The Nursing Role

Fig. 9.1

The complexity of nursing care needs for hospitalised patients with hip fracture

The sharing of care between orthopaedic surgeons and orthogeriatricians can become fragmented and less effective if the care is not managed or coordinated effectively. Nurses are integral contributors to the orthogeriatric team [21] because of their role as care co-ordinators [8, 28]. Team coordination is often led by a specialist nurse or coordinator including; hip fracture nurse specialists, elderly/elder care nurse specialists, trauma nurse coordinators, nurse practitioners and advanced nurse practitioners.

Many nurses working in orthogeriatric settings are better prepared educationally for the care of adults with musculoskeletal problems than to meet the complex needs of older people. Multiple specialist ‘orthogeriatric’ nursing skills are needed as well as fundamental adult nursing skills. There is, consequently, an important education and skills gap. Competence in nursing is fluid and reflects developments in all aspects of professional practice as demonstrated in the work of Benner [4], who introduced the idea that expert nurses develop skills and understanding of care over time through a sound educational base as well as a multitude of experiences. The complex nursing care requirements of orthogeriatric patients means that they need to have their care led by those who are experts in the field and have an intuitive understanding of what is required. Multidisciplinary collaborative working has supported the development of advanced practice nurses (or allied health professionals) who are variously described as clinical nurse specialists, nurse practitioners or physicians’ assistants. They have a variety of different skills that are complementary to the multi-disciplinary team and enhance patient care. Care should be overseen by those who are at least proficient and have several years’ experience of working with older patients following fracture. Proficient nurses perceive and understand patients’ care needs holistically and from individual perspectives, having learnt from their experience to know what to expect in certain situations. They oversee care provided by others who are less proficient in order to ensure its quality as well as give care themselves in order to maintain their proficiency and improve their knowledge and skills. Specialist nursing qualifications in orthogeriatric care do not currently exist, so nurses are obliged to be reflective self-led learners who are able to extend their own knowledge of both caring for patients following trauma and the complex care of older people together through reflection.

9.3 Nursing Care and Nurse-Sensitive Indicators

Quality indicators within the standards that underpin hip fracture audit have already had a significant impact on the quality of medical and surgical care. However, these currently only briefly consider nursing indicators. It is essential that indicators of the value of nursing care are identified and ways to measure them developed. The overall contribution of health care delivery is often measured in terms of health status, outcomes, readmissions rates, length of stay, complication rates and mortality [9], but these do not necessarily help to capture the specific contribution of nursing. Length of stay, in particular, can be a misleading measure for success given concerns about decreased levels of expert nursing care when patients are discharged or transferred to less specialised settings too early.

Nursing is broad and complex and the nursing profession has traditionally had difficulty in articulating its unique benefits. Indicators of nursing care quality include nurse-sensitive patient outcomes such as patient comfort and quality of life, risk outcomes and safety, patient empowerment and patient satisfaction [9]. More specific indicators include healthcare-associated infection, pressure ulcers, falls, drug administration errors and patient satisfaction [12, 15]. Information is currently provided that relates to patient safety and seldom focuses on other aspects of clinical effectiveness and the impact on quality of care or patient experience. In orthogeriatric care a starting point might be to work on the development of nurse sensitive indicators for pain, delirium, pressure ulcers, hydration and nutrition, constipation, prevention of secondary infections and venous thromboembolism (VTE). Whilst many of these complications are discussed in other chapters, it is important to include evidence-based nursing management strategies that co-exist with medical models of care; reducing the risk of developing complications, aiming to reduce the risk of morbidity and mortality, whilst improving recovery, maintaining functional ability and improving patient outcomes and experiences. Pain management, nutrition, hydration, remobilisation, rehabilitation and motivation (Fig. 9.2) are all central to prevention of complications for patients following hip fracture and these are all nursing care priorities.

Fig. 9.2

Fundamental nursing aspects of the prevention of complications in hospitalised patients with hip fracture

Although this chapter is concerned with nursing interventions in orthogeriatric care generally, it is impossible to ignore the fact that, of all fragility fractures, hip fracture is the most significant injury: it is the most common reason for admission to an orthopaedic ward, accounts for much orthopaedic bed occupancy and a large portion of the total cost of all fragility fractures. It is also the most expensive fracture in terms of volume and unit costs. Complexity of patient needs, prevalence, number of bed days and cost means that the focus of inpatient care tends to relate predominantly to this category of injury. However, the principal skills and knowledge needed to look after hip fracture patients well apply across the management of all older patients with fractures and include all fundamental aspects of nursing care for the adult as well as highly specialised interventions for older people [16, 17].

9.4 Pain

Pain in older people is often under-reported by patients and ignored by health care professionals. Older people are, therefore, at risk of unmanaged or undermanaged pain resulting in higher risk of delirium, impaired mobility, chronic pain and poorer long term functional ability [4]. Cognitive impairment increases the risk of pain not being recognised. The individual and highly variable nature of pain and an individual’s response to it make accurate assessment a central aspect of nursing care to facilitate individualised pain management and monitoring. Later on, if pain is poorly controlled mobilisation will be delayed, increasing the risk of the complications of prolonged immobility leading to increased dependency and associated rise in the risk of delirium.

Verbal reports of pain are valid and reliable in patients with mild to moderate dementia or delirium, but the assessment of pain in a patient with more severe cognitive impairment may be more difficult. However, many studies have shown that cognitively impaired and acutely confused patients receive less analgesia than their unimpaired counterparts. The use of an assessment tool to help staff understand the individual needs of a person with dementia such as the ‘This is me’ tool [1], encourages relatives and carers to share individual patient information, characteristics and behaviour that enables staff to better understand pain experience and needs. For pain assessment to be effective it must be carried out frequently and recorded accurately as an essential aspect of regular patient assessment when vital signs are being recorded, when medication is being given or when other care is being provided. The aim of pain management should be to give sufficient pain relief to allow fundamental nursing care to be performed with least distress to the patient, including changes of position, movement and transfers. Reassessment and appropriate administration of analgesia should be central to routine care.

Responsibility for managing pain varies according to the role, competence and skill level of the nurse. Every registered or licensed nurse should undertake frequent, accurate pain assessment and administer prescribed analgesia, whilst observing its impact and any side effects and reporting these to the interdisciplinary team. As nurses become increasingly responsible for more advanced patient care interventions, non-medical prescribing will permit nurses to assess pain and to formulate a plan for pain management in collaboration with the patient, their carers and the care team. Advanced practitioners can often prescribe a range of medications including opioid and non-opioid analgesics to enable a faster response to patient needs, but this requires enhanced nursing skills. Administration of nerve blocks pre-operatively for patients with hip fracture is becoming increasingly common, with advanced and specialist nurses having a role in the administration either in the ED or in-patient units. They minimise the need for opiates, which have multiple risk factors in older and frail patients, and have been shown to have a significant positive effect on the pain experience [25].

9.5 Delirium

The nursing team spends the most time with patients so are most likely to recognise the signs of delirium discussed in Chap. 8. Good communication with patients, family and carers can help practitioners to recognise subtle changes that suggest underlying causes. If a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, the team should discuss with the patient and/or family medication and other methods to maintain safety such as low beds and higher levels of supervision. At-risk patients and their carers need information about delirium and what they might experience along with reporting changes and inconsistencies in behaviour to the nursing team [23].

There are a number of nursing interventions also thought to prevent delirium [23] as well as contribute to effectiveness of care from other perspectives:

An environment that helps to re-orientate patients; large-face clocks and calendars, well-lit areas with clear signage to provide clues about the location and time of day.
Gentle re-orientation of patients by providing introductions and explanation of location. Family and friends should be encouraged to visit as often as possible and be supported in modifying their own communication.
Dehydration, hypoxia and constipation prevention and management.
Supported mobilisation to enable patients to feel more in control.
Recognition and management of infections.
Regular assessment of pain.
Ensure that dentures fit correctly and encourage patients to eat.
Resolve any reversible causes of sensory impairment especially related to hearing and visual aids.
Facilitating sleep and rest.

Many of the interventions listed represent good management of all older people so should be an integrated part of nursing care in the orthogeriatric setting.

9.6 Pressure Ulcers

Pressure ulcers are serious complications of immobility, hospitalisation and surgery and can affect up to one third of hip fracture patients [5]. Those who sustain a pressure ulcer require significantly more nursing care and have longer hospital stays with increased costs of care and greater use of health care resources following discharge [6]. Given the exceptional risk of tissue damage in patients with hip fracture, prevention and management of pressure ulcers are central to nursing care effectiveness and patient safety. Their prevention is also a largely nursing issue, although a team approach is needed to manage risk factors effectively [22].

Assessment of the skin should take place on admission followed by frequent reassessment [17]. Pressure ulcers can develop rapidly in vulnerable patients, so prompt and repeated assessment of risk using an appropriate and validated tool is central to identifying those intrinsic and extrinsic factors that may lead to pressure ulcers in individual patients. Identification of specific risk factors can then assist in planning and delivering appropriate interventions for prevention that manage or modify those factors [24]. Examples of intrinsic and extrinsic factors relating to many patients with hip fractures are considered in Table 9.1.

Table 9.1

Common pressure ulcer risk factors for patients following hip fracture and surgery