Clinical corner
Published: 28 July 2010
Work in an acute trust?
VTE mortality rates too high... let’s take action
A new role agreed for musculoskeletal hip and knee practitioners
Hats off to Brian!
2010 Hip Fracture Database report nears completion
Work in an acute trust?
NICE is setting up a programme to support nurses in acute trusts with the implementation of NICE guidance. Click here to see what’s on offer and how trusts can access support from the NICE team.
VTE mortality rates too high... let’s take action
SOTN committee member Mary Drozd offers tips on preventing venous thromboembolism.
There is a small group of nurses from different specialties within the RCN working together to influence nursing practice in relation to venous thromboembolism (VTE) prevention. On behalf of SOTN, I have volunteered to be a part of this group because it is an aspect of nursing care that I am particularly interested in and I firmly believe we can all make a positive impact and reduce these risks for our patients.
Assess then prevent
The mortality rate as a result of a VTE remains unacceptably high and our orthopaedic and trauma patients are at very high risk. There are various preventative measures available to minimise this risk if we only consider how patients are assessed for VTE risk and the preventative measures available. Please visit the NICE website for the latest evidence related to VTE prevention and management.
Apart from the pharmacological prophylaxis and the appropriate thromboembolitic deterrent (TED) stockings, as nurses we can teach and encourage our patients to do deep breathing, foot and ankle exercises, mobilise as soon as possible and, equally as important, we must ensure that the patients in our care are adequately hydrated. These simple yet essential measures are vital. Let’s make a difference and reduce the risk of VTE for trauma and orthopaedic patients.
A new role agreed for musculoskeletal hip and knee practitioners
The Department of Health (DH) – in conjunction with representatives from the RCN, the British Orthopaedic Association, the Arthroplasty Care Practitioners Association (ACPA), Skills for Health and Edge Hill University – has developed and now agreed on a competency framework for a role involving the care of patients before and after total hip replacement (THR) and total knee replacement (TKR). SOTN committee member Brian Lucas, RCN representative for this competency framework, reports on its progress.
Four stages
The ‘Nationally transferable role (NTR) of musculoskeletal practitioner, hip and knee’ identifies four separate stages of the patient pathway: pre-operative, intra-operative, acute post-operative (up to six weeks), and follow-up six weeks post surgery. An agreed set of competencies has been developed for each of these stages.
The assessment documentation is based on the assessment process used for orthopaedic registrar trainees. There are five separate assessment forms, rather than four, to match the stages of the patient pathway, as it was recognised that the pre-operative stage can require two separate skill sets; one of assessing if a patient requires surgery and one of assessing the patient’s fitness for surgery. Local competencies may be added, but core competencies cannot be removed, as the role is designed to be nationally transferable.
Assessment groupings
As an example, the competencies for a practitioner assessing a new referral are grouped under the sections of ‘clinic administration’, ‘history taking’, ‘examination’, ‘interpretation/relevance of investigations’, ‘formulation of differential diagnosis’, treatment options’, ‘if hip/knee surgery is indicated’ (explanation of risks/benefits etc) and ‘underpinning knowledge’.
Within each heading there are a number of competencies, such as: ‘puts patient at ease and communicates clearly’ (in the history taking section). Each competency is assessed as ‘not observed or not appropriate’ (N), ‘unsatisfactory’ (U), or ‘satisfactory’ (S). Each group or section of competencies (for example, history taking) would be graded level 0 (insufficient evidence observed to reach a judgement) to level 4 (able to assess new hip and knee patients independently without direct supervision, senior/mentor available later to discuss cases). An overall grade (0–4) would also be given at the end of the assessment document.
Assessment would be carried out by the relevant orthopaedic consultant surgeon or by a person delegated by the consultant; this could include senior musculoskeletal practitioners who have already been assessed.
Getting trained
Education could be provided locally by orthopaedic consultants and also by existing advanced practitioner modules. E-learning packages may be developed to support the training requirements. The competency assessment process could be used as a learning needs assessment for new appointees into a role or those in training, as part of the annual appraisal, or when experienced practitioners transfer to a new employer. It is recognised that other more generic advanced practitioner skills, such as leadership skills, are not covered by the competency assessment, but a line manager should cover these in the annual appraisal process.
The project group agreed that there would be local flexibility regarding postholder titles but that as an NTR, the generic title of musculoskeletal practitioner (MSKP) should be used. This competency framework could be developed into other NTRs, for example, MSKP Trauma. Regulation of the role would remain with its originating profession (such as the Nursing and Midwifery Council) and Agenda for Change (AfC) bandings would be decided locally.
The next stage is to test the assessment tools across the country and also within primary care. After the NTR has been finalised, the documentation will be held on the Skills for Health website and ‘owned’ by the Department of Health. It should be freely available for practitioners to download and use by the end of 2010.
Hats off to Brian!
Congratulations to SOTN committee member Brian Guildhall, who was awarded a Doctor of Philosophy in Nursing from City University London in a graduation ceremony at the Guildhall, City of London, 18 May 2010.
Brian began his PhD part time in September 2003. His thesis is entitled: Changing experiences of total knee replacement: an action research study utilising a social cognitive perspective.
His study involved using an action research approach to examine and change how we prepared patients for total knee replacement (TKR) surgery. Brian examined both the changes made and the change process. The study resulted in the development of a multi-disciplinary assessment and education clinic – the ‘Knee Clinic’ – and a comprehensive patient information booklet.
The study highlighted how user involvement can be a key environmental factor impacting on successful clinical practice change and how the environment and participants’ personal characteristics influenced what was achieved (and not achieved). The changes made are still in place and have been extended to benefit total hip replacement (THR) patients.
2010 Hip Fracture Database report nears completion
In May 2010, the Database announced that 129 hospitals have reached the entry criteria for inclusion in the 2010 report, which will contain analysis on 36,555 hip fracture records and should be published in July. For further information and the database’s most recent newsletter, visit: www.nhfd.co.uk or contact Project Manager Maggie Partridge at: Maggie.fractures@ucl.ac.uk.