A Competence Framework

for Orthopaedic and Trauma

Practitioners
CLINICAL PROFESSIONAL RESOURCE
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

Acknowledgements
The working group wish to thank the Royal Vikki Flynn, Senior Charge Nurse, Ninewells
College of Nursing (RCN) for their support Hospital, Dundee
and funding. Special thanks to members
Professor Rebecca Jester, Professor of
of the working group who represented all
Nursing, Institute of Health, University of
four countries of the United Kingdom (UK)
Wolverhampton.
comprising nurses and an allied health
professional experienced in orthopaedic and Alice Judd. Physiotherapist. Ministry of Defence.
trauma care across the lifespan. In addition, Hampshire
acknowledgement of the two external reviewers
Heather Mahoney, Frailty Nurse Lead, Trauma
for their constructive feedback.
Unit, University Hospital of Wales
Project Leads: Pamela Moore, Nurse Development Lead
Orthopaedics, Musgrave Park Hospital Belfast.
Julia Judd. Advanced Nurse Practitioner.
Children’s Orthopaedics. Southampton Critical Readers:
University Hospital
Dr Brian Lucas. Associate Lecturer, The Open
Karen Barnard. Advanced Trauma Nurse
University.
Practitioner. Royal Berkshire NHS Foundation
Trust. Dr Julie Santy-Tomlinson, Senior Lecturer, The
University of Manchester.
Working Group
Sonya Clarke, Chair Society of Orthopaedic and Please contact the Chair for RCN Society of
Trauma Nursing (SOTN), Senior Lecturer, School Orthopaedic and Trauma Nursing regarding any
of Nursing and Midwifery, Queen’s University queries or feedback regarding this document:
Belfast. publications.feedback@rcn.org.uk
Mary Drozd, Senior Lecturer, Institute of Health,
University of Wolverhampton.

This publication is due for review in June 2024. To provide feedback on its contents or on your
experience of using the publication, please email publications.feedback@rcn.org.uk

Publication RCN Legal Disclaimer

This is an RCN competence document. This publication contains information, advice and guidance to
help members of the RCN. It is intended for use within the UK
Description
but readers are advised that practices may vary in each country
The RCN recognises the importance and value of orthopaedic and outside the UK.
and trauma practitioners in clinical practice. These
The information in this booklet has been compiled from
competencies have been revised to support these practitioners in
professional sources, but its accuracy is not guaranteed. Whilst
a clear, consistent and evidenced based format to reflect their
every effort has been made to ensure the RCN provides accurate
specific, specialist knowledge and skills. The competencies can
and expert information and guidance, it is impossible to predict
be employed in various roles across acute, primary and
all the circumstances in which it may be used. Accordingly, the
community settings in the United Kingdom (UK) and the
RCN shall not be liable to any person or entity with respect to any
framework is inclusive for all practitioners working in the NHS,
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indirectly by what is contained in or left out of this website
Publication date: February 2019 Review date: June 2024. information and guidance.
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 ROYAL COLLEGE OF NURSING

Contents
1. Acknowledgements 2

2. Introduction 4

Development of the competencies 4

The new document 4

RCN competence statement: Caring for the child, young person and adult with a
co-morbidity 4

The structure of the competence framework 5

Using the framework 5

Anticipated benefits of the framework 6

Glossary 8

3. The competencies 9

Domain 1: Partner-guide 9

Domain 2: Comfort enhancer 11

Domain 3: Risk manager 14

Domain 4: Technician 18

4. References 22

5. Websites 26

Appendix 1: Practitioners’ comments 27

Appendix 2: Exemplar learning contract 29

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A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

2. Introduction
This document is intended to provide a It presents best practice statements based on
framework for orthopaedic and trauma highest possible evidence or, in the absence of
practitioners in clinical practice. It is recognised this, consensus opinion through the expertise of
that orthopaedic and trauma practitioners the working group. The group acknowledge that
require specific, specialist knowledge and skills there are different levels of evidence and have
reflecting different levels of practice and job used the best available evidence to inform the
roles (Clarke and Santy-Tomlinson 2014, RCN document.
2012a), and that appropriate education and
training is essential to support practitioners’ The document was shared with practitioners
development and competence. This document at the RCN Congress (2018) and reviewed by
includes specific musculoskeletal trauma, but representatives from the pay bands during its
excludes major general trauma; this is covered in development, to solicit feedback on its format
a separate document detailing competencies for and ease of use (Appendix 1). The framework
the care of major trauma patients within major can be used alongside the Knowledge and Skills
trauma centres and trauma units which has been Framework (KSF) (DH, 2004) for practitioner
developed by the National Major Trauma Nursing appraisal and contribute to individuals’
Group and can be found at: www.nmtng.co.uk/ continuing professional development (CPD). It
adult-trauma-wards.html can also be used in conjunction with learning
contracts to maintain and improve competence
and inform the NMC revalidation process.
The development of the An exemplar learning contract is provided in
competencies Appendix 2. Whilst every effort has been made
to reflect contemporary trauma and orthopaedic
Revision of The Orthopaedic and Trauma nursing practice nationally, it is acknowledged that
competencies (RCN, 2012) was undertaken there will be variances in practice in different
by a working group with representatives from institutions and across the UK. Specifically
Northern Ireland, Scotland, England and Wales. organisations themselves must determine the
scope of practice of staff employed across the
The new document range of pay bands.

The revised competence framework has been Please note that, in the competence framework,
reformatted so that it reflects the Nursing the term ‘carer’ or ‘family’ refers to family
and Midwifery Council (NMC), The Code: members, patient advocates or people who
Professional standards of practice and provide significant unpaid care to the patient.
behaviour for nurses and midwives (2018). Each
competency has been linked to the following RCN competence
NMC standards:
statement: Caring for the
Prioritise People, Practise Effectively, child, young person and
Preserve Safety and Promote Professionalism
and Trust.
adult with a co-morbidity
The orthopaedic and trauma competencies
Within the new framework the expectations of
in this document can be applied across the
orthopaedic and trauma practitioners in National
lifespan of patients with a MSK condition as
Health Service (NHS) pay bands 2-8 (NHS
they transition through the health care system
Employers) are clear, consistent and evidenced
(varied health care providers, different settings
based (wherever possible). The framework is
such as in hospital or community, in-patient and
inclusive for all practitioners (working in the
out-patient), from child, young adult, adult and
NHS, independent or voluntary sector), caring
older adult. The practitioner has a responsibility
for musculoskeletal (MSK) patients across
to recognise and understand the individual
the lifespan, and across acute, primary and
needs of patients including any co-morbidities,
community settings in the United Kingdom (UK).
mental health conditions, cognitive impairment
As a guideline, the document meets the or learning disability that may impact on
requirements of the RCN Quality Framework. the patient’s return to health. Individual

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 ROYAL COLLEGE OF NURSING

practitioners and health care providers need

to have a constant awareness of adult, child
The structure of the
and young person safeguarding and must do competence framework
everything possible to ensure those at risk are
This updated document has been designed
protected from abuse, harm and neglect.
using the existing four core domains within
Intercollegiate adult safeguarding competencies orthopaedic and trauma practice:
can be found here: www.rcn.org.uk/
• partner/guide
professional-development/publications/pub-
007069 • comfort enhancer
Government recommendations for Safegaurding • risk manager
Children and Young People can be found here:
• technician
www.gov.uk/government/publications/
safeguarding-children-and-young-people/ (Santy 2001) (See Table 1).
safeguarding-children-and-young-people
Table 1
Person centred care requires effective
communication, collaboration and coordination The Core Competence Domains
with the multi-disciplinary team (MDT). Domains of practice:
Including patients and family/carers (where • partner/guide
appropriate) in decision making about their care • comfort enhancer
and treatment is essential to ensure they are well • risk manager
informed and active participants in the journey • technician
to recovery following trauma or orthopaedic Competence statements are described under the
procedures. headings:
• Skills and Behaviours
All patients, across the lifespan and those
with additional needs, must be cared for by • Knowledge and Understanding
competent practitioners – for example, registered These are the expectations of practitioners working
nurse (RN) child or registered children’s nurse in different roles, stating the specific orthopaedic
and trauma knowledge, understanding and skills
(RCN), for children and young people (CYP). that are required for each band of practice e.g.
Practitioners caring for CYP must have a sound bands 2-8 (health care assistant to advanced
knowledge of child anatomy and physiology, practitioner).
including child development. CYP practitioners Evidence: Online data sources were searched
will understand and appreciate the different for the best available, current, valid and relevant
physical and psychological aspects of caring evidence to support the document. Where research
for children with an orthopaedic or trauma evidence was not available, a consensus of expert
opinion from the working party integrating existing
condition, the employment of distraction therapy and new knowledge and practice developments
and play, the use of age related pain assessment informed the recommendations.
tools, pharmacological and non-pharmacological
pain management strategies, provision of a
The + sign indicates the inclusion of previous
family and child friendly environment, the
statements for lower bands, building up from
promotion of successful interaction with the
health care practitioner to registered nurse, to
child, conservative management versus surgical
specialist and advanced practitioner.
intervention, using correctly sized equipment
and implementing appropriate care plans (RCN,
2010a; RCN, 2012b; RCN, 2012c). Using the framework
The practitioner caring for the older adult Read in conjunction with the NHS KSF (2004)
requires knowledge of the ageing process and its and the NMC Code (2018), the framework can be
impact on patients’ physical, psychological and employed as part of the performance appraisal
social needs and care needs. process and used as a tool to assist RNs with
NMC revalidation.

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A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

You can self-assess your level of competence, Learning contracts can be used to facilitate
formulating a personal development plan for the individual’s continuing professional
skills and knowledge of orthopaedic and trauma development plan. An example is given in
nursing. appendix 2.

Ensure that you understand what the competence It is suggested that you keep a professional
statement is asking of you and take responsibility portfolio of personal evidence of competence and
for producing the supporting evidence for the that knowledge, skills and practice are updated
achievement of each competence. regularly. Completion of a learning contract
can form an integral part of your professional
There are learning activities that can be used to portfolio.
provide evidence of competence. (see Table 2)

Table 2 Anticipated benefits of the

Suggested Activities and Evidence to
framework
Support Competence
The competence framework aims to benefit
Self-directed study practitioners, their employers, patients and the
Undertaking learning programmes and/or public by providing a foundation on which to
academic qualifications develop and evaluate the safety and effectiveness
Seeking learning opportunities in the workplace – of orthopaedic and trauma practice. The
for example, job shadowing framework provides clarity for organisations
Supervised practice with direct observation as to what they may expect from orthopaedic
Viva voce (an oral assessment/exam) and trauma practitioners and can also be
Observed structured clinical examination (OSCE)
used as a benchmark for organisations to use
in staff recruitment, development, appraisal
Practice write-ups
and individual performance management. It
Oral and/or written reflections on the care you have is relevant to all practitioners now and in the
provided
future, including health care assistants and
Portfolio of evidence assistant/associate practitioners who are directly
Reflective practice involved in the care of orthopaedic and trauma
Critical incident analysis patients across the lifespan. The framework
can also be used to develop curricula for the
Writing papers for publication in professional
journals which may include audits, case studies, education of orthopaedic and trauma nurses
literature reviews and primary research. so that education programmes can support the
Presentations to colleagues (e.g. local, national and development of specialist skills and knowledge.
international seminars and conferences)
Developing learning and teaching resources for Benefits for practitioners
patients, families and colleagues
The framework aims to provide guidance in the
Certificates of attendance at conferences, study
following areas:
days and symposia with written reflections on
learning
• delivery of high standards of evidence-based
Evidence of group work to develop practice care
Policy and protocol development
• Continuing Professional Development (CPD),
Standard operating procedures
identification of education and training
Evidence of membership of advisory groups needs in relation to the levels of skills,
Research and evidence-based reviews behaviours and knowledge required resulting
in structured professional development
planning using Learning Contracts

• appraisal and revalidation (Registered

Professionals) and for career progression in
relation to orthopaedic and trauma practice.

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 ROYAL COLLEGE OF NURSING

Benefits for employers

The framework aims to provide guidance in the
following areas:

• expected levels of knowledge, skills and

behaviours for practitioners working within
different pay bands

• appraisal processes for individual

practitioners and identification of workforce
learning and development needs

• workforce planning to support delivery of

orthopaedic and trauma services including
recruitment and selection of staff.

Benefits for the patients and public

• providing assurance to patients and the
public that practitioner competence is
assessed and validated using the framework
and learning and training needs are
addressed through individual and workforce
development

• minimising variation in standards

of competence, between providers of
orthopaedic and trauma services.

Evidence: Benner P (1984); Department of Health

(2004); Nursing and Midwifery Council (NMC)
(2014); NMC (2018); NMC (2017); RCN (2009);
RCN (2012)

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A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

Glossary
AKI – acute kidney injury.

Appliances – example Orthotics: A support,

brace, or splint used to support and position a
part of the body.

Compartment syndrome – harmful pressure

within an isolated muscle compartment.

External fixation – method of stabilising bones

and joints using metal rods or frames outside of
the body.

MDT – multidisciplinary team.

MSK – musculoskeletal, (includes bones, joints,

ligaments, tendons, muscles, and nerves).

Neurovascular – system of nerves and blood

vessels.

NEWS2 – national early warning score to

improve the detection and response to clinical
deterioration in adult patients. See:
www.rcplondon.ac.uk/projects/outputs/
national-early-warning-score-news-2

Traction – a system of weights and pulleys

applied to a part of the body to exert a pulling
force, to align and position a bone or rest a limb.

UTI – urinary tract infection.

VTE – venous-thrombo-embolism; a term that

encompasses DVT (deep vein thrombosis) and PE
(pulmonary embolus).

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 ROYAL COLLEGE OF NURSING

3. The competencies
Domain 1. Partner guide Partner guide competencies

This domain relates to the partnership between Competence 1: To have knowledge of MSK
the patient and the health care practitioner conditions/injuries in order to provide holistic
who guides the patient through their journey in care
orthopaedic and trauma health care. Supporting Competence 2: To have knowledge and skill in
the patient and ensuring they are at the centre the provision of information, education and
of their care is essential. In addition, working support to patients and family/carers about the
in partnership with the patient’s family/carers patient’s MSK condition/injury
is vital, as is liaison and collaboration with all
members of the MDT to ensure seamless holistic Competence 3: To have knowledge and skill in
care. the promotion of MSK health, as well as general
health and wellbeing

Competence 4: To have knowledge and skill in

ensuring accurate, timely record-keeping and
communication with the MDT in order to provide
seamless holistic care.

Key words:

• Support and guidance

• Patient information and education

• Health promotion

• Rehabilitation

Evidence: Clarke and Santy-Tomlinson (2014);

The UK Quality Code for Higher Education
(2014); RCN (2018); Scottish Government (2017);
RCN 2010b

9
 Domain 1: Partner Guide Framework
Links with the following NMC Code 2018: Prioritise people; Practise Effectively

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Skills and Assists with + + + + + +
behaviours patient care Assists with Facilitates person- Facilitates Co-ordinates care Actively develops Leads strategic
throughout their patient care centred patient care holistic care and guides patients the practice planning and
journey of care, through effective under the indirect through effective and families on of others in policy/guideline
and effectively communication supervision of a communication their orthopaedic/ patient and carer development
communicates, under the indirect registered nurse. appropriate to trauma care education and in relation to
under the direct supervision of a individual need. journey. support in relation supporting and
Documents
supervision of a registered nurse. to MSK injuries/ guiding patients
MSK care/risk Promotes
registered nurse. conditions and in the Trauma and
assessments/ evidence-based
complications care delivery promotion of MSK Orthopaedic (T&O)
accurately and in and delegates health. setting.
a timely manner to appropriately. Manages complex
provide information Provides issues and acts
to the MDT. information/advice autonomously
to the patient/ in planning and
family/carers in implementing
regard to general patient care.

10
health and well-
being and MSK
conditions/injuries.
Knowledge Has a basic + + + + + +
and knowledge of As band 2. Has knowledge of Knowledge of Knowledge of Knowledge of Advanced
understanding common MSK the impact (short/ evidence-based complex MSK strategies to knowledge of
conditions/injuries medium/long term) strategies and conditions/injuries promote MSK national and
to inform holistic of MSK condition/ MDT resources and the impact of health within the international
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

patient care. injury on the to support the co-morbidities. wider community. innovations and
individual and their individual and/or Is aware of national guidelines that
family. their families. and international contribute to
Knowledge of innovations and and inform MSK
health promotion guidelines that nursing.
strategies. contribute to, Critically evaluates
and inform MSK MSK and advanced
nursing. practice current
Provides education research,
for staff in complex suggesting new
MSK conditions/ hypotheses to
injuries and the investigate where
impact of appropriate.
co- morbidities.

Learning Contract: Use a learning contract to facilitate and guide your development (see appendix 2).
 ROYAL COLLEGE OF NURSING

Domain 2: Comfort Key words:

enhancer • Pain and comfort assessment.

Comfort is a concept which is central to the • Pain and comfort management.

fundamental care of the orthopaedic/trauma
patient. It is a complex human experience which • Moving and handling.
can be interpreted in different ways and is closely Evidence: Tutton and Seers (2004), Drozd et
related to the experience of pain, especially al (2007), Hogan (2011); Hartling et al (2016),
for patients who have received a MSK injury. Kolcaba & DiMarco (2005), Health and Safety
The comfort of orthopaedic/trauma patients is Executive (2012); Clarke and Santy-Tomlinson
paramount for high-quality care and positive (2014); National Institute for Health and Clinical
health outcomes. This essential aspect of care Excellence (NICE) (2010a); NICE (2014).
may be more complex for the orthopaedic/
trauma patient due to the nature of their
condition, injury or surgery. MSK instability
and movement can result in significant pain and
discomfort.

Competence in providing essential care within

this context is therefore central to high-quality
care and again highlights the need for that care
to be provided in a specialist setting where
practitioners possess the requisite specialist
competence.

Comfort enhancer competencies

Competence 1: To have the knowledge and skill
to recognise pain and discomfort, assessing pain
levels using appropriate pain tools.

Competence 2: To have the knowledge and skill

to position the patient’s trunk, limbs and joints,
using slings and other devices, as well as using
other non-pharmacological methods to promote
comfort and reduce pain, such as ice/heat packs,
pillows.

Competence 3: To have knowledge in the

administration of analgesia and other drugs
needed to maintain patient comfort, including
side effects, contra-indications and devices used
in administration.

Competence 4: To have knowledge and skill when

moving and handling patients with orthopaedic
conditions/injuries, in accordance with Health
and Safety Executive (HSE) guidelines (2012) and
local policy.

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 Domain 2: Comfort Enhancer Framework
Links with following areas of NMC Code (2018) – Prioritise People and Preserve Safety

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Skills and Assists with the + + + + + +
behaviours essential care Assists with the To assess and Assess, plans, Assesses plans, Actively seeks to Prescribes,
which takes into essential care which record pain levels implements and delivers and improve practice inimplements,
account the takes into account using recognised evaluates care in evaluates care the assessment and monitors and
patient’s pain and the patient’s pain scales. order to meet the for patients evaluates pain
management of
comfort levels and comfort levels patient’s anxiety, with complex management
To inform registered pain and comfort
under the direct under the indirect distress, pain and comfort and pain regimens – both
nurse of outcome of for patients.
supervision of a supervision of a comfort needs. management pharmacological
pain assessment for
registered nurse. registered nurse. needs. and non-
the implementation Monitors nursing
Assists the and administration care against current Provides guidance/ pharmacological.
registered nurse of pain medication local/national teaching to junior Contributes to
with positioning as needed. polices and improve staff members in development of
a patient’s trunk/ standards where regard to T&O/MSK local guidelines
Can utilise
limbs/joints to possible. conditions/injuries. and policies for
distraction
reduce pain and T&O patients.
techniques for Positions a patient’s
enhance comfort.
adults/children. trunk/limbs/joints
Assists the in order to reduce
Can perform

12
registered nurse pain and enhance
simple positioning
or therapist with comfort.
techniques to
safely rolling/
provide comfort/ Utilises adjuncts
turning/moving
pain relief to such as pillows
a patient with a
patients with T&O/ and other devices,
spinal injury.
MSK injuries/ eg. Braun frame,
Have up to date conditions under the traction, splints,
patient Moving indirect supervision collars etc. in order
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

and Handling of the registered to maintain comfort

training as per HSE nurse. and reduce pain.
Guidelines (2012).
Can safely move/
turn/roll a spinal
injured patient in
accordance with
local/national
guidelines
Adheres to local
health and safety
guidelines and
policies in relation
to T&O/MSK
injuries/conditions.
 Domain 2: Comfort Enhancer Framework (continued)
Links with following areas of NMC Code (2018) – Prioritise People and Preserve Safety

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Knowledge Has basic knowledge + + + + + +
and and understanding of: As band 2. Has knowledge and Has knowledge and As band 5. As band 5. Knowledge and
understanding • different moving and understanding of: understanding of: understanding of
handling techniques • different pain • non- guideline/policy
that can be used: assessment tools pharmaceutical development in
–w
 hen assisting strategies to relation to T&O
• importance of
patients to change maintain comfort/ patients’ comfort
accurate record
position when in a reduce pain enhancement.
keeping
cast, traction, etc. • different types of
• different
–w
 hen assisting communication analgesia; their
patients to safely methods. dosages, routes,
stand when non- side effects and
weight bearing contra-indications
on one side • different devices
(see Domain for administering
4 technician – analgesia
mobility and

13
• local and national
transfer)
health and safety
• safe techniques of guidelines in
moving/rolling/ relation to moving
turning spinal injured and handling
patients patients, including
• different adjuncts spinal injured
that can be used to patients.
maintain comfort
and reduce pain in
patients
• local health and
safety guidelines/
policies in relation to
moving and handling
of patients.

Learning Contract: Use a learning contract to facilitate and guide your development (see appendix 2).
ROYAL COLLEGE OF NURSING
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

Domain 3: Risk Manager bring inherent risk and furthermore orthopaedic

treatment modalities such as surgery also carry
Orthopaedic practitioners need to safely assess associated risks.
and manage the delivery of evidence-based,
Table 3 illustrates examples of both MSK specific
person-centred orthopaedic and trauma
and general/associated risks posed to trauma
care. One of the central aspects is the prompt
and orthopaedic patients. These examples are not
identification and management of risk to patient
meant to be exhaustive; but provide an overview
safety and well-being. Risks are both speciality
of the most common risks and complications.
specific and general. MSK conditions and injuries

Table 3: Complications and risks

Complications and risks associated with MSK General/associated complications and risks
Conditions and Injuries
Neurovascular compromise Risk of falls
Compartment syndrome Malnutrition
Venous thrombo embolism (VTE): Deep venous Dehydration/AKI
thrombosis and pulmonary embolism
Fat embolism Acute Delirium
Joint arthroplasty dislocation Sepsis
Primary and secondary wound infection Chest infection
Osteomyelitis Urinary tract infection
Fracture blisters Constipation
Pin site infection Urinary retention
Complex regional pain syndrome Psychological e.g. depression, post-traumatic stress
disorder
Pressure ulcers
Loss of independent mobility

All patients regardless of age are at potential Increasingly patients are being treated and cared
risk of speciality and/or general/associated for across different settings including primary,
complications. Certain groups of people may be secondary, community, their own homes and
at increased risk due to an inability, or reduced independent care settings. Enhanced recovery
ability, to communicate symptoms which would pathways, hospital admission prevention and
indicate the onset of a complication and this early discharge schemes mean that most of
includes people with special needs, learning/ the patient’s care is often not delivered within
intellectual disabilities, language barriers, acute the specialist orthopaedic setting. Trauma and
delirium and /or cognitive impairment. An orthopaedic (T&O) practitioners are key in
example is the risk of ‘diagnostic overshadowing’ the prevention, recognition, assessment and
where the symptom a patient presents with may management of specific complications and risks
be overlooked or seen as related to the cognitive associated with MSK conditions/injuries and
impairment, rather than the MSK condition or treatments, for example patients who develop an
injury. Orthopaedic practitioners must work acute delirium resulting in significant upset and
with these patients and their families to ensure distress to the patient and their family (Belleli
that their concerns and needs are addressed 2014). T&O trained practitioners can reduce the
through use of appropriate communication and severity of complications by detecting signs and
assessment aids, family/carer partnership and symptoms early. Therefore, partnership working
liaison with specialist services for dementia and with patients and their families and health care/
learning disability. specialist service teams is essential to ensure that
these risks continue to be assessed for, prevented

14
 ROYAL COLLEGE OF NURSING

and/or managed effectively. Lack of recognition Evidence: Belleli et al (2014); Drozd and Clinch
of complications will lead to increased length of (2016); Limbert and Santy-Tomlinson (2017);
stay, morbidity and mortality. NICE (2010b); NICE (2013); NICE (2015); NICE
(2016), RCN (2004), RCN (2014), Ali, Santy-
Risk Manager Competencies: Tomlinson and Watson (2014), Healthcare
Quality Improvement Partnership (2015), Shaikh
Competence 1: To recognise potential risks (2009), Lyons (2015), Sanders and Mauffrey
and complications associated with MSK (2013), National Major Trauma Nursing Group
conditions, injuries and treatment interventions. (2017), Votrubec and Thong (2013); Healthcare
(See table 3) Improvement Scotland (2014), NICE (2010),
Docherty and Mounsey (2016), MacLullich,
Competence 2: To have knowledge and skill
Ryan and Cash (2014), NHS England (2015),
to assess potential risk to individuals and
Healthcare Quality Improvement Partnership
populations using valid and reliable tools and
(2017), Hertz and Santy-Tomlinson 2018.
methods.

Competence3: To have knowledge and skill in

risk management strategies in order to optimise
patient safety and wellbeing.

Competence 4: To have knowledge and skill to

enable prompt recognition when complications
occur and to instigate evidence-based or best
practice interventions in order to minimise harm
to the patient.

Competence 5: To have knowledge and skill in

order to communicate potential T&O risks and
complications to senior nurses and medical
teams and to the patients and their families in a
manner that reflects their individual needs.

Key words:

• Risk assessment

• Risk management

• Complications

• Orthopaedic and trauma practitioner

knowledge

• Discharge planning.

15
 Domain 3: Risk Manager Competency Framework
Links with following areas of NMC Code (2018) – Practise Effectively and Preserve Safety

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Skills and Assists the + + + + + +
behaviours Registered Nurse Educates patients, Conducts risk Conducts risk Initiates further Leads analysis Appraisal of
(RN) with the families and assessment of assessment of investigations and monitoring tools to assess
risk assessment carers regarding patients under patients at a to establish of prevalence of risk and make
of patients and potential risks indirect supervision frequency and or confirm complications. recommendation
reports suspected and complications of a RN at a breadth appropriate complications. for policy
Managing
risk/complications under the direct frequency and to the individuals and practice
human and fiscal
promptly to a supervision of a RN. breadth determined condition and stage development at
resources to
senior practitioner. by the RN. of recovery. local and national
optimise risk free
e.g. Recognises Uses valid and care environments . level.
early warning signs reliable tools as
of acute delirium part of the risk
and records and assessment process,
reports findings for example:
to RN e.g using • Peripheral
NEWS2. Neurovascular
Observations

16
(RCN)
• Falls – Multi-
factorial risk
assessment
• 4AT delirium
• NEWS2.
Initiates the
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

management of
suspected or actual
complications.
Educates patients,
families, carers and
other members
of staff (including
students) regarding
potential risks/
complications and
how to assess for
them.
 Domain 3: Risk Manager Competency Framework (continued)
Links with following areas of NMC Code (2018) – Practise Effectively and Preserve Safety

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Knowledge Has a basic + + + + + +
and knowledge and Basic Knowledge and Has core T & O knowledge Has specialist T & Specialist T & O Advanced T &
understanding understanding knowledge and understanding and understanding of O knowledge and knowledge of O knowledge of
of common understanding of the evidence-based assessment, understanding of: innovation and innovation and
complications and of how to assessment examination procedures development development
• resource
their signs and educate tools used to and clinical investigations related to risk related to risk
utilisation
symptoms related patients and identify risk of to facilitate detection of management management
and skill mix
to MSK conditions their families. complications complications. strategies at a local strategies at a local
to facilitate
and injuries, e.g. and and national level. and national level.
Core T & O knowledge and effective
early and frequent deterioration. Influences local
understanding of methods minimisation and
mobilisation and & national policy
to accurately communicate management
movement to and practice on
actual and potential of speciality
minimise risk of evidence based
complications, both specialty and associated
VTE. practice which
and associated. complication
risks to individual includes identifying
Knowledge and
patients and areas requiring
understanding of
groups of further research.
complications associated

17
with specific musculoskeletal patients.
conditions and injuries (see
table 3).
Knowledge and
understanding of individual
patient factors that would
increase their risk of T & O
and associated complications,
for example:
• patients with
communication and/
or special needs and/or
cognitive difficulties,
• patients with a past medical
history of falls, DVT;
morbidly obese patients
Knowledge and
understanding of evidence-
based T & O risk management
strategies and interventions.
ROYAL COLLEGE OF NURSING

Learning Contract: Use a learning contract to facilitate and guide your development (see appendix 2).
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

Domain 4: Technician Many of these technical aspects of trauma

and orthopaedic care are highly specialised,
This domain encompasses the highly technical requiring advanced nursing skills. Maintaining
nature of orthopaedic and trauma practice; for expert specialist skills through regular training,
example, the knowledge, understanding and education and practice is imperative for the
skill required to provide care for patients with provision of evidenced based safe and effective
specialised devices and equipment used to either orthopaedic and trauma care.
treat orthopaedic conditions and injuries, or to
protect patients from complications. Technician competencies
The trauma and orthopaedic practitioner, Competence 1: To have knowledge of the different
therefore, needs to be competent in managing treatment modalities for the care of patients with
and using such treatment modalities. MSK conditions/injuries.

These technical aspects of care carry their own For examples see Table 4.
risk of complications and are, therefore, linked to
the risk management domain.

Table 4 Technician Competencies

Traction Hamilton Russell • Gallows/Bryants • skeletal • slings
and springs
Casts Upper and lower body • spinal jackets • hip spicas.
Full casts and plaster slabs
External fixators Ilizarov • Taylor spatial frames • monolateral •
Hoffman
Appliances Braces • slings • splints • cervical collars
Orthotics/prosthetics Artificial limbs, shoe modifications
Mobility/transfer aids Elbow/gutter crutches • walking sticks • walking
frames • wheelchairs • hoists and slings • sit-to-stand
transfer aids • transfer boards

Competence 2: To have knowledge and skill in • Communication and education of the patient
the safe assessment and management of the and family/carer (see domain 1 and 2)
patient to include: application and management
of equipment (excluding the application of • Pain management (see domain 2)
external fixators), management of complications • Risk management of complications specific
and holistic care of the patient. to treatment modality (see domain 3)
• In traction • Timely and accurate documentation of
• With a cast actions and reporting of nursing care
concerns
• With an external fixator
• Collaborative working with the MDT in all
• Using/wearing an orthopaedic appliance settings (see domain 1)

• Using mobility/transfer aids. • Education and training of practitioners

in specific treatment modalities e.g.
Competence 3: To have knowledge and skill in disseminates evidence-based best practice.
the provision of person centred care across the Audits further practice.
lifespan:
Evidence: BAPA (2013), Beck et al (2003),
• Knowledge of the MSK condition, relating Bertrand et al (2017), Blanchard & Brittain
co-morbidities, the management aims and (2016), British Orthopaedic Association (2007),
purpose of treatment

18
 ROYAL COLLEGE OF NURSING

British Orthopaedic Association (2015), British

Red Cross (2015), Chan et al (2013), Clarke and
Santy-Tomlinson (2014), Dandy and Edwards
(2009), Ferreiro Peteiro (2015), Judd (2008),
Lethaby et al (2011), MASCIP (2008), National
Major trauma Nursing Group (2017), Newton-
Triggs et al (2011), NICE (2011), NICE Spinal
injury assessment NG41 (2016), NICE 2016,
Patterson 2006, RCN (2004), RCN (2013), RCN
(2014), RCN (2015), Saithna (2011), Salminen
(2009), Santy-Tomlinson et al (2011), SIGN
(2009): Timms et al (2010).

19
 Domain 4: Technician competencies
Links with following areas of NMC Code (2018) – Prioritise People, Practise Effectively, Preserve Safety and Promote Professionalism and Trust.

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Skills and Assists with care + + + + + +
behaviours throughout the Assists with care Facilitates holistic Utilises evidenced Co-ordinates and Actively develops Leads strategic
patient’s journey throughout the care in the based resources/ guides patients the practice planning and
with a specialist patient’s journey patient’s journey and families on of others in policy/guideline
guidelines, and
orthopaedic device with a specialist with a specialist their journey patient and development
actively manages
under the direct orthopaedic device orthopaedic device with a specialist carer education in relation to
co-morbidities.
supervision of a under indirect under indirect orthopaedic and support on the treatment
registered nurse or Promotes evidence-
supervision of a supervision of a device. their journey modalities used
physiotherapist/ based care
registered nurse or registered nurse or Utilises evidence- with a specialist in the patient’s
occupational delivery for the
a physiotherapist/ a physiotherapist/ based resources/ orthopaedic journey with
therapist. patient and family
occupational occupational guidelines to device. a specialist
on their journey
therapist. therapist. teach and instruct And includes: orthopaedic
with a specialist
And includes: And includes: other health device.
orthopaedic device Specifics:
Specifics:. Specifcs: professionals in And includes:
Delegates nursing • Alters an external
specific treatment Specifics:
Re-applies simple • Performs pin site care appropriately. fixator including
modalities.
splints/ skin traction care. And includes: strut changes • Advises on
under direction of And includes: and frame appropriate

20
• Measures for Specifics:
senior practitioner. mobility aids. Specifics: adjustments specialist
• Applies/removes orthopaedic
Removes a backslab • Measures and fits • Prescribes
complex traction/ device for
under instruction. a cervical collar different
appliances e.g. the patient’s
• Wedge a cast appliances/cast.
Thomas splint management.
after medical
• Trim/bi-valve/
instruction.
window/split/
• remove a cast
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

• Implements use
of appropriate
mobility aid.
 Domain 4: Technician competencies (continued)
Links with following areas of NMC Code (2018) – Prioritise People, Practise Effectively, Preserve Safety and Promote Professionalism and Trust.

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

Knowledge Has a basic + + + + + +
and knowledge of As band 2. Has knowledge Knowledge of Knowledge Knowledge of Advanced
understanding common MSK of the impact evidence-based of specialist evidence-based knowledge and
conditions/injuries (short/medium/ literature relating orthopaedic/MSK national guidelines facilitates the
to inform holistic long term) of MSK to specialist devices used in the to prevent adoption of new
patient care. condition/injuries orthopaedic/ MSK management and and manage evidence-based
on the individual devices used in the care of patients co-morbidities. guidance relating
and their family for management and with complex MSK to specialist
specific treatment care of patients, and conditions/injuries. orthopaedic/MSK
modalities. of MDT resources Knowledge of devices.
And includes: to support the strategies to
individual and/or support the patient
Specifics:
their families . and family and
• Importance of
Knowledge of the impact of
neurovascular
of managing co-morbidities.
observations and
co-morbidities
prompt reporting
(see risk manager
of concerns

21
domain).
• Recognises and
And includes:
reports problems
– pin site Specifics :
infection. • Identifying
potential and
actual problems
– plaster sores,
impending
compartment
syndrome
• DVT, skin allergies
• Extended use of
a hard-cervical
collar
• Log rolling
procedure.

Learning Contract: Use a learning contract to facilitate and guide your development (see appendix 2).
ROYAL COLLEGE OF NURSING
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

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5. Websites
Acute Kidney Injury. Available at: www.nhs.uk/ National Osteoporosis Society. Available at:
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health-professionals/
Arthritis and musculoskeletal Alliance (ARMA).
Available at: www.arma.uk.net Nursing and Midwifery Council (NMC) Available
at: www.nmc.org.uk
British Orthopaedic Association. Available at:
www.boa.ac.uk Royal College of Nursing Society of Orthopaedic
and Trauma Nursing. Available at www.rcn.
National Early Warning Scores. Available at: org.uk/get-involved/forums/society-of-
www.rcplondon.ac.uk/projects/outputs/ orthopaedics-and-trauma-nursing
national-early-warning-score-news
Sepsis. Available at: www.nhs.uk/conditions/
National Institute for Health and Clinical sepsis/
Excellence (NICE) Guidelines. Available at:
www.nice.org.uk

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 ROYAL COLLEGE OF NURSING

Appendix 1: Practitioners’
comments
RCN Congress Belfast 2018
Society of Orthopaedic and Trauma Nursing Forum
Fringe – a Competence Framework for Orthopaedic
and Trauma Practitioners
The primary aim of this event was to discuss This fringe event aimed to:
the RCN Society of Orthopaedic and Trauma
Nursing (SOTN) forum’s latest project. The 1. Raise awareness of the new competencies to
‘fringe’ was targeted at all orthopaedic and guide orthopaedic practitioners
trauma nurses (bands 2-8) and nurse managers. 2. Present an overview of the developing new
The 2018 orthopaedic competencies have been competencies
revised and regenerated by a team of experts
working across the lifespan within orthopaedic 3. Seek delegate views of the new competencies
and trauma academia and practice. It was a
four country approach of expert nurses and 4. Seek suggestions on how to produce a final
one physiotherapist. The updated competencies working publication for practice
have been designed to guide a practitioner to
Outcome of fringe event:
either confirm their level of competence, or
work toward new competencies. Essential skills 1. Delegates did welcome the new competencies
and knowledge for competence in domains of
orthopaedic practice are given for each NHS 2. Delegates were informed of the pending new
band of nurse. These can be utilised in practice, competencies
facilitated with a learning contract, or become
an integral part of the appraisal process or 3. Consultation achieved with a range of T&O
contribute to the NMC revalidation process. practitioners.

27
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS

Feedback from nurses on different pay bands regarding the document

Pay bands Format Application User friendliness Learning contract

2 Clear identification Shows individual Can apply to Good application for
of all banding progress from band 2 practice. staff development.
levels. to 3.
Can be used to
determine correct
banding for experience.
3 Easy to read. Useful for appraisal Made sense. Good idea.
Some columns Easy to use
lengthy
4 Understood format. Ideal for appraisal. Facilitates working Useful tool.
Knew what was Good for new members towards competency
being asked as a of staff.
practitioner Demonstrates
managers expectations.
5 Felt it was Useful tool as part Demonstration of Can be used to prove
sometimes hard to of ongoing appraisal evidence to meet learning of particular
follow the columns. programme. competency was competence.
nebulous.
6 Relevant to Very helpful for Might be beneficial Really liked inclusion of
practice. revalidation. to print learning a learning contract.
contracts for
portfolio
7 Easy to read. Useful for identifying Straightforward and Like learning contracts
Clear format linked staff members easy to use. – will be useful when
to NMC code of individual strengths and working towards future
practice. weaknesses. development.
Can be used to identify Can be used as proof of
staff development progression.
needs.
8 Very good. Good resource for Easy to follow. Recognised evidence
Concise. assessment of practice. based tool.
Can be included into
personal portfolio for
revalidation.

28
 Appendix 2: Exemplar Learning Contract
Name of Practitioner:

Role of Practitioner and place of work: e.g. Band 5 Staff Nurse – trauma ward

Name of Manager/Mentor:

Domain/ Detail of Skill/knowledge Learning activities Summary Verification by Date of

competence competence deficit identified planned to address of evidence Manager/mentor. achievement
and level being skill/knowledge to support Short commentary and signature of
addressed deficit. achievement of on learning of practitioner and
learning. Please practitioner. manager/mentor.
cross reference
to portfolio of
evidence and NMC
code of practice.
Risk Manager Band 5 Need to increase Self-directed learning toA written summary Review written
Competence Conducts risk knowledge of review: of key learning from summary of learning
1: To recognise assessment of evidence based Healthcare Quality self-directed reading with Manager.

29
potential risks patients at a approaches to Improvement Partnership and visit to specialist
and complications frequency and assessing patient’s (2015) National Audit falls clinic and action
associated with breadth appropriate risk of falling. of Inpatient Falls audit plan for how this could
(MSK) conditions, the individuals report 2015. London. be implemented into
injuries and treatment condition and stage Royal College of practice.
interventions. of recovery. Physicians and Falls and
Uses valid and Fragility Fracture Audit
reliable tools as Programme.
part of the risk NICE (2015 updated
assessment process. 2017) Falls in older
people. Quality standard
86. Available at:
www.nice.org.uk/
guidance/qs86 Accessed
12.12.17.
Hertz, K and Santy-
Tomlinson, J (2018)
Fragility Fracture
Nursing. Holistic care
and management of the
orthogeriatric patient.
ROYAL COLLEGE OF NURSING

Visit to Specialist Falls

Clinic.
 Name of Practitioner:

Role of Practitioner and place of work:

Name of Manager/Mentor:

Domain/ Detail of Skill/knowledge Learning activities Summary Verification by Date of

competence competence deficit identified planned to address of evidence Manager/mentor. achievement
and level being skill/knowledge to support Short commentary and signature of
addressed deficit. achievement of on learning of practitioner and
learning. Please practitioner. manager/mentor.
cross reference
to portfolio of
evidence and NMC
code of practice.

30
A COMPETENCE FRAMEWORK FOR ORTHOPAEDIC AND TRAUMA PRACTITIONERS
The RCN represents nurses and nursing, promotes
excellence in practice and shapes health policies

RCN Online
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Published by the Royal College of Nursing

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February 2019
Review date: June 2024
Publication code: 007 036

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