International scoping exercise into expertise in children's orthopaedic nursing and educational pathways

Background

CON is in danger of being assimilated within generic surgical and medical nursing, with little recognition that certain skills and knowledge remain unique and are essential to providing the best care.

The problem is multifactorial: nurses are given limited insight into CON in their undergraduate training, without which it is unlikely they will be stimulated into wanting to learn more; mixed-specialty wards require the nurse to be a ‘jack of all trades’; support from expert children's orthopaedic advanced practice nurses (APNs) is usually available only in large teaching hospitals; the demise of orthopaedic hospitals, with loss of specialism and policy-driven transfer of children's orthopaedic care to generalist children's wards (Department of Health, 2003); natural loss of expertise through retirement; 12-hour shifts resulting in restricted time being available for education; and staff lassitude and lack of motivation (Geiger-Brown et al, 2012; Ball et al, 2014).

Should nurses wish to expand their knowledge and skills in the specialty of children's orthopaedics, they would realise there is a huge gap in the provision of dedicated postgraduate courses and alternative educational resources are not validated, standardised or appropriately certificated.

Maintenance of valid knowledge, skills and competence in practice are the individual responsibility of all nurses, required by the nursing professional bodies of both the UK and Australia (Nursing and Midwifery Council (NMC), 2015; Nursing and Midwifery Board of Australia, 2016).

Orthopaedic child patients and their families deserve, demand and have a right to be cared for by competent nurses who possess specific knowledge and skills to provide the best care (Royal College of Nursing (RCN), 2003; DH, 2012; NMC, 2014). There are questions, however, over how nurses achieve this and the aim of this article is to review this by means of a scoping exercise comparing the UK with Australia.

Literature review

There is limited evidence in the literature that supports and recognises CON as a specialty in itself. UK studies by Santy (2000) and Drozd et al (2007) describe the essence, core values, philosophies and personal attributes of the orthopaedic nurse, and similar work in Australia (McLeish, 2012) and New Zealand (Blake-Palmer, 2006) attempts to define orthopaedic nursing as a specialty. However, none of these studies is specific to the subspecialty of CON. Judd's (2010) examination of CON expertise was impaired by nurses' apparent difficulty in articulating explicit skills and knowledge. Although there was a realisation that the domain of practice is distinct, defining the differences between children's and adult orthopaedic nursing was challenging since the knowledge and skills for both are inextricably linked. This in itself lends to the problem of delivering an educational programme purely for the nurse caring for a child with an orthopaedic condition.

Travel scholarship

In 2016, the author was awarded a Florence Nightingale Foundation travel scholarship. This was used to undertake a scoping exercise to determine specialist children's orthopaedic skills and knowledge and to identify current strategies for delivering education and training, comparing the UK and Australia.

Scoping exercise and study

Scoping exercises are a method of investigating key issues; they involve sourcing and reviewing evidence to explore a specific question, and the results can be implemented to influence practice (Colquhoun et al, 2014). The study used a variety of scoping methods (a literature review, questionnaires and focus group interviews) (Davis et al, 2009) in combination.

Networking

Through the networks of the RCN Society of Orthopaedic and Trauma Nursing and the Children and Young People's Orthopaedic and Trauma Community (CYPOTC), the International Collaboration of Orthopaedic Nurses and the Australian and New Zealand Orthopaedic Nurses Association, the author established connections to facilitate site visits in Australia (in Melbourne, Adelaide, Cairns and Perth) and Northern Ireland (NI) to meet nurses, clinical educators (CEs), advance practice nurses (APNs), university lecturers and doctors.

Questionnaires

Nurses and families in the UK responded to questionnaires formulated using information on the expertise of CON from previous investigative work by Judd (2010).

The questions concentrated on identifying the key knowledge and skills felt to be pertinent and important to being able to provide safe, effective care for orthopaedic child patients.

A random selection of 10 parents of children at the author's centre were invited to complete and return a questionnaire to give their opinion on nurses' orthopaedic knowledge and skills. The questionnaires were anonymous and made available at the end of their child's stay. Responses were voluntary and had no direct link to a patient nor impact on a child's care.

An initial pilot questionnaire to nurses working on the ward in the author's centre enabled some minor adjustments to be made to the question format to ensure clarity before it was distributed more widely. The final questionnaire was circulated manually to nurses in different pay bands, working on both a specialist children's orthopaedic ward (10) and two mixed specialty children's surgical wards in the UK (9 and 12).

In addition, CYPOTC members were invited through the group's email to complete an abbreviated questionnaire via the online SurveyMonkey tool. The CYPOTC has approximately 60 members, who are nurses in different pay bands and allied health professionals. Responses were requested from the nurses only.

Ethical approval for the questionnaires was not sought, with the opinion that the project was an information-gathering, scoping exercise with voluntary participation to assess the gap in children's orthopaedic nurse education.

Education providers

Informal interviews were carried out with CEs, APNs, ward nurses and university lecturers in NI, Adelaide, Melbourne and Cairns. The intention was to gain an understanding of the barriers to offering a postgraduate CON module or a pathway and, in the absence of one, review how participants tackled the requirements of continuing professional development (CPD) for nurses caring for the orthopaedic child patient.

Informal focus group interviews

Discussions in the form of semistructured focus group interviews (Robinson, 2002) were held in large teaching hospitals in Australia and NI. A brief background to the study was given before a couple of key questions were asked to drive the discussion. These focused on how nurses would describe or define CON, what they considered to be essential knowledge and skills to deliver best practice and what they might expect to be included in a children's orthopaedic course, if it was to be provided.

The numbers, seniority and level of expertise of nurses in these group sessions varied. It was particularly helpful to meet postgraduate students undertaking the ‘Orthopaedics across the lifespan’ course in NI. This gave perspective to the main investigation of the study, demonstrating one way in which nurses could further their knowledge and skills in CON.

Results

The amalgamated views of nurses on the expertise of CON, provided in the questionnaires and the informal focus group interviews are presented in Table 1.

It was notable that the answers with depth, understanding and explanation were given by the more experienced nurses. The results show nurses' understanding of the essence of CON, in an attempt to provide a concept of the specialty and distinguish it as a specific domain of practice. Inherently discerning nursing activities that require supplementary children's orthopaedic knowledge has always been problematic (Judd, 2010). Statements attributed to CON are not necessarily exclusive to the specialty, with many transferable and relevant to both child and adult orthopaedic care.

Nurses working on a specialist children's orthopaedic ward provided more substantial answers because of their greater exposure to complex problems. Similarly, respondents to the online questionnaire (n=15) were already making a statement of interest, knowledge and experience in CON, through their membership of RCN CYPOTC. Nine (60%) were not aware of any online educational resources for CON. A question asking whether paediatric orthopaedic postgraduate education was required had a majority of affirmative answers. Two examples were:

The latter statement reflects the view of many university lecturers, as student numbers dictate a course's sustainability.

Eight (50%) CYPOTC respondents, who were predominantly APNs, had completed a postgraduate orthopaedic course of some description. However, only one was a dedicated children's orthopaedic and trauma course and the remainder were adult focused with the inclusion of a couple of lectures on CON. All of the courses cited in the respondents' answers are no longer in existence, which was attributed to a lack of demand and the dilution of specialist children's orthopaedic centres.

CYPOTC respondents cited learning from others' expertise (nursing and medical staff) and attending medical and nursing study days or conferences as ways of maintaining knowledge and skills (Figure 1). Preference for format delivery for education allowed participants to choose more than one option. Unsurprisingly, face-to-face (33%, five respondents) or online (33%, five) formats were popular, but more interesting was a response of 80% (12) stating a competency framework relevant to their practice would be beneficial (Figure 2).

There was a poor rate of return from questionnaires from families regarding the care of their child (3 of 10), but some relevant points are included to provide their insight:

This was echoed with the statement:

Asked to rate their child's care, responses varied from ‘good’ to ‘excellent’; asked whether the nurse could answer questions about their child's orthopaedic problem, it was evident that the NP knew about the subject, while ‘some nurses were pretty vague’. This may be attributed to parents' expectation that all trained nurses had the same level of knowledge, regardless of pay band or seniority.

Generally in the UK and Australia, CON education appears to be provided through in-house training. Similarities between the UK and Australia were that the CEs and NPs linked to the children's surgical wards strived to deliver a regular teaching programme. In Australia, this was more successful and is perhaps down to the nature of support for those in post and allocation of teaching time for the nurses. Although teaching sessions were not always ‘orthopaedic’, the importance of education and training of specific children's orthopaedic knowledge and skills was acknowledged. In the UK, however, it was more on an ad hoc basis and often dependent on whether nurses could be freed from the ward.

In Adelaide's children's hospital, there is a designated children's orthopaedic teaching programme, which is provided by the NP and supported by the CE; at the general hospital, the orthopaedic NP (in adult care) supports nurses with provision of a wealth of online information and care pathways. Similarly, in Melbourne, the CEs were responsible for the teaching programme. In both centres, the weekly teaching sessions are protected and facilitated by the 8–hour nursing shift pattern, which ensures nurses are released from their clinical duties. There was no specific provision for CON education in Cairns or Perth. The paediatric orthopaedic consultants interviewed in Melbourne and Adelaide agreed that nurse education was valuable but, while they were supportive of training NPs working alongside them, this did not include the ward-based nurses. The expectation was that the NP had specific expertise of ‘complex’ care and the less experienced nurse had minimum knowledge of ‘frequent’ care, such as plaster care, traction management and neurovascular observations.

Discussion

Overall, this scoping exercise comparing CON education in the UK and Australia revealed both similarities and disparities. Postgraduate nurses corroborate the discrete knowledge and skills of CON, distinguishing it as a specific domain of practice. While no specific postgraduate course exists, other methods for maintaining knowledge and skills are available.

It was apparent that nurses achieve much of their learning on the job. There is wealth of in-house education programmes internationally, particularly in the children's hospitals in Melbourne and Adelaide, where there is a strong ethos toward delivering weekly teaching sessions. This is facilitated by the 8-hour shift patterns, which enable nurses to be released from the ward, as well as protected teaching time. In the UK, however, 12-hour shifts mean there is no nursing overlap time.

Successful teaching and support was evident in the general hospital in Adelaide, facilitated by the expertise of the NP who oversees and is consulted on the care of both adults and children with orthopaedic problems. Online clinical practice guidelines available from the Royal Children's Hospital in Melbourne are useful, although CON content is limited and unawareness of their existence was apparent. Similarly, patient guidelines and pathways are available in some UK centres.

In-house resources involve duplication and an immense amount of work being done by individuals reinventing the wheel, and none constitute validated educational tools. All are self-regulated, do not offer CPD and are not supported by academia so are not recognised. Generic orthopaedic nursing topics are covered by commercial courses, but availability is variable, dependent on interest and expensive.

Provision of pre-registration children's orthopaedic knowledge and skills is limited, often comprising a single lecture, reducing its importance and value to student nurses. The niche aspect of CON is universal and postgraduate courses offer nominal insight.

Of concern is the lack of postgraduate adult orthopaedic courses in the UK and Australia because of low student numbers and therefore financial sustainability. NI has addressed this in the provision of a combined postgraduate programme offering collaborative education for patients across their lifespan. This not only ensures sufficient student numbers but also bridges the gap of transition between children's and adult care. The nurses who had completed the course welcomed the opportunity to study orthopaedics from the perspective of both the child and the adult patient, comparing and contrasting care through the whole patient journey. This course may be the forerunner of future orthopaedic courses, with its success already generating consideration from other universities. Other creative ways of delivering nurse education to be considered are e-learning courses, or inclusion as part of a department's online mandatory training.

During the tour, it was suggested to the author that nurses may be reluctant to undertake further study and that they largely lacked motivation. This may be attributed to a lack of stimulation, encouragement and facilitation, as well as a poor understanding of CON because of limited exposure and education.

Educational pathways, competency frameworks and learning contracts are all tools that enable nurses to demonstrate knowledge and skills development. They can be employed as part of nurses' CPD and used as a basis for revalidation, but appear to be nonexistent in CON. To address this, nurses are using a combination of attendance at locally delivered or external courses and study days, learning on the job and using self-taught methods to maintain their children's orthopaedic knowledge and skills (Table 1).

Perhaps recognising the lack of course availability, CYPOTC respondents showed a preference for employing a specific competency framework as an alternative way of demonstrating knowledge and skills in CON. While interesting, this result may be biased; through membership of CYPOTC, the respondents would be aware of the work being undertaken to revise and update the RCN's (2012) competence framework for orthopaedic and trauma practitioners. They may see a competency framework as an as an ideal opportunity to facilitate and direct career development, and be used as part of an individual's CPD and included within the nurse's revalidation process. The framework, written by expert nurses and due to be published in May, will be an influential tool by which nurses' competence can be assessed and compared directly to the competencies required for their role. Since the finalised document is likely to be generic in nature, covering all aspects of orthopaedic nursing care, the discrete knowledge and skills required for CON (Table 1) could be incorporated as an addendum, with potential to further develop the structure on which an educational pathway can be built.

Another way to ensure children and families receive the care they deserve, delivered by competent and confident nurses, could be compulsory completion of a competency framework for CON through hospitals' statutory mandatory training programmes.

Bespoke, work-based learning programmes facilitated by an academic learning adviser could also allow nurses to enhance their professional development through reflection on their practice and experiences. Tailor-made learning contracts, with support in practice from an identified mentor could be a way forward for individual children's orthopaedic nurses.

Lack of financial support was voiced as a reason for not attending a relevant course or conference. Nurse education in the UK is severely limited, compromised by budget reductions of up to 60% for CPD (Merrifield, 2018), compounded by competitive application process and study leave being ‘frozen’ in many hospitals (Ely, 2018). In contrast, nurses in South Australia receive a monetary incentive of $24 a week for educational purposes.

Conclusion

This scoping exercise involved visiting centres of expertise for children's orthopaedics as well as district general hospitals providing care for less complex orthopaedic child patients. Regardless of patient complexity, it is imperative that nurses are able to demonstrate appropriate learning and maintenance of the requisite knowledge and skills for their domain of practice, without which care is at risk of being suboptimal and children and families lose trust in the nursing profession.

This study did not accrue any new information regarding nurses' beliefs of the distinct knowledge and skills pertinent to CON but it was important to confirm this.

The expertise of CON is in danger of being lost because a validated education infrastructure is nonexistent in both the UK and Australia. With the demands of NMC revalidation, we need to look to the future in planning a strategy for the continuous learning of nurses in practice. A recognised career pathway to develop competent and confident nurses to provide up-to-date, evidenced-based care for the orthopaedic child patient needs to be determined to address this.

KEY POINTS

CPD reflective questions