Sandra Flynn1 and Brian Lucas2
1 Countess of Chester Hospital, Chester, UK
2 Queen Elizabeth Hospital, Kings Lynn, UK
The aim of this chapter is to introduce the notion of multi-disciplinary team working and the disciplines that make up the team within orthopaedic and trauma care. The term ‘multi-disciplinary’ is used to describe the collaborative work of the various health professional groups (Finn et al., 2010) who are drawn together to use their knowledge and skills towards a common patient goal (Solheim et al., 2007). The multi-disciplinary approach can facilitate positive outcomes, helping to ensure that the needs of the patient, family or carer are fully met. Healthcare professionals assume responsibility for promoting and restoring health, preventing illness and relieving suffering. Clinical expertise that is based on sound clinical knowledge, employing discretionary judgement, understanding illness and its trajectory and appreciating the varied human response to illness is central to professional healthcare practice. The ability to take care of patients well requires healthcare professionals who can project an open and warm presence that allows them to connect with each patient in a personalised way (Paulson 2004).
The team and importance of a multidisciplinary approach
The complexity of chronic conditions and the expanding development in medical care and treatment options available has led to the need for effective and efficient health care teams (Wiecha and Pollard 2004) and a multi-disciplinary approach to the provision of care and rehabilitation. The orthopaedic multi-disciplinary team comprises a group of individuals who are committed to a shared purpose in the best care of the patient with musculoskeletal conditions or injuries, shared performance goals, skills which overlap and complementary expertise. A common approach and focus on teamwork consists of several key dimensions relating to team coordination including effective communication, shared knowledge, problem solving and mutual respect (Gittell et al., 2000). It is important for orthopaedic and trauma practitioners to understand and engage the varied roles of the multi-disciplinary team so that they complement each other and work together to deliver a high quality service and provision of care for a diverse patient population. In addition to promoting better outcomes for patients, research has demonstrated that multi-disciplinary collaborative working affords opportunties to enhance skills and knowledge, provide informal education and promote a culture of respect and understanding amongst healthcare professionals (Tzenalis and Sotiriadou 2010).
The role of the multi-disciplinary team includes:
- treatment/management of conditions
- research and clinical audit.
Musculoskeletal pathways of care differ from patient to patient and the number of healthcare professionals involved in an individual pathway of care will vary according to the complexity of their needs (Jester et al., 2011). Care needs to be client-centred and a team approach helps to ensure services are delivered in partnership with the patient and their family/carer.
Optimal management and care of patients with musculoskeletal conditions requires the expertise of specialists from different disciplines. Collectively the multi-disciplinary team provides a holistic, seamless service over the full continuum of care. The individual practitioners who have roles within the musculoskeletal multi-disciplinary team are discussed in the following section, but it is acknowledged that teams may vary according to sub-specialty and locality and that not all roles may be represented.
The nursing role in orthopaedic and trauma care
Nursing roles within the specialty of trauma and orthopaedics are diverse and found in a variety of settings within secondary care. Nursing areas of practice include, but are not limited to, adult and paediatric orthopaedic units, trauma units, outpatient departments, day surgery centres, operating theatres, accident and emergency departments and rehabilitation units. Nursing staff provide an important link within the team, working with the patient and other health care professionals to develop, plan, implement, coordinate and evaluate plans of care. Nursing roles include:
- Health Care Assistant/Assistant Practitioner
- Registered Nurse
- Ward/Unit/Department Manager
- Pre-assessment Nurse
- Clinical Nurse Specialist
- Nurse Practitioner
- Trauma Co-ordinator
- Surgical Care Practitioner
- Consultant Nurse.
The notions of ‘advanced’ and ‘specialist’ practice/practitioner encompass a number of job tiles and roles within the specialty of trauma and orthopaedic nursing. Each role is multifaceted and exhibits contrasting quantities of clinical activity, education, management, leadership, collaboration and research, depending upon the individual job profile and client/service requirements. Advanced level nursing is concerned with a higher level of clinical practice, regardless of specialist area or role, which is beyond that of first level registration (DoH 2010) and is continually evolving while remaining firmly rooted in the provision of direct care or clinical work with patients, families and populations. The main activities of advanced roles lie within four domains:
- leadership and collaborative practice
- practice development and quality improvement
- continuing professional development, education and training.
In 2000 the role of Nurse Consultant was established in the UK with the following aim (DoH 1999):
(…help to provide better outcomes for patients by improving services and quality, to strengthen leadership and to provide a new career opportunity to help retain expert nurses…)
The nurse consultant provides highly specialised professional advice, consultancy, clinical expertise and leadership to patients, carers and colleagues in collaboration with medical, nursing and allied health professional colleagues. The nurse consultant develops and delivers highly specialised care using advanced skills and competencies. An essential component of the role in musculoskeletal care is to initiate research in the field of orthopaedic and trauma nursing to ensure evidence-based practice is embedded in all aspects of care and treatment. The role is structured around four core functions:
- expert clinical practice
- education, training and development
- professional leadership and consultancy
- practice and service development, research and evaluation.
In the National Curriculum Framework for Surgical Care Practitioners (DoH 2006) a surgical care practitioner is defined as:
(A non-medical practitioner, working in clinical practice as a member of the extended surgical team, who performs surgical intervention, pre-operative and post-operative care under the direction and supervision of a consultant surgeon.)
The role of the Surgical Care Practitioner (SCP) is varied and the practitioner works under the supervision of a consultant surgeon or senior member of the surgical team. Responsibilities include:
- pre-operative assessment and physical examination
- assisting with preparation of patients for surgery
- assisting with surgical procedures in the operating theatre under the supervision and direction of the operating surgeon
- being first or second assistant at operations
- ordering of pre and post-operative investigations as part of the multi-professional team
- post-operative care e.g. wound assessment.
Patients requiring orthopaedic or trauma care need skilled nursing intervention throughout their pathway of care from initial diagnosis through to long-term follow-up. This may be provided by one practitioner across the entire pathway or through different nurses working in specific roles, such as in pre-operative assessment, ward care or post-operative and post-discharge review. Each has its own merits and drawbacks (Lucas 2002a). For clarity the pathway elements and the potential nursing roles within them will be described separately.
Some orthopaedic nurse practitioners are involved in the initial diagnosis of an orthopaedic condition in primary or secondary care and in developing, with the patient, a treatment plan. This can include adding the patient’s name to the waiting list for surgery if appropriate (Lucas 2006). To do this they require advanced assessment and decision making skills and a good working relationship with orthopaedic surgeons (Judd 2005, Lucas 2006).
Preparation of patients for surgery
Patients waiting for surgery have complex needs and a multifactorial assessment/education, taking into account physical and psychosocial needs, should be undertaken (Lucas et al., 2013). With shorter waiting times for surgery, due to initiatives that reduce the pathway from initial consultation to definitive treatment, it is important that patients are well prepared for surgery. Within joint replacement/arthroplasty services there has been the development of information classes which support this education. The nursing role within this may include education about the procedure, hospital stay and post-operative recovery, as well as the collecting of patient assessment data such as Patient Reported Outcome Measures (PROMs). In order to maximize the learning experience for patients, nurses who lead such classes need knowledge of educational principles (Hartley et al., 2012). Orthopaedic nurses may also carry out the pre-operative assessment of patients to ensure they are fit for anaesthesia and surgery, although this may also be seen as the role of an anaesthetic nurse practitioner. Box 5.1 examines the evidence base for nurse-led preoperative assessment. For some day case surgery the nurse practitioner may carry out a procedure such as carpal tunnel release following appropriate education and training (Newey et al., 2006).
The nursing role within the inpatient stay spans from the fundamental care from a nurse on an orthopaedic ward, to the nurse practitioner whose role encompasses many aspects of traditional junior doctor roles such as prescribing and discharging patients. All of these require suitable skills and competencies (see Chapter 3). Nurses are also central to the implementation of enhanced recovery programmes, with criteria-based discharge by nurses and an emphasis on ‘normality’ with drips/drains removed as soon as possible (Wainwright and Middleton 2010) (see Chapter 14).
After discharge following elective orthopaedic surgery patients may have information needs, and nurses can provide telephone advice (Hodgins et al., 2008). Early supported discharge schemes with nursing involvement have proved to be cost-effective and popular with patients (Hill et al., 2000). A Cochrane Review concluded that there is high patient satisfaction with such schemes although the evidence is inconclusive on cost savings and readmission rates (Shepperd et al., 2009). Nurse practitioners may review patients in the outpatient setting for physical care such as wound dressings/suture removal or to monitor recovery from surgery. Such follow-up may be short-term, with patients being discharged after 4–6 weeks or, in the case of joint replacement, for long periods or, even, life (Flynn 2005).
The orthopaedic and trauma nursing role in trauma care varies depending on the severity of injury and the nature of the treatment required.
Minor orthopaedic trauma not requiring admission
For patients with injuries such as a Colles fracture, care is usually entirely within the outpatient setting. The role of the orthopaedic trauma nurse is multifaceted. In some clinics nurse practitioners are involved in diagnosing the injury, requesting and interpreting X-rays and undertaking the appropriate treatment such as cast application (Wardman 2002). They may also review patients after initial treatment and discharge them to primary care. Fragility Fracture Nurses may ensure that those with fragility fractures are referred to osteoporosis screening services if appropriate or run a fragility fracture service (Clunie and Stephenson 2008) (see Chapter 18).
Major orthopaedic trauma requiring inpatient admission
Nurse practitioners within trauma services fast-track patients from the emergency department (ED) to an inpatient trauma unit, particularly patients such as those with a hip fracture. Such practitioners can often prescribe intravenous fluids and order and interpret X-rays. Trauma Coordinator roles have also developed in many units and involve ensuring the patient undergoes appropriate timely admission procedures, is prepared for surgery and that patient transfer to and from surgery is well coordinated. Some also assist during surgery or help in pain control through such initiatives as femoral nerve block (Randall et al., 2008). Post-operatively the nursing role encompasses the acute recovery of patients and may also include nurse practitioner roles such as nurse initiated discharge (Webster et al., 2011). After discharge the nurse in the trauma pathway may have a similar role to that described in the elective pathway; a point of contact/advice for patients and involvement in the post-operative follow-up of patients. This may include specialist roles with specific groups of patients requiring long-term follow-up such as those with external fixators which includes care of the device as well as psychological care of the patients through self-management and nurse-led support groups (Dheensa and Thomas 2012). Box 5.2 examines the value of multidisciplinary rehabilitation programmes.
Box 5.2 Evidence Digest Cochrane Review: Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy (Khan et al., 2009). Reproduced with permission from The Cochrane Collaboration