- Email: [email protected]
A competency framework for orthopaedic and trauma nursing
Journal of Orthopaedic Nursing (2005) 9, 81–86
Journal of Orthopaedic Nursing
www.elsevierhealth.com/journals/joon
A competency framework for orthopaedic and trauma nursing Julie Santy RGN, BSc(Hons), MSc, ENB 219, Lecturer a,*, Jean Rogers RGN, BSc(Hons), CertEd, Practice Educator b, Peter Davis MBE, MA, BEd(Hons), CertEd, RN, DN, ONC, Senior Health Lecturer c, Rebecca Jester PhD, BSc(Hons), RGN, ONC, DN, RNT, Associate Dean d, Julia Kneale BSc(Hons), RGN, RNT, Senior Lecturer e, Chris Knight MSc, Cert Health Ed, DN, RGN, ONC, RNT, Health Lecturer f, Brain Lucas RGN, ENB219, BA(Hons), PGdip, MSc, Orthopaedic Advanced Practitioner g, Jenny Temple MA, SMS, RN, ONC, Adult Pathway Lead h a
University of Hull, Faculty of Health and Social Care, Cottingham Road, Hull HU3 2JZ, UK Stockport NHS Foundations Trust, UK c University of Nottingham, UK d University of Wolverhampton, UK e University of Central Lancashire, UK f University of Nottingham, UK g Whipps Cross University Hospital, UK h University of Plymouth, UK b
KEYWORDS
Summary Competency frameworks are an increasingly common method of driving forward practice quality and meeting the demand for job evaluation and professional development. This paper describes a project supported by the United Kingdom (UK) Royal College of Nursing Society of Orthopaedic and Trauma Nursing to develop a competency framework for orthopaedic and trauma nursing. It describes the process employed in the development of the framework, the results of consultation with UK orthopaedic and trauma nurses and the final competency statements. The framework
Competency; Career development; Knowledge and skills
* Corresponding author. Tel./fax: +44 1482 464 692. E-mail address: [email protected] (J. Santy).
1361-3111/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2005.02.003
82
J. Santy et al. is of relevance to all orthopaedic and trauma nurses who need to work with their employers to identify how the statements can be translated into practice outcomes. There are implications for orthopaedic and trauma nursing education. c 2005 Elsevier Ltd. All rights reserved.
EditorÕs comment Orthopaedic nursing worldwide continues to emphasise and develop its specialty status. The literature contains much debate and comment on this topic. However, most commentators rarely add to the body of knowledge. This ground breaking article, produced from current research, provides a wealth of data and new knowledge for orthopaedic nurses to use and carry forward into the future. PD
Introduction In early 2001 the UK Royal College of Nursing Society of Orthopaedic and Trauma Nursing (RCN SOTN) set up a project group to develop a competency framework for orthopaedic and trauma nursing. Orthopaedic and Trauma nurses had agreed for some time that a competency framework was necessary to help drive forward practice improvement, job and role evaluation and development (DoH, 2004), curriculum development and research as well as articulating the value of specialist orthopaedic and trauma nursing (Kneale and Knight, 1997). The work was undertaken in three phases: Phase 1: Identification of common beliefs about orthopaedic and trauma nursing and the care needs of orthopaedic and trauma patients. Phase 2: Development of a set of core competencies for orthopaedic and trauma nursing. Phase 3: Piloting of the core competencies in practice. The aim of a phased approach was to ensure that orthopaedic and trauma nurses were involved in the process of the competency framework development at all stages. Central to this was the identification of explicit beliefs and values about orthopaedic and trauma nursing. As trauma nursing was incorporated into the RCN Society of Orthopaedic NursingÕs name and philosophy in 2000 (Santy, 2000), these competencies are designed to represent the nursing of those who have sustained musculoskeletal trauma and are being managed by orthopaedic trauma and rehabilitation teams within the acute and primary care setting. With respect to trauma they are not meant to represent the care of patients in Accident and Emergency or Intensive Care settings. These areas would be covered by different competencies devel-
oped by other forums and practitioners in collaboration with the RCN SOTN. Consultant Nurse level has not been included in this the first competency framework. Consultant nurses in orthopaedic and trauma nursing remain rare. Although the role of the consultant nurse in orthopaedics and trauma was discussed at the workshops no consensus was reached about how this role could be developed within the specialty. This is a specific piece of work that could be undertaken in the near future and added to subsequent versions of the competency framework when it is reviewed. It is of note that some elements of the senior practitioner/expert nurse role within this framework may overlap with future development of the consultant nurse role in orthopaedic and trauma nursing. Who or which organisation should undertake this work requires urgent discussion. Similarly, there is a need for exploration of the Health Care Assistant level and Assistant Practitioner within orthopaedic and trauma settings. A number of other bodies such as the Association of Orthopaedic Technicians and groups representing other plaster room and outpatients staff need to be considered as well as operating department practitioners. These issues are too complex to be considered within this work as they encompass disciplines other than nursing. This report was compiled at the end of phase 2 after final consultation with the practitioners involved in the development of the competencies at earlier stages. The competencies have also been distributed for consultation by senior staff within the RCN involved in developing nursing competencies. This feedback has been incorporated. The RCN SOTN funded this project and in addition some catering. Most venues for the workshops were provided by local health care providers, universities and SOTN local groups. The working group wishes to thank these groups for their support and participation.
A competency framework for orthopaedic and trauma nursing
83
Phase 1
Fig. 1 represents these concepts and their relationship.
Phase 2 During 2003 and early 2004, a series of workshops were held at 10 RCN, hospital and university sites around the United Kingdom: Nottingham, Dudley, Stockport, Glasgow, Belfast, North Wales, Exeter, Middlesborough, Hull and London.
Co-ordinator Comfort Enhancer Partner/Guide Risk Manager Technician
The continuum of care
Orthopaedic and trauma patients are those whose musculo-skeletal conditions originate or are caused by environmental factors, genetic factors, infection/immunity, degenerative processes, and trauma. These conditions are commonly managed through surgery and/or casts/orthotics/app-liances. Mobility, disability and independence are central concepts to the orthopaedic patientÕs needs. Orthopaedic and trauma nursing care is provided from birth to death across all age ranges. The continuum of care in orthopaedic nursing crosses all boundaries and takes place in all settings from pre-hospital care, through acute and primary settings to the patientÕs place of residence (Lucas, 2002). Specialist and generic knowledge, education and research underpin orthopaedic nursing practice.
Mobility/disability/ independence
At the SOTN annual conference in Belfast in September 2001, the working group ran a series of focus groups (Barbour and Kitzinger, 1999) to develop an interpretation of the nature of orthopaedic and trauma nursing. The focus groups were audio taperecorded and their transcripts processed through thematic analysis. The process of analysis involved experienced orthopaedic nursing academics listening to the tapes as a group, identifying major concepts and then negotiating a common interpretation of the content (Kvale, 1996). At this stage, existing literature was incorporated into the interpretation (Davis, 1999; Love, 1995; Santy, 2001). Five core activities of orthopaedic nursing were identified. These were comfort enhancer, coordinator, partner/guide, risk manager, and technician and reflect previous research by Santy (2001). These core activities were felt to inclusively represent orthopaedic and trauma nursing practice. The context of these five core activities was placed within a framework that included the notions that:
Musculo-skeletal conditions, surgery and injury
From Birth to death A Foundation of specialist and generic knowledge, research and education Figure 1 Nature of orthopaedic and trauma nursing (after Santy, 2001).
These locations were chosen to allow as many areas of the UK to be represented as possible. The workshops were attended by a self-selected group of orthopaedic and trauma nurses working in a variety of settings within orthopaedic and trauma nursing. They were led by the same facilitator, with assistance from others. Nurses were from elective and trauma units, outpatient departments, plaster rooms and fracture clinics and childrenÕs orthopaedic units. In addition to orthopaedic and trauma nurses working in traditional ward and clinic based roles, practitioners with existing and more recently developed advanced practice and nurse consultancy roles were included along with a number of orthopaedic and trauma unit nurse managers. In total, approximately 140 orthopaedic and trauma practitioners contributed to the workshops. The workshops aimed to identify competencies and levels of practice within each of the five core activities of orthopaedic and trauma nursing and to consult orthopaedic nurses about their development. Participants were asked to evaluate each workshop at the end of the day. The comments were overtly positive. Participants particularly appreciated the opportunity to meet with colleagues to spend time considering the practice of orthopaedic and trauma nursing and to influence its future. Feedback was also used to adapt subsequent workshops to make them more effective. Participants were split into small groups for this work and identified a group member to document and feedback the discussion to the main group.
84
J. Santy et al.
The workshop programme included discussion about the following areas:
What and who is an expert/consultant orthopaedic and trauma nurse?
The underpinning core values, beliefs and philosophy of orthopaedic and trauma nursing. The personal attributes of orthopaedic and trauma nurses. The core activities of orthopaedic and trauma nursing and levels of practice within these.
During 2003 the Royal College of Nursing began to develop a draft framework of core competencies for nursing. The structure of this framework was incorporated into the workshops and has been used to underpin the orthopaedic and trauma nursing competencies. The competency
1. COMPETENT NURSE 1. Provides nursing care to meet the hygiene and comfort needs of patients that takes into account their orthopaedic/trauma condition and is sensitive to their cultural and spiritual needs. 2. Assesses and monitors pain levels of patients with chronic and acute pain showing an understanding of the musculo-skeletal condition. 3. Administers prescribed analgesia according to prescription and prescribed need. 4. Utilises a small selection of alternative/complementary strategies for pain relief.
1. COMPETENT NURSE 1. Accurately assesses patients with a range of conditions and/or injuries and records such assessments. 2. Plans, and evaluates care for a wide range of patients. 3. Undertakes basic pre-assessment of patients awaiting admission for elective orthopaedic surgery. 4. Effectively plans and manages discharge and/or transfer for patients with uncomplicated discharge needs. 5. Arranges appropriate post discharge support of patients with uncomplicated needs. 6. Liaises with other members of the multidisciplinary team regarding uncomplicated discharges.
1. COMPETENT NURSE 1. Uses a knowledge anatomy & physiology, conditions, surgery and injuries to give basic information to patients and carers. 2. Gives basic preoperative, post-operative and pre-discharge advice to patients and carers following orthopaedic surgery, conditions and injury. 3. Actively provides support and education to patients undergoing surgery and/or with injury or other conditions. 4. Supports and encourages patients when mobilising according to their rehabilitation plan and with a focus on maintaining musculoskeletal integrity. 5. Recognises the psychological consequences of orthopaedic and trauma conditions and reports issues and problems to more senior staff. 6. Uses simple health promotion strategies to promote musculo-skeletal health within the immediate community.
A. COMFORT ENHANCER 2. EXPERIENCED/PROFICIENT NURSE 1. Skilfully uses alternative strategies to provide hygiene and comfort interventions. 2. Plans, assesses and delivers care to patients with complex pain management needs. 3. Makes referrals to experts such as the local pain team if available according to client need.
B. CO-ORDINATOR 2. EXPERIENCED/PROFICIENT NURSE 1. Co-ordinates the care of groups of patients. 2. Undertakes full and complex pre-assessments of patients awaiting surgery. 3. Effectively plans complex discharges/transfers of patients.
C. PARTNER/GUIDE 2. EXPERIENCED/PROFICIENT NURSE 1. Uses an in-depth knowledge of relevant anatomy & physiology, conditions, surgery and injuries to give detailed information and education to patients and their carers, according to their specific needs. 2. Gives complex pre-operative, post-operative and pre discharge advice to patients and carers. 3. Educates less experienced staff in anatomy & physiology, orthopaedic and trauma conditions, surgery and injuries. 4. In partnership with therapists, selects and supports the use of aids to mobility appropriate to individual needs. 5. Develops and executes, within the interdisciplinary team, remobilisation and rehabilitation plans according to patient needs. 6. Assesses the psychological impact of orthopaedic and trauma conditions on individuals and provides appropriate psychological support. 7. Uses complex health promotion strategies to promote musculo-skeletal health within the wider community.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Audits practice in relation to hygiene and comfort needs of patients. 2. Prescribes analgesia under agreed protocols/patient group directives. 3. Actively seeks to improve practice in the assessment and management of pain. 4. Develops guidance and protocol for the use of alternative and complementary therapies. 5. Provides expert advice to less experienced staff providing care to patients with pain of an unresolved or complex nature.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Develops and improves practice in relation to admission and discharge. 2. Advises other staff on the discharge of patients with complex discharge needs. 3. Audits and monitors discharges. 4. Creates a culture of quality care by leading on specific improvements that ensure the complex needs of orthopaedic and trauma patients are met.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Actively develops education and practice in the area of orthopaedic and trauma care. 2. Writes and updates patient and carer written information. 3. Actively develops and supports the practice of others in patient education and support. 4. Updates other staff in contemporary practices, evidence and issues in orthopaedic and trauma nursing practice. 5. Provides expert psychological support to orthopaedic and trauma patients and refers to other appropriate professionals where the patient’s psychological needs indicate. 6. Develops and leads strategic plans to promote the musculo-skeletal health of the wider community.
Figure 2 Competency statements NOTE 1: this competency framework was validated by the Royal College of Nursing in November 2004 and will be published on their website at a later date.
A competency framework for orthopaedic and trauma nursing
1. COMPETENT NURSE 1. Recognises the signs and symptoms of the following complications and refers on to other appropriate staff: a. Venous Thrombo-embolism b. Compartment Syndrome c. Fat Embolus d. Chest Infection e. Urinary Tract Infection f. Pressure sores g. Wound infection h. Osteomyelitis i. Neurovascular compromise j. Cast/splint sores/complications 2. Uses common active measures to prevent the above complications. 3. Delivers appropriate prescribed care in the presence of any of the above complications. 4. Actively adheres to the local policy for manual handling in order to prevent injury to self, patients and others.
1. COMPETENT NURSE
D. RISK MANAGER 2. EXPERIENCED/PROFICIENT NURSE 1. Knowledgably and safely prescribes care to patients at risk of: a. Venous Thrombo-embolism b. Compartment Syndrome c. Fat Embolus d. Chest Infection e. Urinary Tract Infection f. Pressure sores g. Wound infection h. Osteomyelitis i. Neurovascular compromise j. Cast/splint sores/complications
85
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Uses knowledge and experience to educate staff and ensure their understanding of the complications of orthopaedic and trauma surgery and conditions. 2. Develops guidance and protocols regarding the prevention and management of orthopaedic and trauma complications. 3. Monitors, evaluates and audits care given to patients at risk of or suffering from orthopaedic and/or trauma complications.
2. Uses complex, evidence-based measures to prevent the above complications. 3. Prescribes care to patients recognised as suffering from any of the above complications and refers to other appropriate staff where necessary.
E. TECHNICIAN 2. EXPERIENCED/PROFICIENT NURSE
3. SENIOR PRACTITIONER/EXPERT NURSE
CASTS, APPLIANCES AND/OR BRACES 1. Advises patients and carers regarding the recognition and prevention of cast complications. 2. Recognises the signs and symptoms of cast complications and refers to others for advice. 3. Removes, splits and bivalves casts safely. 4. Safely applies a small selection of simple casts, braces and appliances. 5. Assesses plans, delivers and evaluates care of patients in casts, appliances and/or braces.
1. Safely applies a wide selection of more complex casts, braces and appliances. 2. Actively decides on and executes a course of action when cast complications are identified.
1. Applies major and complex casts, appliances and/or braces. 2. Plans and delivers education and training in cast, appliance and brace application and care to others. 3. Audits cast, appliance and brace application. 4. Develops policy and guidance for cast, appliance and brace application and care.
3. Skilfully applies and prescribes care to patients requiring less common forms of traction.
5. Prescribes traction according to the specific management and treatment needs of patients. 6. Educates others to ensure traction application and care skills are maintained and improved. 7. Develops local guidance and protocols for traction application and patient care.
TRACTION 6. Applies a basic understanding of the principles of traction to safe assessment, planning, delivery and evaluation of care to clients in traction apparatus common to that unit. 7. Applies simple forms of traction common to the unit in which they practice.
EXTERNAL FIXATORS/SKELETAL PIN SITES 8. Delivers and evaluates care to clients with external fixation devices. 9. Delivers care of skeletal pin sites based on local and national guidance. 10. Recognises the signs and symptoms of pin site infection and refers to appropriate staff.
8. Prescribes care to patients with external fixators skeletal pin sites. 9. Teaches patients and carers pin site care.
8. Develops local guidance on the care of external fixators and skeletal pin sites based on available evidence and national/international guidance.
Figure 2 (continued)
statements (Fig. 2) have also been checked for alignment to the RCN UK wide competency framework draft version 6 (RCN, 2004) which reflects version 7 of the NHS Knowledge and Skills Framework (KSF) (DoH, 2004). This will facilitate implementation of the competencies in practice. Following final consultation with practitioners the SOTN sought approval to publish the competency statements through the RCN as a guidance document for practitioners and mangers working in all settings where orthopaedic and trauma patients are receiving care and treatment. RCN accreditation was also granted in November 2004. These competencies are developed with regard for the developing core competencies for nursing drafted from the Royal College of Nursing
and, therefore, represent the specialty of orthopaedic and trauma nursing only and not generic nursing activities.
Nature, core values, beliefs and scope Orthopaedic and trauma nurses share the core beliefs, values and philosophies of nursing generally but have specific ones of their own that relate to this highly specialised area of nursing practice. Orthopaedic and trauma nurses believe their aim is to apply a knowledge and understanding of the musculo-skeletal system, orthopaedic and
86 trauma conditions and injury to the holistic care of patients who suffer from musculo-skeletal disease, injury or disorder, be they of acute or long term nature. This encompasses a wide range of patients across the age spectrum from birth until the end of life and in a variety of settings including the primary, acute and community care sectors and in both public and government funded facilities. The spectrum of orthopaedic and trauma nursing includes nurses who work in the community, outpatients, acute in-patients (elective and trauma), rheumatology, spinal injuries and spinal surgery, peri-operative, and childrenÕs orthopaedic settings as well as nurse specialists who work with patients with specific conditions and problems such as osteoporosis, back pain and falls. Orthopaedic and trauma nurses believe that their primary function and goal is to assist the orthopaedic and trauma patient, in partnership with the patient and family, to gain a level of mobility and activity that meets their potential. Orthopaedic and trauma nursing also enables patients and their carers to cope with and accept any residual disability. Orthopaedic and trauma nurses believe that they owe it to their patients to be educated to the highest possible standard in all relevant aspects of nursing as well as in the specialist aspects of orthopaedic and trauma nursing. These specialised aspects of orthopaedic and trauma nursing care are included in the competency framework. Practice is underpinned by an indepth knowledge of the musculo-skeletal system as well as applied sciences such as physiology, psychology and sociology.
J. Santy et al.
Personal attributes Orthopaedic and trauma nurses believe that their specialty is both mentally and physically demanding, but that it is endlessly rewarding when watching previously immobile or disabled patients regain their lives. Orthopaedic and trauma nurses must be highly motivated individuals who are committed to the care and rehabilitation of their patients. A positive outlook and a sense of humour are essential in helping patients to cope with the challenges that they face.
References Barbour, R., Kitzinger, J., 1999. Developing Focus Group Research. Politics, Theory and Practice. Sage, London. Davis, P., 1999. Using models and theories in orthopaedic nursing. Journal of orthopaedic nursing (Suppl 1), 3–8. DoH, 2004. The NHS Knowledge and Skills Framework (KSF) and the development review process: final draft. Department of Health, London. Kneale, J., Knight, C., 1997. Do orthopaedic nurses have an effect of the quality of patient care?. Journal of Orthopaedic Nursing 1 (3), 115–117. Kvale, S., 1996. Interviews. An Introduction to Qualitative Research Interviewing. Sage, Thousand Oaks. Love, C., 1995. Orthopaedic Nursing: study of its specialty status. Nursing Standard 9 (44), 36–40. Lucas, B., 2002. Orthopaedic patient journeys: a UK perspective. Journal of orthopaedic nursing 6 (2), 86–89. Royal College of Nursing, 2004. RCN UK-Wide competency Framework (2004 Draft version 6). RCN, London, unpublished. Santy, J., 2001. An investigation of the reality of nursing work with orthopaedic patients. Journal of Orthopaedic Nursing 5 (1), 22–29. Santy, J., 2000. Orthopaedic and trauma nursing. WhatÕs in a name? Journal of Orthopaedic Nursing 4 (3), 127–129
Journal of Orthopaedic Nursing
www.elsevierhealth.com/journals/joon
A competency framework for orthopaedic and trauma nursing Julie Santy RGN, BSc(Hons), MSc, ENB 219, Lecturer a,*, Jean Rogers RGN, BSc(Hons), CertEd, Practice Educator b, Peter Davis MBE, MA, BEd(Hons), CertEd, RN, DN, ONC, Senior Health Lecturer c, Rebecca Jester PhD, BSc(Hons), RGN, ONC, DN, RNT, Associate Dean d, Julia Kneale BSc(Hons), RGN, RNT, Senior Lecturer e, Chris Knight MSc, Cert Health Ed, DN, RGN, ONC, RNT, Health Lecturer f, Brain Lucas RGN, ENB219, BA(Hons), PGdip, MSc, Orthopaedic Advanced Practitioner g, Jenny Temple MA, SMS, RN, ONC, Adult Pathway Lead h a
University of Hull, Faculty of Health and Social Care, Cottingham Road, Hull HU3 2JZ, UK Stockport NHS Foundations Trust, UK c University of Nottingham, UK d University of Wolverhampton, UK e University of Central Lancashire, UK f University of Nottingham, UK g Whipps Cross University Hospital, UK h University of Plymouth, UK b
KEYWORDS
Summary Competency frameworks are an increasingly common method of driving forward practice quality and meeting the demand for job evaluation and professional development. This paper describes a project supported by the United Kingdom (UK) Royal College of Nursing Society of Orthopaedic and Trauma Nursing to develop a competency framework for orthopaedic and trauma nursing. It describes the process employed in the development of the framework, the results of consultation with UK orthopaedic and trauma nurses and the final competency statements. The framework
Competency; Career development; Knowledge and skills
* Corresponding author. Tel./fax: +44 1482 464 692. E-mail address: [email protected] (J. Santy).
1361-3111/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2005.02.003
82
J. Santy et al. is of relevance to all orthopaedic and trauma nurses who need to work with their employers to identify how the statements can be translated into practice outcomes. There are implications for orthopaedic and trauma nursing education. c 2005 Elsevier Ltd. All rights reserved.
EditorÕs comment Orthopaedic nursing worldwide continues to emphasise and develop its specialty status. The literature contains much debate and comment on this topic. However, most commentators rarely add to the body of knowledge. This ground breaking article, produced from current research, provides a wealth of data and new knowledge for orthopaedic nurses to use and carry forward into the future. PD
Introduction In early 2001 the UK Royal College of Nursing Society of Orthopaedic and Trauma Nursing (RCN SOTN) set up a project group to develop a competency framework for orthopaedic and trauma nursing. Orthopaedic and Trauma nurses had agreed for some time that a competency framework was necessary to help drive forward practice improvement, job and role evaluation and development (DoH, 2004), curriculum development and research as well as articulating the value of specialist orthopaedic and trauma nursing (Kneale and Knight, 1997). The work was undertaken in three phases: Phase 1: Identification of common beliefs about orthopaedic and trauma nursing and the care needs of orthopaedic and trauma patients. Phase 2: Development of a set of core competencies for orthopaedic and trauma nursing. Phase 3: Piloting of the core competencies in practice. The aim of a phased approach was to ensure that orthopaedic and trauma nurses were involved in the process of the competency framework development at all stages. Central to this was the identification of explicit beliefs and values about orthopaedic and trauma nursing. As trauma nursing was incorporated into the RCN Society of Orthopaedic NursingÕs name and philosophy in 2000 (Santy, 2000), these competencies are designed to represent the nursing of those who have sustained musculoskeletal trauma and are being managed by orthopaedic trauma and rehabilitation teams within the acute and primary care setting. With respect to trauma they are not meant to represent the care of patients in Accident and Emergency or Intensive Care settings. These areas would be covered by different competencies devel-
oped by other forums and practitioners in collaboration with the RCN SOTN. Consultant Nurse level has not been included in this the first competency framework. Consultant nurses in orthopaedic and trauma nursing remain rare. Although the role of the consultant nurse in orthopaedics and trauma was discussed at the workshops no consensus was reached about how this role could be developed within the specialty. This is a specific piece of work that could be undertaken in the near future and added to subsequent versions of the competency framework when it is reviewed. It is of note that some elements of the senior practitioner/expert nurse role within this framework may overlap with future development of the consultant nurse role in orthopaedic and trauma nursing. Who or which organisation should undertake this work requires urgent discussion. Similarly, there is a need for exploration of the Health Care Assistant level and Assistant Practitioner within orthopaedic and trauma settings. A number of other bodies such as the Association of Orthopaedic Technicians and groups representing other plaster room and outpatients staff need to be considered as well as operating department practitioners. These issues are too complex to be considered within this work as they encompass disciplines other than nursing. This report was compiled at the end of phase 2 after final consultation with the practitioners involved in the development of the competencies at earlier stages. The competencies have also been distributed for consultation by senior staff within the RCN involved in developing nursing competencies. This feedback has been incorporated. The RCN SOTN funded this project and in addition some catering. Most venues for the workshops were provided by local health care providers, universities and SOTN local groups. The working group wishes to thank these groups for their support and participation.
A competency framework for orthopaedic and trauma nursing
83
Phase 1
Fig. 1 represents these concepts and their relationship.
Phase 2 During 2003 and early 2004, a series of workshops were held at 10 RCN, hospital and university sites around the United Kingdom: Nottingham, Dudley, Stockport, Glasgow, Belfast, North Wales, Exeter, Middlesborough, Hull and London.
Co-ordinator Comfort Enhancer Partner/Guide Risk Manager Technician
The continuum of care
Orthopaedic and trauma patients are those whose musculo-skeletal conditions originate or are caused by environmental factors, genetic factors, infection/immunity, degenerative processes, and trauma. These conditions are commonly managed through surgery and/or casts/orthotics/app-liances. Mobility, disability and independence are central concepts to the orthopaedic patientÕs needs. Orthopaedic and trauma nursing care is provided from birth to death across all age ranges. The continuum of care in orthopaedic nursing crosses all boundaries and takes place in all settings from pre-hospital care, through acute and primary settings to the patientÕs place of residence (Lucas, 2002). Specialist and generic knowledge, education and research underpin orthopaedic nursing practice.
Mobility/disability/ independence
At the SOTN annual conference in Belfast in September 2001, the working group ran a series of focus groups (Barbour and Kitzinger, 1999) to develop an interpretation of the nature of orthopaedic and trauma nursing. The focus groups were audio taperecorded and their transcripts processed through thematic analysis. The process of analysis involved experienced orthopaedic nursing academics listening to the tapes as a group, identifying major concepts and then negotiating a common interpretation of the content (Kvale, 1996). At this stage, existing literature was incorporated into the interpretation (Davis, 1999; Love, 1995; Santy, 2001). Five core activities of orthopaedic nursing were identified. These were comfort enhancer, coordinator, partner/guide, risk manager, and technician and reflect previous research by Santy (2001). These core activities were felt to inclusively represent orthopaedic and trauma nursing practice. The context of these five core activities was placed within a framework that included the notions that:
Musculo-skeletal conditions, surgery and injury
From Birth to death A Foundation of specialist and generic knowledge, research and education Figure 1 Nature of orthopaedic and trauma nursing (after Santy, 2001).
These locations were chosen to allow as many areas of the UK to be represented as possible. The workshops were attended by a self-selected group of orthopaedic and trauma nurses working in a variety of settings within orthopaedic and trauma nursing. They were led by the same facilitator, with assistance from others. Nurses were from elective and trauma units, outpatient departments, plaster rooms and fracture clinics and childrenÕs orthopaedic units. In addition to orthopaedic and trauma nurses working in traditional ward and clinic based roles, practitioners with existing and more recently developed advanced practice and nurse consultancy roles were included along with a number of orthopaedic and trauma unit nurse managers. In total, approximately 140 orthopaedic and trauma practitioners contributed to the workshops. The workshops aimed to identify competencies and levels of practice within each of the five core activities of orthopaedic and trauma nursing and to consult orthopaedic nurses about their development. Participants were asked to evaluate each workshop at the end of the day. The comments were overtly positive. Participants particularly appreciated the opportunity to meet with colleagues to spend time considering the practice of orthopaedic and trauma nursing and to influence its future. Feedback was also used to adapt subsequent workshops to make them more effective. Participants were split into small groups for this work and identified a group member to document and feedback the discussion to the main group.
84
J. Santy et al.
The workshop programme included discussion about the following areas:
What and who is an expert/consultant orthopaedic and trauma nurse?
The underpinning core values, beliefs and philosophy of orthopaedic and trauma nursing. The personal attributes of orthopaedic and trauma nurses. The core activities of orthopaedic and trauma nursing and levels of practice within these.
During 2003 the Royal College of Nursing began to develop a draft framework of core competencies for nursing. The structure of this framework was incorporated into the workshops and has been used to underpin the orthopaedic and trauma nursing competencies. The competency
1. COMPETENT NURSE 1. Provides nursing care to meet the hygiene and comfort needs of patients that takes into account their orthopaedic/trauma condition and is sensitive to their cultural and spiritual needs. 2. Assesses and monitors pain levels of patients with chronic and acute pain showing an understanding of the musculo-skeletal condition. 3. Administers prescribed analgesia according to prescription and prescribed need. 4. Utilises a small selection of alternative/complementary strategies for pain relief.
1. COMPETENT NURSE 1. Accurately assesses patients with a range of conditions and/or injuries and records such assessments. 2. Plans, and evaluates care for a wide range of patients. 3. Undertakes basic pre-assessment of patients awaiting admission for elective orthopaedic surgery. 4. Effectively plans and manages discharge and/or transfer for patients with uncomplicated discharge needs. 5. Arranges appropriate post discharge support of patients with uncomplicated needs. 6. Liaises with other members of the multidisciplinary team regarding uncomplicated discharges.
1. COMPETENT NURSE 1. Uses a knowledge anatomy & physiology, conditions, surgery and injuries to give basic information to patients and carers. 2. Gives basic preoperative, post-operative and pre-discharge advice to patients and carers following orthopaedic surgery, conditions and injury. 3. Actively provides support and education to patients undergoing surgery and/or with injury or other conditions. 4. Supports and encourages patients when mobilising according to their rehabilitation plan and with a focus on maintaining musculoskeletal integrity. 5. Recognises the psychological consequences of orthopaedic and trauma conditions and reports issues and problems to more senior staff. 6. Uses simple health promotion strategies to promote musculo-skeletal health within the immediate community.
A. COMFORT ENHANCER 2. EXPERIENCED/PROFICIENT NURSE 1. Skilfully uses alternative strategies to provide hygiene and comfort interventions. 2. Plans, assesses and delivers care to patients with complex pain management needs. 3. Makes referrals to experts such as the local pain team if available according to client need.
B. CO-ORDINATOR 2. EXPERIENCED/PROFICIENT NURSE 1. Co-ordinates the care of groups of patients. 2. Undertakes full and complex pre-assessments of patients awaiting surgery. 3. Effectively plans complex discharges/transfers of patients.
C. PARTNER/GUIDE 2. EXPERIENCED/PROFICIENT NURSE 1. Uses an in-depth knowledge of relevant anatomy & physiology, conditions, surgery and injuries to give detailed information and education to patients and their carers, according to their specific needs. 2. Gives complex pre-operative, post-operative and pre discharge advice to patients and carers. 3. Educates less experienced staff in anatomy & physiology, orthopaedic and trauma conditions, surgery and injuries. 4. In partnership with therapists, selects and supports the use of aids to mobility appropriate to individual needs. 5. Develops and executes, within the interdisciplinary team, remobilisation and rehabilitation plans according to patient needs. 6. Assesses the psychological impact of orthopaedic and trauma conditions on individuals and provides appropriate psychological support. 7. Uses complex health promotion strategies to promote musculo-skeletal health within the wider community.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Audits practice in relation to hygiene and comfort needs of patients. 2. Prescribes analgesia under agreed protocols/patient group directives. 3. Actively seeks to improve practice in the assessment and management of pain. 4. Develops guidance and protocol for the use of alternative and complementary therapies. 5. Provides expert advice to less experienced staff providing care to patients with pain of an unresolved or complex nature.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Develops and improves practice in relation to admission and discharge. 2. Advises other staff on the discharge of patients with complex discharge needs. 3. Audits and monitors discharges. 4. Creates a culture of quality care by leading on specific improvements that ensure the complex needs of orthopaedic and trauma patients are met.
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Actively develops education and practice in the area of orthopaedic and trauma care. 2. Writes and updates patient and carer written information. 3. Actively develops and supports the practice of others in patient education and support. 4. Updates other staff in contemporary practices, evidence and issues in orthopaedic and trauma nursing practice. 5. Provides expert psychological support to orthopaedic and trauma patients and refers to other appropriate professionals where the patient’s psychological needs indicate. 6. Develops and leads strategic plans to promote the musculo-skeletal health of the wider community.
Figure 2 Competency statements NOTE 1: this competency framework was validated by the Royal College of Nursing in November 2004 and will be published on their website at a later date.
A competency framework for orthopaedic and trauma nursing
1. COMPETENT NURSE 1. Recognises the signs and symptoms of the following complications and refers on to other appropriate staff: a. Venous Thrombo-embolism b. Compartment Syndrome c. Fat Embolus d. Chest Infection e. Urinary Tract Infection f. Pressure sores g. Wound infection h. Osteomyelitis i. Neurovascular compromise j. Cast/splint sores/complications 2. Uses common active measures to prevent the above complications. 3. Delivers appropriate prescribed care in the presence of any of the above complications. 4. Actively adheres to the local policy for manual handling in order to prevent injury to self, patients and others.
1. COMPETENT NURSE
D. RISK MANAGER 2. EXPERIENCED/PROFICIENT NURSE 1. Knowledgably and safely prescribes care to patients at risk of: a. Venous Thrombo-embolism b. Compartment Syndrome c. Fat Embolus d. Chest Infection e. Urinary Tract Infection f. Pressure sores g. Wound infection h. Osteomyelitis i. Neurovascular compromise j. Cast/splint sores/complications
85
3. SENIOR PRACTITIONER/EXPERT NURSE 1. Uses knowledge and experience to educate staff and ensure their understanding of the complications of orthopaedic and trauma surgery and conditions. 2. Develops guidance and protocols regarding the prevention and management of orthopaedic and trauma complications. 3. Monitors, evaluates and audits care given to patients at risk of or suffering from orthopaedic and/or trauma complications.
2. Uses complex, evidence-based measures to prevent the above complications. 3. Prescribes care to patients recognised as suffering from any of the above complications and refers to other appropriate staff where necessary.
E. TECHNICIAN 2. EXPERIENCED/PROFICIENT NURSE
3. SENIOR PRACTITIONER/EXPERT NURSE
CASTS, APPLIANCES AND/OR BRACES 1. Advises patients and carers regarding the recognition and prevention of cast complications. 2. Recognises the signs and symptoms of cast complications and refers to others for advice. 3. Removes, splits and bivalves casts safely. 4. Safely applies a small selection of simple casts, braces and appliances. 5. Assesses plans, delivers and evaluates care of patients in casts, appliances and/or braces.
1. Safely applies a wide selection of more complex casts, braces and appliances. 2. Actively decides on and executes a course of action when cast complications are identified.
1. Applies major and complex casts, appliances and/or braces. 2. Plans and delivers education and training in cast, appliance and brace application and care to others. 3. Audits cast, appliance and brace application. 4. Develops policy and guidance for cast, appliance and brace application and care.
3. Skilfully applies and prescribes care to patients requiring less common forms of traction.
5. Prescribes traction according to the specific management and treatment needs of patients. 6. Educates others to ensure traction application and care skills are maintained and improved. 7. Develops local guidance and protocols for traction application and patient care.
TRACTION 6. Applies a basic understanding of the principles of traction to safe assessment, planning, delivery and evaluation of care to clients in traction apparatus common to that unit. 7. Applies simple forms of traction common to the unit in which they practice.
EXTERNAL FIXATORS/SKELETAL PIN SITES 8. Delivers and evaluates care to clients with external fixation devices. 9. Delivers care of skeletal pin sites based on local and national guidance. 10. Recognises the signs and symptoms of pin site infection and refers to appropriate staff.
8. Prescribes care to patients with external fixators skeletal pin sites. 9. Teaches patients and carers pin site care.
8. Develops local guidance on the care of external fixators and skeletal pin sites based on available evidence and national/international guidance.
Figure 2 (continued)
statements (Fig. 2) have also been checked for alignment to the RCN UK wide competency framework draft version 6 (RCN, 2004) which reflects version 7 of the NHS Knowledge and Skills Framework (KSF) (DoH, 2004). This will facilitate implementation of the competencies in practice. Following final consultation with practitioners the SOTN sought approval to publish the competency statements through the RCN as a guidance document for practitioners and mangers working in all settings where orthopaedic and trauma patients are receiving care and treatment. RCN accreditation was also granted in November 2004. These competencies are developed with regard for the developing core competencies for nursing drafted from the Royal College of Nursing
and, therefore, represent the specialty of orthopaedic and trauma nursing only and not generic nursing activities.
Nature, core values, beliefs and scope Orthopaedic and trauma nurses share the core beliefs, values and philosophies of nursing generally but have specific ones of their own that relate to this highly specialised area of nursing practice. Orthopaedic and trauma nurses believe their aim is to apply a knowledge and understanding of the musculo-skeletal system, orthopaedic and
86 trauma conditions and injury to the holistic care of patients who suffer from musculo-skeletal disease, injury or disorder, be they of acute or long term nature. This encompasses a wide range of patients across the age spectrum from birth until the end of life and in a variety of settings including the primary, acute and community care sectors and in both public and government funded facilities. The spectrum of orthopaedic and trauma nursing includes nurses who work in the community, outpatients, acute in-patients (elective and trauma), rheumatology, spinal injuries and spinal surgery, peri-operative, and childrenÕs orthopaedic settings as well as nurse specialists who work with patients with specific conditions and problems such as osteoporosis, back pain and falls. Orthopaedic and trauma nurses believe that their primary function and goal is to assist the orthopaedic and trauma patient, in partnership with the patient and family, to gain a level of mobility and activity that meets their potential. Orthopaedic and trauma nursing also enables patients and their carers to cope with and accept any residual disability. Orthopaedic and trauma nurses believe that they owe it to their patients to be educated to the highest possible standard in all relevant aspects of nursing as well as in the specialist aspects of orthopaedic and trauma nursing. These specialised aspects of orthopaedic and trauma nursing care are included in the competency framework. Practice is underpinned by an indepth knowledge of the musculo-skeletal system as well as applied sciences such as physiology, psychology and sociology.
J. Santy et al.
Personal attributes Orthopaedic and trauma nurses believe that their specialty is both mentally and physically demanding, but that it is endlessly rewarding when watching previously immobile or disabled patients regain their lives. Orthopaedic and trauma nurses must be highly motivated individuals who are committed to the care and rehabilitation of their patients. A positive outlook and a sense of humour are essential in helping patients to cope with the challenges that they face.
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