Analysis of qualitative data
Identical themes contributed to patient satisfaction in both treatment groups. A general lack of information was the most important factor of discontent. Three other main themes were functional recovery, speed of recovery and doctor-patient interaction (Table 3). After analysis, participants from the focus groups confirmed that our presented themes were the most important factors contributing to satisfaction after treatment. All factors will be described. Patient quotes are preceded with a code, formed by patient’s age at presentation, gender (M = male, F = female) and treatment group (O = operative, N = nonoperative).
Table 3
Main themes and subthemes
| Themes | Subthemes |
Main themes | Information | Pros and cons of treatment options Being heard X-ray explanation Rehabilitation advise |
Recovery from injury | Range of motion Strength Return to function Pain Irritation from surgical hardware Cosmetic result |
Speed of recovery | Speed of diagnosis Delay to surgery Duration of follow-up Time to return to function |
Doctor-patient interaction | Empathy Trust Kindness |
Minor themes | Parking facilities Travel distance/time Waiting times at the outpatient department |
Information
The treatment decision was a key phase in the treatment process for many participants. Participants expressed a need for thorough understanding of the treatment options and implications. Participants were looking for certainty in choosing the best treatment approach. Several participants said they delegated to their surgeon, who was the expert in making the best decision. Others indicated wanting clear-cut information on percentages of risks and benefits, and were dissatisfied when this information was not provided to them.
25M-O: The surgeon gave a confident and competent impression, and the pros and cons were discussed […] what I could expect and how long it would be before I could do everything again was clear […] we made a joint decision to have the surgery, and I’ve never regretted it.
4 9M-N: I understand that I’m responsible for my own choices […] let’s just look at percentages: 60 percent have it, it’s 40, most are in that corner, and I choose that too […]. I think, just give me the information, I’m asking for it.
Many patients turned to X-rays or other imaging modalities for certainty or confirmation in the treatment decision. Participants expressed that they found an explanation of the imaging to be important, and were disappointed when no images were shown.
61F-N: I didn’t see any X-rays either, they didn’t show me what the fracture looked like, so I’ve been making a fuss about it.
Some even requested the X-rays to ascertain a progression of consolidation.
50F-N: […] when I asked a day later for the X-ray to see if that was really the case […] is it really attached.
Preferences for treatment were also very much based on the radiological findings. Some participants thought that nonoperative treatment can only result in good outcomes if the X-ray shows bony apposition.
43M-N: If conservative treatment gives good results, I wouldn’t really have to or want to be operated, as long as they could clearly confirm whether the sling would be enough […] if the parts of the collarbone touch against it.
Likewise, participants found it especially difficult to accept nonoperative management when they considered the fracture to be severe.
49M-O […] if you see that it’s split and is broken and split in three places, and you think to yourself, you can see even as a layperson that it is not going to heal by itself.
22M-N: I myself don’t understand how it can be expected to turn out all right if you have multiple fractures and the bones are out of place.
Strikingly, several patients in the nonoperative group did not regard a sling or collar-and-cuff as a treatment at all – rather, they felt dismissed and felt like nothing was being done about the fracture.
50F-N: They told me what I had and didn’t do anything more with it […] to me that’s not a real treatment.
Delayed union after nonoperative management was common and often resulted in surgery. Although initially patients were relieved that they did not need surgery, choosing nonoperative management and switching to the operative group caused a feeling of regret.
37M-N 3: Well maybe at that moment you like the idea of not having an operation […] Later on you will see it differently, but at that moment you think it is the better option.
More information was also needed regarding rehabilitation after injury. Some would have liked advice on how to perform daily activities in the acute phase, others stated that they would have liked focused exercises or a referral to a physical therapist to aid their recovery.
22M-N: You have no tips on how to climb out of bed or anything like that […] You don’t know that, nobody tells you.
49M-O: […] You’re on your own, make an appointment with the physiotherapist, who will help you. Then you do some research on the Internet and then, then you figure it out, but I mean, in the end you have to sort it out yourself.
Likewise, all participants who did receive a referral to a physical therapist reported a benefit to their perceived recovery.
60M-O: Yes, indeed with physiotherapy […] If you do the home exercises, because you don’t have that much to do anyway, you do improve really quickly.
Recovery from injury
Functional recovery
All participants expected full recovery in terms of strength and range of motion. Although many did recover, others experienced continuing disability, with some unable to resume work, sports and other hobbies.
60M-O: I expected to recover fully. I had assumed that. A year-and-a-half and two operations further, yes it still bothers me […] I also can’t do the work I used to anymore, I can’t do my hobbies.
49M-N: And actually it took about two weeks, I could do almost everything again, I could do it. If you think about it, it’s fast […] Imagine, two weeks and it’s 100 percent good again. But it never recovered completely […]
Pain relief
Initial pain relief was important in determining satisfaction. Especially participants experiencing delayed union reported prolonged periods of pain. However, patients from both treatment groups reported continued discomfort when wearing a bra, seat belt or backpack even after bony union.
54M-N: That pain, you see […]. I can do everything again. But if I stay a bit longer in one position then it does become painful. The pain is a 3 or 4 on a scale of 10, I think.
31F-N: Sometimes it pulls to the shoulder, but also when I have something around it, like the car seat belt, it feels piercing, as if someone had stuck a knife in it. I feel it for a moment and then it’s gone […] a handbag, that is also uncomfortable.
Cosmetic result
Aesthetic appearance, including scars, bumps, asymmetry and posture, was a minor issue for participants from both groups as long as they recovered functionally.
61F-N: I’m very satisfied, I can do everything again. Only that bulge doesn’t look that nice, but okay.
38M-O: yeah, beautiful is something else. You can see the scar tissue but it doesn’t bother me.
Speed of recovery
Most participants expected a quick recovery and were disappointed when their actual pace of recovery did not match this expectation.
33M-O: I thought they would put a plate, then take it out. Done. But things went differently. I thought that with all the advances nowadays, they operate and you’re done with it, […] everything will work like it used to. But it isn’t working.
Especially participants in the nonoperative group had negative associations with treatment, as they felt it took too long.
28M-O: What gets me is that first they said that it can heal naturally and then they said nah we’ll have to operate. Thinking back, I probably would’ve preferred them to put a plate there immediately, because now I am ten or eleven weeks further.
The feeling of decisional regret was reinforced by a feeling of seemingly quick recovery after surgery.
24M-N: One day after the operation I could do as much as nine weeks without the operation.
Especially semi-professional athletes had a clear preference for operative management, based on experiences among team members, friends or relatives of faster return to function.
29F-O: I made a rather quick decision to let them operate, even though it was probably a no-brainer, as in other people’s experiences it heals more quickly.
One participant experiencing delayed union would have liked earlier advanced imaging (MRI, CT-scan) to have extra certainty about choosing the right treatment.
43M-N: Maybe when in doubt […] do an MRI immediately anyway […] so they can assess more quickly whether a sling is the first choice or they should operate.
Even patients from the operative group indicated feeling disappointed with the delay to surgery.
55M-O: I am quite satisfied with the treatment, only the operation should have been done sooner than two weeks after the accident […] those are two lost weeks.
Doctor-Patient interaction
Patients across treatment groups were satisfied with the interaction with their treating surgeon. Surgeons were generally regarded as trustworthy and sympathetic. Some participants did feel that their surgeon was rushing, thereby negatively influencing their treatment experience.
38M-O: The first doctor that treated me was rather distant and didn’t seem to have a lot of time. The second doctor was exceptionally good and really took the time.
Other minor items
Emergency department
All patients perceived their initial treatment at the emergency department as satisfactory. This was expected, as in our practice patients presenting to the emergency department with a clavicle fracture are routinely referred to the outpatient clinic for definitive treatment decisions.
Waiting times, travel distance, hospital interior
Our script touched on other items like waiting times, travel distance to the clinic and hospital interior. None of these were mentioned by participants in the free discussion, and were thus regarded as less important in determining satisfaction.