Analysis of influencing factors of psychological resilience in patients with traumatic fractures and its effect on posttraumatic growth

Abstract

BACKGROUND

Traumatic fractures are mainly caused by various exogenous traumatic events, which not only damage patients’ physical health but also affect their psychological state and aggravate stress responses.

AIM

To analyze the influencing factors of psychological resilience of patients with traumatic fractures and the effect of psychological resilience on posttraumatic growth (PTG).

METHODS

This study included 188 patients with traumatic fractures admitted to the First People’s Hospital of Shangqiu from November 2022 to November 2023. The participants were categorized based on the patient’s psychological resilience assessed by the Connor-Davidson Resilience Scale (CD-RISC) into the better resilience group (CD-RISC score ≥ 60 points, n = 80) and the poor resilience group (CD-RISC score < 60 points, n = 108). Patients’ sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). The identification of the influencing factors of psychological resilience in patients with traumatic fractures was realized by binary Logistic regression (with factors such as sex, age, injury cause, trauma severity, fracture site, personality, and PSQI included for analysis). The determination of the PTG status of all participants used the Chinese version of the Posttraumatic Growth Inventory (C-PTGI). Furthermore, a Spearman correlation analysis was conducted to analyze the association between psychological resilience and PTG.

RESULTS

The psychological resilience of patients with traumatic fractures was related to age, sex, trauma severity, and personality. The better resilience group demonstrated statistically lower PSQI scores than the poor resilience group (P < 0.05). The Logistic regression analysis revealed sex, age, trauma severity, personality, and sleep quality as influencing factors of CD-RISC scores in patients with traumatic fractures (all P < 0.05). The score of each C-PTGI dimension and the total score (relating to others, new possibilities, personal strength, spiritual change, and appreciation of life) were higher in the better resilience group than in the poor resilience group (all P < 0.05). Spearman correlation analysis indicated a positive association of the CD-RISC score in patients with traumatic fractures with the scores of all dimensions of C-PTGI and the total C-PTGI score (all P < 0.05).

CONCLUSION

The factors influencing the psychological resilience of patients with traumatic fractures include age, sex, trauma severity, personality, and sleep quality, and psychological resilience is closely associated with PTG.

Key Words: Traumatic fracture; Psychological resilience; Sleep quality; Posttraumatic growth; Connor-Davidson Resilience Scale; Chinese version of the Posttraumatic Growth Inventory

Core Tip: Traumatic fractures cause different degrees of physical damage to patients. The injured limbs may present with pain, swelling, and ecchymosis. Visceral damage, shock, or even fatality may ensue in severe circumstances, imposing substantial distress and setbacks on patients’ physiological and psychological adaptability. This study included 188 patients with traumatic fractures. The influencing factors of psychological resilience in such patients were confirmed to involve sex, age, trauma severity, personality, and sleep quality. Among female patients, those aged < 40 years, individuals with a higher degree of trauma severity, introverted patients, and those with suboptimal sleep quality, enhanced care, and psychological intervention should be strengthened to improve their psychological resilience as much as possible. This, in turn, exerts a favorable effect on the patient’s posttraumatic growth status. Our study provides effective guidance for the rehabilitation of patients with traumatic fractures.

INTRODUCTION

Trauma is considered a significant cause of death and disability globally. It not only ranks as the fifth leading cause of death for humans worldwide but also stands as the primary cause of death among young people[1,2]. Fractures frequently appear as a consequence of traumatic injuries, triggered by exogenous high-energy or low-energy traumatic events, including traffic accidents and falls from heights. It constitutes an orthopedic disease characterized by a high admission rate and a substantial in-hospital mortality risk in China[3]. A nationwide survey reports that the weighted incidence risk of traumatic fractures demonstrates a yearly escalating trend, particularly among participants aged ≥ 65 years[4]. Traumatic fractures inflict varying degrees of harm to patients’ bodies, with pain, swelling, and ecchymosis of the injured limb as well as visceral injury, shock, and death in severe cases[5,6]. Further, the disease exerts a negative effect on normal life, causing considerable distress and setbacks to patients’ physical and psychological adaptation[7,8]. An observational study indicates that the psychological resilience of elderly patients undergoing hip fracture surgery is significantly correlated with physical function and that active psychological intervention for such patients may be beneficial to postoperative physical function recovery[9]. Other research indicates that a higher psychological resilience level is closely associated with greater walking speed and distance among older adults after hip fractures, once again emphasizing that high psychological resilience contributes to physical function and exercise capacity improvement[10]. Psychological resilience is the rapid and effective adaptability of an individual in response to stress when confronted with adversity or setbacks. Individuals with high psychological resilience help in recovering and maintaining mental health during difficulties as well as reducing and preventing stress disorders[11-13]. Posttraumatic growth (PTG) is a favorable and positive adaptation process that typically occurs after an individual experiences a catastrophic accident through active regulation and adaptation of cognition and frequently causes growth in multiple domains such as relating to others, new possibilities, personal strength, spiritual change, and appreciation of life for the individual[14,15].

We hold the view that the research on the psychological resilience of patients with traumatic fractures is beneficial for facilitating their smooth recovery postoperatively. Hence, this study emphasizes analyzing the influencing factors of psychological resilience in patients with traumatic fractures and the effect of psychological resilience on PTG, to provide more effective clinical guidance for the smooth recovery of such patients.

MATERIALS AND METHODS

General information

This study included 188 patients with traumatic fractures admitted to the First People’s Hospital of Shangqiu from November 2022 to November 2023. The participants were categorized based on the evaluation of psychological resilience using the Connor-Davidson Resilience Scale (CD-RISC) into a better resilience group with 80 cases and a poor resilience group with 108 cases.

Inclusion and exclusion criteria

Inclusion criteria including: A clear diagnosis, requiring surgical treatment[16]; no peripheral neuralgia nor abnormal central pain perception; length of stay of ≤ 28 days; age of ≥ 18 years old; clear consciousness and normal cognitive ability, and ability to fill out or answer questionnaires independently or with the investigator’s assistance. Exclusion criteria including: Central nervous system disorders caused by acute trauma; concurrent serious stress events during treatment; severe spinal cord or craniocerebral injury; neuralgia, or complications that influence the intervention effect; primary tumor; severe pain that impacts the determination of results; chronic pain history. Figure 1 illustrates a flowchart of patient recruitment and exclusion.

Figure 1  Flowchart of patient recruitment and exclusion.

Detection indicators

Detection indicators including: (1) Collection of general information: The general information of all participants was obtained through a self-designed questionnaire in combination with the hospital’s medical record system. The main contents included sex, age, cause of injury, trauma severity, fracture site, and personality. Among them, trauma severity was assessed with the abbreviated injury scale-injury severity score[17], with injury severity score of ≤ 16 as a minor injury, > 16 to ≤ 25 as a serious injury, and > 25 as a critical injury; (2) Psychological resilience assessment was performed with the CD-RISC[18], a tool with 25 items and 3 dimensions, including tenacity, strength, and optimism. A five-level Likert scoring system was used, with a total score ranging from 0 to 100 points and a higher score indicating greater psychological resilience. Patients with a CD-RISC score of ≥ 60 were assigned to the better resilience group; otherwise, they were included in the poor resilience group; (3) Sleep quality. It was assessed according to the Pittsburgh Sleep Quality Index (PSQI)[19]. The total PSQI score is 21, with higher scores indicating poorer sleep quality; and (4) PTG status. The Chinese version of the Posttraumatic Growth Inventory (C-PTGI)[20] was utilized for assessment. The scale mainly contains five dimensions, namely, relating to others, new possibilities, personal strength, spiritual change, and life appreciation. Each of the 20 items was scored 0-5 points, with a total score of 0-100 points. The higher the score, the higher the PTG level.

Statistical analysis

Data processing was conducted with Statistical Package for the Social Sciences version 22.0. Measurement data that conformed to the normal distribution were presented as mean ± SD, and a t-test was conducted. Count data were expressed as the number of cases (%) and an χ² test was conducted for comparison between the two groups. Binary Logistic regression was used to analyze the influencing factors of psychological resilience in patients with traumatic fractures. The association of psychological resilience with PTG was analyzed with the Spearman correlation. P values of < 0.05 indicated a statistically significant difference.

RESULTS

Analysis of general information on the better and poor resilience groups

The data analysis (Table 1) indicated statistical inter-group differences in sex, age, trauma severity, and personality (P < 0.05). Specifically, the better resilience group included more male cases, more people aged > 40 years, more patients with minor injuries, and more extroverted individuals. However, no significant difference was determined between groups in terms of injury causes and fracture sites (P > 0.05).

Table 1 General data of the better and poor resilience groups, n (%).

Data	Better resilience group (n = 80)	Poor resilience group (n = 108)	χ2	P value
Gender			5.113	0.024
Male (n = 114)	56 (70.00)	58 (53.70)
Female (n = 74)	24 (30.00)	50 (46.30)
Age (years)			4.516	0.034
< 40 (n = 85)	29 (36.25)	56 (51.85)
≥ 40 (n = 103)	51 (63.75)	52 (48.15)
Cause of injury			1.086	0.581
Traffic accident (n = 105)	45 (56.25)	60 (55.56)
Falling from heights (n = 54)	25 (31.25)	29 (26.85)
Others (n = 29)	10 (12.50)	19 (17.59)
Severity of trauma			6.521	0.038
Minor injury (n = 71)	38 (47.50)	33 (30.56)
Serious injury (n = 46)	19 (23.75)	27 (25.00)
Critical injury (n = 71)	23 (28.75)	48 (44.44)
Fracture site			1.252	0.535
Tibial shaft fracture (n = 59)	22 (27.50)	37 (34.26)
Radius fracture (n = 70)	30 (37.50)	40 (37.04)
Humeral fracture (n = 59)	28 (35.00)	31 (28.70)
Personality			7.315	0.007
Extroversion (n = 73)	40 (50.00)	33 (30.56)
Introversion (n = 115)	40 (50.00)	75 (69.44)

Analysis of sleep quality in the better and poor resilience groups

Sleep quality assessment with the PSQI scale revealed that the PSQI score of the better resilience group was 7.44 ± 3.19 points, whereas that of the poor resilience group was 10.33 ± 3.71 points, indicating statistically lower PSQI scores in patients with better psychological resilience compared to those with poorer resilience (P < 0.05, Figure 2).

Figure 2 Analysis of sleep quality in the better and poor resilience groups. ^cP < 0.001. PSQI: Pittsburgh Sleep Quality Index.

Analysis of the influencing factors of psychological resilience in patients with traumatic fractures

Binary Logistic regression analysis was conducted with factors with significant differences, such as sex, age, cause of injury, trauma severity, fracture site, personality, and PSQI, as independent variables, and whether the CD-RISC score achieved better resilience as dependent variables. The data indicated that sex [odds ratio (OR) = 2.100, P = 0.046], trauma severity (OR = 1.795, P = 0.006), and personality (OR = 2.547, P = 0.012) were risk factors influencing psychological resilience in patients with traumatic fractures, whereas age (OR = 0.454, P = 0.032) and PSQI (OR = 0.7305, P < 0.001) were protective factors (Tables 2 and 3).

Table 2 Assignment.

Factor	Variable	Assignment
Gender	X1	Male = 0, female = 1
Age (years old)	X2	< 40 = 0, ≥ 40 = 1
Cause of injury	X3	Traffic accident = 0, falling from heights = 1, others = 2
Trauma severity	X4	Minor injury = 0, serious injury = 1, critical injury = 2
Fracture site	X5	Tibial shaft fracture = 0, radius fracture = 1, humeral fracture = 2
Personality	X6	Extroversion = 0, introversion = 1
PSQI (points)	X7	Continuous variable

PSQI: Pittsburgh Sleep Quality Index.

Table 3 Logistic regression analysis of influencing factors of psychological resilience in patients with traumatic fractures.

Factor	β	SE	Wald	P value	OR	95%CI
Gender	0.742	0.372	3.985	0.046	2.100	1.014-4.351
Age (years)	-0.790	0.369	4.578	0.032	0.454	0.220-0.936
Cause of injury	0.072	0.247	0.084	0.772	1.074	0.662-1.745
Trauma severity	0.585	0.211	7.682	0.006	1.795	1.187-2.713
Fracture site	-0.341	0.227	2.247	0.134	0.711	0.456-1.110
Personality	0.935	0.373	6.275	0.012	2.547	1.226-5.292
PSQI	-0.315	0.059	28.888	< 0.001	0.730	0.651-0.819

OR: Odds ratio; CI: Confidence interval; PSQI: Pittsburgh Sleep Quality Index.

Analysis of PTG in the better and poor resilience groups

The analysis of PTG using the C-PTGI scale revealed that the better resilience group demonstrated significantly higher scores in terms of relating to others (14.96 ± 2.59 points vs 13.92 ± 2.66 points), new possibilities (13.79 ± 3.00 points vs 12.57 ± 2.78 points), personal strength (13.75 ± 2.52 points vs 12.77 ± 2.17 points), spiritual change (14.90 ± 2.30 points vs 13.97 ± 3.01 points), and appreciation of life (16.39 ± 2.61 points vs 14.39 ± 3.36 points) and the total score (73.79 ± 5.48 points vs 67.62 ± 6.12 points) than the poor resilience group (P < 0.05; Figure 3).

Figure 3 Analysis of the posttraumatic growth of the better and poor resilience groups. A: Inter-group comparison of scores in terms of relating to others; B: Inter-group comparison of scores in terms of new possibilities; C: Inter-group comparison of scores in terms of personal strength; D: Inter-group comparison of scores in terms of spiritual change; E: Inter-group comparison of scores in terms of appreciation of life; F: Inter-group comparison of scores in terms of the total score. ^aP < 0.05, ^bP < 0.01.

Association between psychological resilience and PTG

We recorded patients with good resilience as 2 and those with poor resilience as 1 to analyze the association between psychological resilience and PTG through Spearman correlation coefficients. The results revealed a significant positive correlation between psychological resilience and the scores of various dimensions and the total score of C-PTGI (P < 0.05, Figure 4).

Figure 4 Relationship between psychological resilience and posttraumatic growth. A: Correlation between resilience and Chinese version of the Posttraumatic Growth Inventory (C-PTGI) (relating to others); B: Correlation between resilience and C-PTGI (new possibilities); C: Correlation between resilience and C-PTGI (personal strength); D: Correlation between psychological resilience and C-PTGI (spiritual change); E: The correlation between resilience and C-PTGI (appreciation of life); F: Correlation between resilience and C-PTGI (total score). C-PTGI: Chinese version of the Posttraumatic Growth Inventory.

DISCUSSION

Traumatic fractures are a kind of adverse stressful event that not only causes physical pain, loss of function, or even disability but also brings considerable mental pressure[21]. Traumatic fracture brings psychological stress to patients secondary to patients with tumors, with 80% of them developing negative emotions, such as anxiety, depression, and pessimism, thereby exerting varying degrees of negative affect on postoperative rehabilitation[22]. This study primarily investigates the influencing factors of psychological resilience in patients with traumatic fractures and the role of psychological resilience in PTG, hoping to provide useful references for the clinical rehabilitation management of such patients.

Several previous studies have conducted in-depth analyses of the influencing factors associated with the psychological resilience of patients with various diseases and investigated which groups of people need additional supervision to provide targeted and effective intervention promptly. Chen et al[23] determined the influencing factors of postoperative resilience of non-small cell lung cancer, including age, average household income, self-efficacy, confrontation, and acceptance–resignation degree. Shan et al[24] revealed that the hope level, education level, residence, and number of children were factors influencing psychological resilience in patients undergoing knee arthroplasty. Relevant analyses are conducted regarding the influencing factors of psychological resilience in certain special non-disease populations. In particular, Shen et al[25] demonstrated that during the coronavirus disease-2019 epidemic in 2019, factors, such as economic status, place of residence, marital status, and whether they had regular employment, affected the psychological resilience of Chinese residents. Additionally, the cross-sectional study by Jin et al[26] revealed that the psychological resilience of Chinese women having a second child was affected by factors such as the intimate relationship with their husbands, the use of social support, and the sex of the first child. Investigating the relevant influencing factors of a particular group is helpful for further understanding which groups of people with specific characteristics require more extra attention and active intervention, which is not only conducive to the rational allocation of medical resources but also helps to improve the efficiency of medical management. However, currently, relatively few relevant analyses have been conducted on the influencing factors of psychological resilience in patients with traumatic fractures. This study included 188 patients with traumatic fractures. The patients were grouped based on the CD-RISC assessment of psychological resilience. Specifically, 80 patients with a CD-RISC score of ≥ 60 were classified as the better resilience group, whereas 108 patients with a CD-RISC score of < 60 were categorized as the poor resilience group. The univariate analysis identified factors, such as sex, age, trauma severity, and personality, to be closely associated with psychological resilience in patients with traumatic fractures. Notably, males, aged ≥ 40 years, mild injury, and extroverted patients demonstrated better psychological resilience. However, the cause of injury and fracture site were not associated with psychological resilience. This study hypothesized that male patients and those of advanced age generally possess stronger psychological resilience and greater stress tolerance. Patients with minor injuries typically experience a more expeditious recovery process, as they more easily overcome the troubles brought about by the illness. Moreover, extroverted patients often demonstrate a higher level of mindfulness and are more inclined to gain the strength to overcome the challenges imposed by the disease through external interactions[27,28]. However, the causes of injuries and the locations of fractures are relatively uncontrollable and predetermined factors, thereby demonstrating no significant effect on patients’ psychological resilience. The aforementioned results indicate that improved attention and supplementary care should be given to females, younger, with severe or critical injuries, and introverted patients. Their psychological fluctuations should be meticulously assessed, and appropriate and timely psychological support should be provided, which holds certain guiding implications for clinical practice.

The PSQI assessment of sleep quality revealed statistically lower PSQI scores in the better resilience group vs the poor resilience group, indicating a close association between greater psychological resilience and better sleep quality. Wu et al[29] indicated a significant negative correlation between psychological resilience and the PSQI score. Indirectly, this implies that a higher psychological resilience level is associated with a superior sleep quality (manifested as a lower PSQI score), which is congruent with the results of our study. Additionally, they emphasized that perceived social support and psychological distress assume a chain-mediated role in the association between psychological resilience and the PSQI score. This indicates that bolstering the perceived social support and attenuating negative emotions are conducive to the amelioration of patients’ psychological resilience and sleep quality. We then conducted a multivariate analysis to assess the influencing factors of psychological resilience in patients with traumatic fractures and revealed that females, higher trauma severity, and introverted personality were risk factors that affected the psychological resilience of patients with traumatic fractures, whereas advanced age and better sleep quality were protective factors. Conversano et al[30] revealed advanced age functions as a protective factor for psychological resilience, whereas the female sex is associated with an increased risk of psychological distress, which is congruent with the results obtained in our current investigation. Additionally, previous research has indicated that the elderly population demonstrates relatively improved adaptability to psychopathological conditions, such as post-traumatic stress disorder, mood disorders, and anxiety disorders, after encountering emergency scenarios caused by natural disasters[31]. Factors, such as culture, family roles, and social expectations, may cause women to have access to fewer resources in terms of social support. Additionally, women tend to demonstrate a relatively higher pain sensitivity. Collectively, these factors may exhibit a deleterious influence on the psychological resilience of females[32]. A more severe level of trauma is frequently accompanied by patients’ perception of a diminished likelihood of recovery and thus a lower level of mindfulness, which is not conducive to the positive shaping of their psychological resilience[33]. PTG status analysis with the C-PTGI scale revealed that patients in the better resilience group demonstrated significantly superior performance to those in the poor resilience group in each dimension of C-PTGI (relating to others, new possibilities, personal strength, spiritual change, and appreciation of life), indicating that superior psychological resilience in patients with traumatic fractures is conducive to facilitating PTG in all respects. We conducted an assessment via the Spearman correlation coefficient analysis to further illuminate the connection. Psychological resilience demonstrated a close positive correlation with the scores of each dimension of C-PTGI and the total score, indicating that the higher the psychological resilience of patients with traumatic fractures, the better their PTG. Kim et al[34] identified a significant positive correlation between psychological resilience and PTG, which aligns with the results of our study. Previous investigations have indicated that psychological resilience represents a form of self-regulation and recuperation in the face of drastic environmental changes or crises. The process through which individuals demonstrate rapid rebound, recovery, and restoration to the pre-crisis state after trauma exposure is typically favorable for positive post-traumatic development[35]. This reveals that facilitating the construction of sound psychological resilience among patients is of crucial significance and is also conducive to PTG promotion. Previous studies have demonstrated that providing self-efficacy intervention or psychological supervision to patients with traumatic fractures is beneficial for improving the psychological resilience level, as well as improving the quality of life and alleviating negative emotions[36,37]. Wang and Cheng[38] revealed that a nursing health education model according to the Rosenthal effect significantly promoted PTG in patients with first-time accidental fractures, improved their psychological resilience, and significantly alleviated depression and anxiety.

This study has several limitations. First, the explicit causal associations among the research variables remain undetermined. Second, the collected scale results may deviate to different degrees due to the self-observation attitudes of the respondents. Finally, ensuring the comparability of the data between the two groups of patients is inherently difficult due to the particularity of the research analysis direction, as the general information contains many potential influencing factors. Future endeavors will be directed toward the continuous refinement of this study from the aforementioned three aspects, to enhance the methodological rigor and validity of the research outcomes.

CONCLUSION

All in all, the factors affecting psychological resilience in patients with traumatic fractures involve sex, age, trauma severity, personality, and sleep quality. Care and psychological intervention should be strengthened to maximize the psychological resilience of female patients, those aged < 40 years, patients with more severe trauma, introverted individuals, and those with poor sleep quality. Furthermore, a significantly positive connection was found between psychological resilience and PTG in patients with traumatic fractures, which again reflects the significance of improving the psychological resilience of such patients. Our research provides effective guidance for the rehabilitation of patients with traumatic fractures.