Supporting patients’ emotional well-being can help foster a safer environment for surgeons and healthcare staff

In the United States, healthcare workers are five times more likely to experience workplace violence than workers in other industries. Workplace violence experienced by healthcare workers is often instigated by patients, former patients, or their visitors. Several factors increase the risk of patients inciting workplace violence, including duration and severity of illness, recreational substance use, and impaired cognition. Challenging aspects of care delivery, such as long wait times or staff shortages or shortcomings, may foster a stressful environment. Complications or adverse outcomes, especially when unexpected, may also contribute to patient aggression.

In orthopaedic settings, patients may experience a range of intense emotions, such as disappointment after being denied requests for unwarranted and unsupported tests, treatments, and medications (e.g., additional opioids). Distress or disappointment resulting from injury, disease, or treatment may cause patients to withdraw from vocational and avocational activities and relationships. Furthermore, stress or emotion contagion can occur when the patient’s distress or intense emotions transfer to the surgeon or other healthcare staff. All of these factors could contribute to tension between the patient and surgeon.

Not all risk factors for healthcare workplace violence are modifiable. However, orthopaedic surgeons can take steps to support their patients’ mental well-being and decrease the likelihood of extreme distress, in the hopes of mitigating the risk of an unsafe workplace environment.

Patient-centered care
Surgeons often meet patients at a particularly vulnerable point in their lives. A fracture surgeon often meets a person in the hospital after a frightening, limb- and life-changing event. Prioritizing the person over the disease or injury is a strategy for building trusting patient-surgeon relationships that can weather adverse outcomes. Connecting with people also humanizes care and helps surgeons maintain joy in their careers.

Basic concepts can help ground surgeons in making these human connections. First, recognize the contrast between levels of illness (discomfort and incapability) and degrees of pathophysiology (disease). Orthopaedic surgeons may focus on looking for a pathophysiology that accounts for these variations, but they should also be curious about the thoughts and feelings of the patient and other stressful circumstances that might impact variation in symptom intensity.

Second, in many cases, acute pain related to injury and surgery eventually resolve. If a patient fractures their humeral shaft and it does not heal, it becomes unstable — but the pain of the initial injury improves. If a patient ruptures their anterior cruciate ligament, they end up with a pivot shift, but the knee does not continue to hurt with most activities. Persistently high levels of discomfort and incapability can be a clue about a patient’s mindset. There may also be an element of nontraumatic degenerative or idiopathic pathophysiology that accounts for nonrecovery.

Patient mental health and healthcare safety
Mental health issues can also contribute to workplace aggression. Mental health disorders represent a spectrum, ranging from mild distress to more pronounced and chronic conditions. Although violence initiated by patients experiencing mental distress is more common in emergency departments and psychiatric wards, such incidents are becoming more common in other inpatient and outpatient settings. Personality disorders, delusions, and severe depression may be associated with patient aggression toward healthcare providers.

Orthopaedic surgeons may feel uncomfortable discussing mental health with their patients, but acknowledging these conditions is beneficial for both patient well-being and the healthcare environment at large. In the orthopaedic setting, patients with diagnoses such as major depression, generalized anxiety disorder, or post-traumatic stress disorder may benefit from additional intervention from a mental health expert.

Practical skills for supporting patients’ emotions
In training, surgeons may internalize the idea that the priority is diagnosis and treatment. However, often the more difficult work is anticipating distress, stress, and misconceptions in their patients and prioritizing the trust and connection that are foundational to a supportive physician-patient relationship. A key step surgeons can take is noticing and addressing unhelpful patient thoughts (such as “success is the elimination of pain”), rumination and overwhelm (“I can’t stop thinking about the pain”), despair (“I’ll never get my life back”), and worry (“There must be something wrong with me”).

Motivational interviewing techniques can help surgeons guide patients to healthier thoughts and emotions. This skill is not a matter of education or explaining — it is a matter of connection and mutual exploration. Orthopaedic surgeons, and all clinicians, may underestimate the importance of effective communication strategies, as well as the need for extensive, ongoing training and practice, just as with operative techniques.

Orthopaedic surgeons can play a critical and irreplaceable role in timely diagnosis and attention to mental and social health. Surgeons can work with case workers, social workers, and psychologists who are trained in relationship- and trust-building to support their patients. These team members can also help patients get in touch with their values and goals while they navigate illness and disease.

The buy-in of leadership and administration is critical to workplace culture and an environment that focuses on whole-person care. Organizational norms, processes, and policies, including behavioral contracts and other supportive tools, can help support patients and surgeons alike. When surgeons are puzzled, frustrated, confused, or worried, they should be made to feel confident about speaking up and confiding in their colleagues. Together, surgeons and their teams are more likely to effectively navigate their patients’ most complex and troubling illnesses.

Heather Vallier, MD, is professor in the Cleveland Clinic Lerner College of Medicine and vice chair for safety, quality, and patient experience for the global Cleveland Clinic Orthopaedic Enterprise.

David Ring, MD, PhD, is associate dean for comprehensive care and associate chair for faculty academic affairs in the Department of Surgery and Perioperative Care at Dell Medical School at the University of Texas at Austin.

References

1. Li YL, Li RQ, Qiu D, et al. Prevalence of workplace violence against health care professionals by patients and visitors: a systematic review and meta-analysis. Int J Environ Res Public Health. 2020;17(1).
2. Lim MC, Jeffree MS, Saupin SS, et al. Workplace violence in healthcare settings: the risk factors, implications, and collaborative preventive measures. Ann Med Surg (Lond). 2022;78:103727. doi:10.1016/j.amsu.2022.103727
3. Eshash N, Al Jabri OJ, Rayan A, et al. Workplace violence against healthcare workers: a literature review. SAGE Open Nursing. 2024;10. doi:10.1177/23779608241258029