Introduction

Shoulder fractures (proximal humerus fractures) are common, painful injuries and incidence rates are rising in line with an ageing population [1]. These injuries are more common in women, with the typical mechanism of injury being a fall from a standing height [2]. Problems such as pain, lack of movement, and reductions in strength can last for many months, and some people do not get back to their previous levels of function [3–5]. Recovery can be hindered by complications such as mal-union and frozen shoulder [6], an increased risk of re-hospitalisation, or further fracture [7]. Previous studies have reported that pain, and loss of function and independence are common following fractures, including shoulder, ankle and wrist fractures [8–11]. Improving pain, restoring function and independence were what patients valued the most [8,9]. McKeown et al. [10] also reported on a study of people who had sustained an ankle fracture, stating that independence and function are important factors in recovery. People who have sustained a distal radius fracture (wrist fracture) have been reported to have concerns regarding dependency, pain, and fear, including fear of falling, fear of pain and fear for the future [11].

There has been no study to date that has looked at the patient experience over the timeline of their recovery following a shoulder fracture, and how this, and their information needs, might change. Appropriate information provided at the right time may lead to improved recovery for patients after a shoulder fracture and may help to empower patients to make informed decisions regarding their health care and to take a proactive approach in their recovery [12]. Recovery has been found to be both a process and an outcome for patients after musculoskeletal trauma [13]. Information leaflets relating to injury, rehabilitation and recovery that are given to people following this injury can be difficult for patients to understand [14]. To ensure that information is accessible and appropriate, it is necessary to understand the patients’ experience of living with a shoulder fracture and what is important to those who have sustained this injury. Thus, this study investigated the following research question: What is the experience of people living with a shoulder (proximal humerus) fracture and how does information provision support recovery for people who have sustained these injuries?

Methods

This qualitative study is one step in a planned multi-methods programme of research that is presented within a pragmatic framework. Pragmatism is based on the belief that knowledge is directly linked to experience [15] so this programme of research fits well within this paradigm, as it is an exploration of the participants’ experiences. The initial stage of this concerned the analysis of the content of information sheets for patients following a shoulder fracture [14,16]. The next planned stage is the co-design and development of an appropriate information leaflet for this cohort of patients (see S2 File. Flow chart of programme of work). The study was registered with clinicaltrials.gov prior to commencement and is reported in accordance with the consolidated criteria for reporting qualitative research [COREQ] [17]. Ethical Approval was gained from the Proportionate Review Sub-committee of the East Midlands—Nottingham 1 Research Ethics Committee on 05 May 2023. REC reference: 23/EM/0115.

Adult patients referred to outpatient physiotherapy in one NHS Trust in Northwest England following a shoulder fracture were identified as eligible for inclusion (Table 1) and recruited between 14^th of June to 28^th of November 2023. Potential participants were provided with a participant information sheet by post, and this was followed up with a telephone call to discuss participation. Written informed consent was gained prior to undertaking the interviews. The recruitment target was up to 15 participants to enable sufficient information power to adequately address the study objectives. This number was decided on by discussion within the experienced qualitative research team taking into account the information power guide as described by Malterud et al. [18]. Sampling was purposive regarding age, gender, levels of deprivation (based on the index of multiple deprivation (IMD) linked to postcode) and ethnicity, to gain a diverse spread of viewpoints and experiences among participants.

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Table 1. Inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pone.0316516.t001

An interview topic guide was developed from a review of the literature, the expertise of the research team and with a Patient and Public Involvement (PPI) Group. The PPI group consisted of 5 former NHS patients, all of whom sustained a shoulder fracture. The group’s age range was 49–84 years old, three were female, four identified as White British and one as Indian, the IMD range was from one to nine, where one is living in an area in the 10% most deprived in England and nine is living in an area in the 10% least deprived. The PPI group were also consulted during protocol development and assisted with the development of the consent form, participant information sheet and interview topic guide. The PPI group were consulted in relation to theme generation and potential implications of the study findings.

Individual, semi-structured telephone interviews were carried out by the lead researcher (PM). PM is a female researcher, who is a physiotherapist by background (with over 10 years’ experience) and trained in qualitative research (with 2 years’ experience). The researcher’s positionality can influence the direction and outcomes of a research study [19,20]. The position of outsider is considered to be one who is outside the group they are studying, whereas, one who is part of the community being studied. [20]. PM, being unknown to the participants, and never having sustained a shoulder fracture, has an outsider positionality with respect to the participants in the study. However, she did have significant knowledge of the service to which the participants were referred, having worked in that service for over eight years. The wider research team has an outsider perspective, having no knowledge of the participants or the particular physiotherapy service, though two (GY and CL) are physiotherapists by training. Telephone interviews were considered to be the optimal choice, in order to reduce the travel burden on participants, as the catchment area for recruitment was large. Telephone technology was deemed to be accessible to the vast majority of potential participants, more so than video conferencing technology.

The timeframes of interview were decided from a pragmatic perspective with the first interviews being approximately two months after injury. This time delay was due to the average referral time from fracture clinic to physiotherapy. A second interview time of five to six months was considered a reasonable timeframe for some recovery to have been achieved but also by the time limitations of the study funding.

The data were analysed using thematic analysis according to the six-step approach as outlined by Braun and Clarke [21]. A semantic approach was used, in that the data was analysed as communicated by the participant and underlying hidden meanings were not explored [22]. The interviews were audio-recorded, pseudonymized and transcribed verbatim by PM, using the software package NVivo (Version 12 Plus). PM checked the transcripts for accuracy and re-read them for familiarity (stage one), after which the initial codes were generated by identifying text relevant to the research question (stage two). An initial list of 54 codes were generated. These codes were iteratively explored and then iteratively refined. Cognate codes were grouped, and sub-themes were developed (stage three). During critical discussion with the co-authors (CL and GY), the codes were reviewed and grouped into preliminary themes (stage four). The preliminary themes and subthemes were critically discussed and refines into themes (stage five). The final stage (stage six) involved reporting of the data analysis within this paper. A reflexive diary was used to record the interviewer’s thoughts, observations, beliefs and biases, which were explored throughout the study. Preliminary analysis was undertaken after each interview, which enabled an iterative process of subsequent data generation.

Results

48 patients were identified as potentially eligible to participate in the study. 29 of these were purposively selected to gain a diverse spread of participants, and therefore, a more diverse spread of viewpoints, and sent a participant information sheet and consent form, and then contacted by telephone to discuss participation in the study. Six declined to participate and did not state a reason; seven were unable to be contacted.

Sixteen participants provided consent and 14 were interviewed (mean age 64; range 44–80 years; three male; 12 White British, one Indian, one Pakistani; IMD range one to nine) (Table 2). The reasons for not participating were: one person needed to cancel due to work commitments and was unable to be subsequently contacted; one person was unable to be contacted to arrange an interview. Fourteen participants were interviewed in the first round of interviews (mean time from injury was 7.8 weeks; range five to12 weeks). Sufficient data was achieved to deliver on the study aims after 14 interviews in the initial round, so recruitment was stopped at 14 participants. Eleven participants were interviewed in the second round of interviews (mean time from injury was 5.5 Months; range 4.5–6 Months). Participant interviews lasted a mean of 20 minutes (range 10–34) across both rounds.

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Table 2. Table of characteristics.

https://doi.org/10.1371/journal.pone.0316516.t002

Four themes were identified which are summarised in Table 3. Anonymised participant quotes have been used to support the findings. Psuedonyms have been suffixed by A and B to correspond to the first and second interviews respectively e.g. a quote followed by Participant 5-B means it is taken from the second interview with participant 5.

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Table 3. Summary of themes and subthemes.

https://doi.org/10.1371/journal.pone.0316516.t003

Discussion

This study explored the patient perspective of living with a shoulder fracture, and to understand what is important to these people with regards to information provision and recovery. This is important to be able to provide the right information for patients at the right time, and in the right way.

Four themes were identified: dependence, vulnerability, information needs and recovery. Dependence, or lack of independence was mentioned by all participants. This is consistent with previous qualitative studies with patients after a fracture [8,23]. A qualitative systematic review of patient perspectives after hip fracture reported that physical functioning, mobility and independence are important factors in recovery [24]. Participants in the current study reported feeling that they were being a burden, which was also reported by King and Hebron [25], in patients with frozen shoulder. However, this loss of independence goes further than merely not being able to care for oneself. There was a sense of loss of identity reported by some participants in this study, due to changing roles. The role reversal from care giver to cared-for person and the loss of role as a worker (when needing to take significant amounts of time off work due to injury) significantly affected those who described these experiences. Genneralli et al. [26] report that sports people commonly suffer from a loss of identity after a musculoskeletal injury. Loss of identity following musculoskeletal injury is also reported by Saunders et al. [27], in relation to their job. Stern et al. [28] report that emotional aspects of recovery are important to patients after a distal radius fracture, and that these should be addressed by clinicians, along with expected timeframes to recovery, to minimise loss of control due to uncertainty. This loss of control was also evident in this study of shoulder fracture patients, especially in the initial stages (first interview). The feeling of control was improved in most participants by the time of the second interview, which tended to align with improved communication and guidance from health professionals, though other factors may also influence participants’ feelings of control.

There is evidence that rehabilitation priorities change with time in major musculoskeletal trauma [13] and this has been shown to be the case for those with shoulder fractures in this study. Shoulder function and independence in self-care develop as priorities in the early stages after a shoulder fracture, and later, returning to other meaningful activities such as work and hobbies. The recovery process is complex and there are various factors that influence recovery. It has been suggested that pain, function/disability and recovery/healing can be thought of as recovery outcomes in themselves but also, they are factors in overall recovery [29]. Vulnerability, including fear of falling and feelings of frailty were common among participants in this study. While some participants reported that their fear of falling reduced as time passed, many had persisting feelings of vulnerability at six months. Vulnerability combined with reduced function led to feelings of isolation, where participants reported being unable to go out like they previously did. After a fracture, patients may have a lack of active engagement in their rehabilitation activities due to feelings of vulnerability [30].

Communication is an important factor in healthcare and can negatively or positively affect patient experiences and outcomes [31]. Appropriate and adequate information provision is an essential part of communication within a therapeutic encounter, and both information provision and communication have been identified as important factors in patient-clinician interactions [32]. As can be seen from the quotes in this study, communication and information can have either positive or negative influences on the patient experience and their recovery. The lack of adequate communication that participants reported, led to a sense of abandonment, with long wait times and not knowing what they could do to help themselves. However, good clear communication, was reported as being helpful in some cases, in that participants felt reassured and had guidance on how they could actively participate in their recovery, for example actively participating in rehabilitation activities. Clear communication and information with shorter waiting times were aspects that have been identified previously as being important in recovery from injury [11,24]. Information needs changed over time, with information about the extent of the injury and practical advice needed first, but later participants emphasized information about reassurance and recovery. This is consistent with previous research reporting that information needs of major trauma patients [33] and ankle fracture patients [9] change over time as recovery progresses. Moos et al., [11] also reported that some participants felt the benefit of guidance by healthcare professionals through their recovery. The theme of information needs was strongly linked to most other themes found in this study. This is similar to what was found by Moos et al., [11] in their study of patient’s experiences after a distal radius fracture.

Those participants who reported religious or spiritual reasons for their injury showed acceptance of their injury. Similar findings have previously been reported [34] where those with spiritual or religious beliefs were accepting of their injury and using positive reframing of their injury. Wiese-Bjornstal et al. [34] also reported that those with religious or spiritual beliefs were less likely to feel that they had direct responsibility for their recovery from sports injury. This may affect the recovery of participants from shoulder injuries in a similar way. It has been shown that those with stronger spiritual or religious beliefs cope better with injury than those without [35].

As demonstrated by the participant quotes from this study, after a shoulder fracture, recovery goes beyond regaining range of movement and function. Feelings of vulnerability and isolation are important factors to consider after a shoulder fracture as these significantly affect daily life. Clinicians should be aware of the full impact of these injuries to effectively guide patients to a full recovery, including overcoming feelings of vulnerability and regaining their sense of identity. Adapting communication appropriately to the changing needs of the patient along the timeline to recovery may help the recovery process.

Conclusions

The path from injury to recovery following a shoulder fracture is multi-dimensional, including loss of function and independence, vulnerability, change in identity and isolation, all of which are important to the person who sustained the injury. It is important to ensure adequate communication and information provision to enable people to have the knowledge and control to be active participants in their recovery. Adopting a person-centred care approach, taking into account the changing priorities and information needs of patients throughout their recovery journey may lead to improved patient care. Future research is needed to design information resources that meet the needs of patients along their timeline of recovery.

Supporting information

Acknowledgments

The authors would like to thank the members of the PPI group who contributed to the development of the interview topic guide, and also the interview participants, without whom the research would not have been possible.