role resistance); normalized scores display means rescaled to be between 0 and 1.

Of all attitudes, qualitative data revealed the most noticeable differences in attitudes between physicians and nonphysician healthcare professionals related to professional confidence addressing psychosocial factors. Nonphysician healthcare professionals appeared to be more confident in their ability to listen to patients experiencing psychosocial distress, express empathy, and raise the concern to the broader medical care team. This finding was related to nonphysician healthcare professionals’ ability to spend more time with patients during clinic visits than surgeons and residents. This difference also appeared related to differences in nonphysician healthcare professionals’ roles and responsibilities. Specifically, surgeons and residents discussed their level of confidence with respect to conducting formal screening and initiating referrals to psychosocial care. In contrast, other types of healthcare professionals discussed their level of confidence with respect to noticing patients in distress and alerting attending physicians to patients’ distress.

Discussion

Psychosocial factors including anxiety, depression, and catastrophic thinking are strong predictors of persistent pain and disability in patients after orthopaedic injuries, yet the engagement of patients in psychosocial care after traumatic injuries is critically limited. To facilitate the multidisciplinary collaboration needed to expand the provision of psychosocial resources for orthopaedic patients, it is essential to understand orthopaedic healthcare professionals’ attitudes toward addressing patient psychosocial factors. Our findings reveal that even though orthopaedic healthcare professionals acknowledge the prevalence of emotional distress in their patients and its impact on recovery, many lack confidence, interest, and willingness to discuss psychosocial issues with their patients. These attitudes are influenced by misconceptions about the modifiable nature of psychosocial factors, lack of tools and training in how to discuss psychosocial factors with patients, and the perceived lack of psychosocial resources available for patients. We need to better equip orthopaedic healthcare professionals with knowledge about psychosocial factors and interventions throughout medical training and continuing education programs. Educational interventions on this topic should address misconceptions about mental health, how psychosocial factors can be modified through evidence-based interventions, ways to discuss psychosocial factors in a destigmatizing manner, and psychosocial resources available to orthopaedic patients.

Limitations

Our findings are limited by several factors. First, our sample consisted of mostly white people and men, particularly among orthopaedic surgeons and residents. Although this demographic composition reflects the broader population of orthopaedic physicians [2, 31], the lack of gender and racial diversity limits the generalizability of the quantitative data and the breadth of perspectives in the qualitative data. Although we did observe thematic saturation among our sample, it is likely we would learn additional insights had we been able to include more diverse participants. Subsequently, and consistent with a qualitative approach [4], our qualitative findings are not meant to be taken as representing the views of a more diverse population of orthopaedic healthcare professionals. Instead, these findings characterize the perspectives of participants within our sample and have valuable implications for the field in that they can be used to generate hypotheses regarding the thoughts, beliefs, and experiences that help explain attitudes toward psychosocial factors in orthopaedic healthcare professionals.

Second, as is the case in qualitative research, the characteristics and background of the researchers influence our data interpretations. Our team, being comprised of psychology researchers, likely influenced the way we perceived participants’ attitudes toward psychosocial factors. For example, we were particularly struck by the instances in which participants demonstrated a lack of knowledge regarding psychosocial factors or misconceptions regarding mental health, and these attitudes may be particularly emphasized among our findings. To account for this bias, we had three researchers independently extract findings from the data and discussed findings as a team. Finally, the sequential order of our data analysis (conducting quantitative analyses first) influenced the qualitative analyses. Specifically, the naming of the dimensions identified through the exploratory factor analysis served as a priori–defined themes, which influenced how qualitative data were coded and interpreted. This means that the themes we present (attitudes about psychosocial factors) may have been worded or separated differently had they been derived from the qualitative data exclusively. However, we found the a priori–defined themes to be an effective structure within which to organize qualitative findings, and we aimed to capture all qualitative findings that emerged from the data within these a priori–defined themes.

Healthcare Professionals’ Attitudes Toward Addressing Psychosocial Factors

We identified six orthopaedic healthcare professionals’ attitudes toward addressing patient psychosocial factors: professional confidence, perceived resource availability, fear of offending patients, fear of negative patient reactions, blame toward patients, and professional role resistance. Professional confidence and perceived resource availability are interrelated attitudes to bolster through the expansion of psychosocial resources in orthopaedic trauma settings and provision of educational programs and training for orthopaedic healthcare professionals regarding psychosocial factors. In contrast, fear of offending patients, fear of negative patient reactions, blame toward patients, and professional role resistance are interrelated attitudes that might serve as barriers to integrating psychosocial resources in orthopaedic settings. These misconceptions about psychosocial factors associated with orthopaedic trauma may prevent healthcare professionals from screening, identifying, and referring patients to psychosocial services [37] and therefore are important to target through educational interventions and training.

How Healthcare Professionals’ Beliefs and Experiences Help Explain Attitudes

Our qualitative findings revealed how healthcare professionals’ confidence and willingness to raise psychosocial issues with patients is largely shaped by their perception of the psychosocial resources available for orthopaedic patients, as well as their perception of their own skills and tools to navigate conversations about psychosocial factors. Our findings extend previous research documenting the very limited availability of psychosocial resources in orthopaedic settings [3, 18, 34] by illustrating how this lack of resources gives rise to healthcare professionals’ beliefs that it is entirely futile to discuss psychosocial factors with orthopaedic patients. Consistent with previous research [36], this suggests that expanding the provision of psychosocial resources for orthopaedic patients and ensuring professionals’ familiarity with referral pathways can increase professionals’ confidence discussing psychosocial factors with patients. Further, our findings extend previous research that has identified variability in orthopaedic healthcare professionals’ mental health knowledge [13, 35, 37] by showing that orthopaedic healthcare professionals specifically desire training in how to discuss psychosocial factors with patients. Equipping orthopaedic healthcare professionals with the skills to use empathic and normalizing language in discussing psychosocial factors with patients can increase their confidence in discussing such factors. At the same time, educational sessions for orthopaedic healthcare professionals can target their misconceptions about mental health (such as the belief that psychological distress is related to a lack of mental toughness or the belief that psychosocial factors are not modifiable within medical settings) to increase these providers’ levels of understanding about psychosocial factors relevant to orthopaedic recovery. Many evidence-based psychosocial interventions exist for orthopaedic patients that utilize skills such as mindfulness and adaptive thinking to help patients manage anxiety and other emotional distress and return to full engagement in activities [7, 34, 36], which can be implemented within orthopaedic settings with collaboration and buy-in from orthopaedic healthcare professionals.

Differences in Attitude Between Physicians and Nonphysician Healthcare Professionals

Quantitative analyses revealed differences between surgeons and residents and nonphysician healthcare professionals only on the dimension of blame toward patients. Surgeons and residents had higher scores on the dimension of blame toward patients than nonphysician healthcare professionals. Qualitative data revealed that the groups had overlapping attitudes regarding this dimension; many healthcare professionals believed that psychological distress is inherent to patients’ personalities or under patients’ conscious control and therefore very difficult to modify. These beliefs are misconceptions, and our findings suggest that these misconceptions are widely shared among orthopaedic healthcare professionals (including surgeons). They also show that healthcare professionals may still blame patients for their mental health conditions and continue to stigmatize mental health issues. Future efforts should focus on developing and implementing educational interventions for orthopaedic healthcare professionals to mitigate this problem. Failing to do so will contribute to increased emotional distress among orthopaedic patients, which has been shown to be associated with more severe pain and impaired function after injury and surgical procedures [5, 18, 23, 29, 33] and in the course of chronic musculoskeletal conditions [19, 28]. Subtle differences were also observed in qualitative data between physicians and nonphysicians regarding confidence addressing psychosocial factors. Nonphysician healthcare professionals tended to have more confidence discussing psychosocial factors with patients, in part related to spending more time with patients. Future mental health screening protocols should therefore consider that nonphysician healthcare professionals may be best suited to notice patients experiencing distress, conduct screenings, and support physicians in connecting patients with psychosocial resources.

Conclusion

We found that although psychosocial distress is perceived to be prevalent among patients receiving orthopaedic care, orthopaedic healthcare professionals report varying levels of confidence discussing psychosocial factors and some misconceptions regarding psychosocial factors relevant to their patients. Together, these findings highlight the need to educate orthopaedic healthcare professionals (during medical school and other primary training for healthcare professionals, medical residency, and continuing education) in ways that address the psychosocial factors relevant to recovery from orthopaedic injury, evidence-based resources available for orthopaedic patients, and effective communication strategies to use when discussing psychosocial factors. Education for orthopaedic healthcare professionals should aim to equip them with skills to raise and discuss psychosocial factors with patients in an empathic and destigmatizing manner and to use specific, efficient referral processes to connect patients with psychosocial resources. As we seek to expand the provision of psychosocial resources available for orthopaedic patients, it is also important for psychologists or other mental health practitioners to be embedded within orthopaedic settings and to have evidence-based psychosocial interventions available for patients as part of multidisciplinary care. Having behavioral medicine providers within orthopaedic settings would support continued education for orthopaedic healthcare professionals, contribute to decreasing mental health stigma within orthopaedic settings, and help support patients’ recoveries after traumatic injuries.