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).

Box 5.1  Evidence Digest: Nurse-led preoperative assessment (Craig 2005)

Inpatient stay

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).

Post-hospital care

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).

Trauma care

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

Medical roles in orthopaedic and trauma care

Orthopaedic Surgeons and supporting medical staff are concerned with all aspects of heath care relating to the patient requiring elective orthopaedic and orthopaedic trauma care be it conservative or surgical. Medical, physical and rehabilitative methods as well as surgery are employed in order to provide the most appropriate treatment. Surgery may be indicated when it is the best option for restoring function following injury or disease of bones, joint and related soft tissues. Medical staff work closely with the multi-disciplinary team, playing an important role in diagnosis and decision making and in prescribing and delivering musculoskeletal treatment and care.

Allied Health Professional roles

Allied Health Professionals are other clinical staff uniquely placed to provide a wide range of specific services that include diagnostic, therapeutic and direct patient care. They work closely with other health care professionals to ensure an integrated and coordinated service to patients and service users (DoH 2010). Within the specialty of orthopaedics and musculoskeletal trauma in many countries, allied healthcare professionals include:

• Physiotherapists
• Occupational Therapists
• Diagnostic Radiologists
• Orthotists
• Prosthetists
• Dieticians.

Physiotherapists in musculoskeletal care are concerned with identifying, maximising and maintaining movement and the functional ability and potential of the patient by focusing on health promotion, disease or injury prevention as well as treatment and rehabilitation (Atkinson et al., 2005). The role of the physiotherapist has evolved considerably in recent years along with a range of skills in assessment, diagnosis and management. The emergence of the role of the extended scope physiotherapist (ESP) has enabled the treatment of patients where appropriate with many ESPs qualified to request radiological and pathological investigations, interpret results, prescribe medications and refer to other services (Lowe and Prior 2008).

Occupational therapy plays a fundamental role in recovery and rehabilitation, working with the orthopaedic multi-disciplinary team to meet treatment goals. The role of the occupational therapist (OT) in musculoskeletal care is to perform a thorough assessment that facilitates an individual’s discharge aiming to assist the patient to live and work as independently as possible (Mooney and Ireson 2009). Physical strength and stamina, proper movement and ability can be affected following musculoskeletal disease or injury and subsequent treatment and OTs work with individuals to promote maximum functional ability so that activities of daily living can be maintained. The occupational therapist will obtain information about the patient’s lifestyle abilities prior to injury, illness or surgery to develop a plan of care which will assist the patient in adjusting to their current physical condition. There may be a need for the individual to learn new skills or adapt the way in which they live and/or work to address disability such as where joint and limb function has been impaired. This is achieved by assisting patients to overcome and manage limitations resulting from their conditions.

Musculoskeletal radiology is concerned with the diagnostic imaging and diagnosis of the skeleton and associated soft tissue. Imaging includes X-rays, computed tomography (CT), ultrasound and MRI. Radiologists are health care professionals who are experts in obtaining and interpreting medical images. They work with other clinicians by reporting findings of examinations and tests and confer with referring medical staff to recommend further examinations or treatments.

Orthotics and prosthetics are applied physical disciplines that use assessment, diagnosis and management of the body as a whole to address neuromuscular and structural skeletal problems by providing orthotic appliances and prostheses including artificial limbs. The orthotist and prosthetist liaise directly with members of the multi-disciplinary orthopaedic team to achieve maximum function, prevent further disability and facilitate improved body image and play an important role in advising on the rehabilitation of patients with physical challenges and disabilities (Lusardi et al., 2012). Orthoses, usually a brace, splint or special footwear, are designed to provide one or more of the following:

• relieve pressure on a diseased joint or stress in a bone weakened by disease or injury
• correct or prevent physical deformity
• stabilise a joint or several joints
• improve mobility
• protect the joint from further injury.

An orthotic prescription is formulated by a member of the multi-disciplinary team and the orthotist will assess the patient’s needs, take measurements, design and then fit and adjust the orthosis. This can be an ongoing process for many patients but more so for children and young people due to their growing and changing immature skeletal frame. An essential part of the role is to educate the individual and/or carer in the fitting and using of the device.

The prosthetist provides artificial replacements for individuals who have lost or were born without all or part of a limb and may face disability. The prosthetist will design and select the most suitable prosthesis from a range of components with the aim of enabling the individual to lead a normal life.

Dietitians are clinicians who apply expert knowledge of nutrition to support individuals in understanding and applying the principles of healthy eating and maximising nutrition throughout their lifespan. They assess patients’ nutritional needs, developing and implementing nutrition programs thus contributing to health promotion and illness prevention strategies (Webster-Gandy et al., 2011).

Additional supporting team members

Additional members of the health care team that are central to patient care include

• Pharmacists – health care professionals who are experts in medicines and how they work and are concerned with the safe and effective use of medication. Their role encompasses an understanding of the biochemical mechanisms of action of drugs, the way medicines are selected and supplied, therapeutic roles, side effects, potential drug interactions and monitoring. Pharmacists are directly involved in patient care and use their expertise to work collaboratively within the team. The overall aim is to ensure patient safety and improve the quality of all medicine related practices (Price 2012).
• Operating Department Practitioners (ODPs) – an integral part of the operating department multi-professional team, helping to ensure effective and safe peri-operative care. This incorporates the anaesthetic, surgical and recovery stages of the patient pathway in orthopaedic and trauma care (see Chapter 14).
• Social worker – collaborates with the multi-disciplinary team on discharge planning to ensure that patients’ needs are met in order that they may be discharged from hospital in a safe and timely fashion. They connect patients and families to appropriate resources and support in the community (Beder 2006).
• Clinical psychologist – assists in the assessment of the mental health needs of the patient. They form part of the healthcare team where patients require assistance through periods of emotional adjustment, information and where there is a need to establish health-inducing behaviour (Beinart et al., 2009).
• Multi-faith workers – the provision of spiritual care is an important consideration and a multi-disciplinary responsibility. Spiritual care encompasses emotional, psychological, social and pastoral support, together with a requirement to meet the religious needs of the patient.

Nurse-led services

The nursing roles described earlier can be part of a traditional consultant-led service or there may be an identified need for a nurse-led service. For example, a nurse-led service for patients requiring joint replacement may have a nurse practitioner assessing referrals from general practitioners, providing pre-operative education, reviewing the patient as an inpatient and providing post-discharge follow-up (Lucas 2002a). Before such services can be established, the case for them has to be made. One method of ensuring that all issues are identified is the ESSENCE model, devised through discussion with extended scope practitioners within the Royal College of Nursing’s Society of Orthopaedic and Trauma Nursing in the UK (see Figure 5.1).

Establish the need/case

A first step is to understand and identify what the drivers for the new service are and what benefits it might bring. These can be local, such as the length of time patients are waiting for a particular service (Judd 2009, Murray 2011) or national initiatives/guidance such as the Best Practice Tariff for hip fractures (see Chapter 18). Those who may benefit are patients (reduced waiting times), commissioners of care (more cost-effective care for larger numbers of patients), nursing itself (the opportunity to develop new skills and knowledge) and the hospital/health care organisation (increased revenue and patient satisfaction). Local champions for change and potential barriers should be considered. This can be through process mapping the current patient journey to identify issues and problems. A written business case can then be devised, which establishes why the nurse-led service is required and what benefits it will bring.

Scoping the service

It should be clear what patient group or groups will be included in the nurse-led service, how they will be referred to the service and how the service links with other existing services. It is advisable to begin with well-defined conditions or patient groups such as simple fractures or post-operative care (Wardman 2002, Judd 2009). Scoping should also include determining whether there is an existing service within your organisation which has similar attributes (nurse-led, protocol driven) and from which learning can take place. External scoping can identify whether a similar service is already functioning elsewhere and this can be found from the literature, conference presentations or professional organisations.

Setting up – the initial steps

Once the case has been accepted for the nurse-led clinic or service, the planning of how it will work in practice can begin in earnest. It will take time to set up well, especially if the development is taking place alongside existing workloads (Lucas 2002b). The service will need to have clear governance arrangements with protocols and procedures setting out the scope of nursing practice (Judd 2009). Issues such as how patients will access the service might be difficult to resolve due to contracting arrangements (Clunie and Stephenson 2008). The nurse should have control over the length of appointments and the numbers booked onto clinics, so that this does not become unmanageable. The education and training required to carry out the roles within the services should also be established and included in the protocols for the clinics or service (Murray 2011). Such training/education may be provided by external providers such as universities or in-house by orthopaedic surgeons (Lucas 2006, Judd 2009). The skills required should be recognised in the job description for the nursing roles within the service.

The establishment of good governance arrangements will also mean that the nurses within the service will be covered by vicarious liability from their employers. There are many practical issues to consider such as facilities (office space, a clinic room, administrative support, clinical support) and these may be difficult to obtain in the beginning until the service has ‘proved itself’ (Judd 2009). The ability to access diagnostic services may be crucial, such as magnetic resonance imaging for patients with back pain (Murray 2011). A risk analysis of the proposed service should be undertaken to identify and answer questions such as what happens during periods of nurse planned or unplanned leave (sickness). Time taken in these initial steps will ensure that the service is more likely to succeed, but some questions cannot be identified and answered until the service actually begins.

Establishing measures/measurements

The rationale for the service outlined in the ‘establish the need/case’ stage indicates what needs to be measured. Considering what data are already being collected that may help establish the value of the new service, such as length of stay or readmission rates, is advisable. Other potential measures could be the safety of the nurse practitioner in carrying out an extended role (Murray 2011), admission avoidance (telephone follow-up), patient outcomes such as pain reduction, number of patients seen, mortality, financial savings and patient satisfaction (Judd 2009, Murray 2011). These measures might be collected over time, as reports on services often have short follow-up only (Flynn and Whitehead 2006) and need to be measures that stakeholders in the service value – for example commissioners may want to see financial savings, such as less GP consultations and less prescribed analgesia (Murray 2011). Once the measures have been identified the use of audit should be considered in the design of measurement tools. If national databases are available for inputting data then it is advisable to use these (Clunie and Stephenson 2008). Good evidence is crucial if the case for continuation or further development of the nurse-led service is to be made.

New service begins

Once the new service or clinic begins it is important to create the opportunity to reflect on how it is working. This may be through discussion with an orthopaedic consultant or through clinical supervision. The nurse needs sufficient support during the early days and ongoing feedback about their own performance and that of the service. It is advisable to start small with a small number of patients until clinical skills develop. Flexibility is also important – even well planned clinics/services may not run exactly as planned (Judd 2009).

Consolidation

Consolidation involves knowing how the service is doing through undertaking the audit already decided upon. It may be useful to repeat the process map of the patient journey to determine whether the implemented service has benefitted the patients. This information should be used to produce a report on the early results which should be presented within the organisation, for example to the Management Board.

Expansion

Expansion encompasses developing nursing knowledge and the service itself. The nurse-led service should be celebrated and publicised within the organisation, externally at conferences and by publication, and visits from others should be encouraged. In these ways the service will become well-known and others can learn from its successes and challenges. Expansion of the service itself may also be considered, this may be expanding the range of patients seen (Wardman 2002) and/or the number of nurses involved in the service (Murray 2011). Such expansion requires returning to the ‘establishing the need’ stage of the ESSENCE model.

Conclusion

There are a variety of multi-faceted roles within orthopaedic and trauma care that complement the role of the nurse in providing effective, coordinated care for the patient. Each practitioner has a set of complementary skills and their roles are equally important but may be required in different parts of the patient journey. The last few decades have seen significant developments in the flexibility and extension of roles which has aimed to more effectively meet patient and service needs. The evidence base for these roles is currently in its infancy.

Recommended further reading

1. Cox, C., Hill, M. and Lack, V. (eds) (2011) Advanced Practice in Healthcare: Skills for Nurses and Allied Health Professionals. Routledge, London.
2. McGee, P. (Ed.) (2009) Advanced Practice in Nursing and the Allied Health Professions, 3rd edn. Wiley Blackwell, Oxford.
3. Wainwright, T. and Middleton, R. (2010) An orthopaedic enhanced recovery pathway. Current Anaesthesia and Critical Care, 21(3), 114–120.

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