7.1 Introduction

As the global population ages, musculoskeletal trauma in older people has become a growing challenge everywhere. Although management of older adults following trauma has some similarities to that for all trauma, there are also differences and specific considerations relating to ageing. The most common cause of injury in older people is a fall, so fall-related trauma will be the focus of this chapter while acknowledging that the care of trauma in older people, whatever the cause, is based on the same principles.

The aim of this chapter is to outline the care of older people following hip fracture, the most common significant injury requiring orthogeriatric care. Although the nursing interventions discussed here apply to orthogeriatric care generally, hip fracture is the most common reason for admission to an orthopaedic unit, so this is the focus. The complexity of needs, prevalence, number of bed days and cost means that the focus of care tends to be predominantly on this category of injury. The principal skills and knowledge needed to look after patients with hip fractures apply to the management of all older people with fractures. This care includes all the fundamental aspects of nursing care for the adult as well as specialised interventions for older people [1, 2].

7.2 Learning Outcomes

At the end of the chapter, and following further study and reflection, the reader will be able to:

  • Identify crucial factors that impact patient outcomes following hip fracture.

  • Describe hip fracture types and their surgical management.

  • Deliver evidence-based acute and perioperative care to patients with hip fracture.

  • Prepare and support the patient during the perioperative and rehabilitation phases.

  • Maintain safety and prevent and recognise complications.

  • Acknowledge the impact of a hip fracture on individuals’ lives and the challenges this creates.

  • Comprehensively prepare the patient for hospital discharge.

7.3 Perioperative Care

Assessment and subsequent care of the patient with a hip fracture are best provided by effective interdisciplinary team working based on sound orthogeriatric principles [3]; it is essential that the causes and effects of the fall, unstable comorbidities and early effective rehabilitation are considered alongside fracture treatment [4].

Physical care attracts the most attention, and caring for patients following hip fracture is an everyday experience for care providers. For the patient, however, it is a life-changing event with severe and frightening consequences [5, 6]. Patients have existential concerns that a hip fracture is a serious injury with complications that can be life-threatening and that it can reduce their future independence and quality of life. These preconceived notions can place patients in a crisis-like situation during hospitalisation and in the days after discharge and can interfere with their ability to retain information and participate in their own recovery.

It is, therefore, essential to consider both physical and psychological impacts of the experience of having a hip fracture [6,7,8].

Surgery is the preferred treatment for hip fracture because it provides stable fixation, facilitates full weight bearing and decreases the risk of complications [9]. Non-operative management carries additional risks of immobility, thromboembolism, pressure ulcers/injuries, other complications and loss of function and independence. Nevertheless, non-operative treatment may sometimes be chosen for very frail patients if pain can be controlled by other means. Some impacted and/or stable fractures may also be treated non-operatively.

There are three phases to perioperative care:

  1. 1.

    The preoperative phase is the period prior to arrival in the operating department for surgery. The goals are to optimise the general health of the patient, stabilise the injury, manage pain, prevent delirium and restore function. Standardised preoperative assessments and patient-centred management protocols are needed. The aim is to facilitate preparation for surgery through coordinated orthogeriatric and anaesthetic care. Surgery within 24 h after admission to hospital has been shown to lower mortality rates [10].

  2. 2.

    Intraoperative care aims to mitigate the pathophysiological effects of surgery without destabilising the patient’s physiology. Patients are at substantial risk of perioperative morbidity and mortality due to age and frailty in combination with a major surgical event. They have decreased physiological reserve, and one or more comorbidities, polypharmacy, frailty and cognitive dysfunction are common with a potential negative impact on physiology (see Chap. 3 for further information about frailty).

  3. 3.

    Post-operative orthogeriatric care aims to mitigate the effects of surgery, facilitate remobilisation, and re-enable and re-motivate patients in preparation for discharge, ideally back to their place of residence before the fracture. The early post-operative phase is crucial as delayed remobilisation is associated with prolonged hospital stay and has a negative impact on 30-day mortality rates [10, 11]. Post-operative care includes, therefore, early mobilisation, pain management, post-operative hypotension and fluid management, postsurgical anaemia management, delirium assessment and nutritional optimisation.

7.3.1 Hip Fracture Diagnosis and Surgery

A hip fracture is diagnosed by the symptoms and verified with X-rays [4, 11], sometimes supplemented with MRI or CT, to establish the diagnosis. Most hip fractures occur in one of the two broad locations: at the femoral neck or in the trochanteric region.

The location of the fracture and the degree of displacement or impaction help determine the best treatment. In nearly all cases, surgery is the treatment of choice as this is the most effective way to manage pain and stabilise the fracture so that the patient can remobilise as soon as possible [9].

  • Femoral neck fracture: This fracture occurs in the neck region of the femur in the intracapsular region (within the hip joint capsule). The configuration of the blood supply to this area means that any type of femoral neck fracture may disrupt the blood supply to the femoral head, causing it to collapse due to avascular necrosis. As this risk is higher after a displaced fracture, these are usually managed with hemi- or total hip arthroplasty. Un-displaced fractures are usually stabilised with parallel implants (see Table 7.1).

  • Trochanteric (or intertrochanteric) hip fracture: This fracture occurs in the upper 8–12 cm of the femoral shaft in the region between the lesser and greater trochanters. As the fracture is extracapsular (outside the joint capsule), the blood supply is less likely to be disrupted, so internal fixation with intramedullary nail or sliding hip screw is preferred (see Fig. 7.1).

Table 7.1 Decision-making criteria for the type of surgery for hip fractures [11, 12]
Fig. 7.1
A chart of three different types of femoral neck fractures and extracapsular fractures, along with their corresponding five surgical treatment and X rays.

How hip fracture surgery decisions are made: an algorithm for hip fracture surgery (Reproduced with permission from Acta Orthop [12])

Subtrochanteric hip fracture: This fracture occurs in the upper part of the femoral shaft with its major extension just below the lesser trochanter. An intramedullary nail is recommended to internally fix a subtrochanteric fracture (see Fig. 7.1). It is also increasingly common for patients admitted to hospital with a fragility fracture to have sustained a peri-prosthetic fracture (a fracture around an orthopaedic implant/prosthesis) around previous arthroplasty implants of the hip and knee, reflecting the more widespread conduct of hip and knee arthroplasty for the management of arthritis. Patients who have previously fractured a hip may also sustain a fracture around the previous fixation implant/hemi-arthroplasty. These fractures are more complex to manage surgically.

7.4 Emergency and Preoperative Care

Sustaining a hip fracture is a sudden traumatic event, threatening many aspects of patients’ lives and a forceful reminder of their mortality [6, 13]. Restoring function is one of the crucial factors affecting the overall outcome after a hip fracture, so physical care attracts the most attention [4]. The primary goals of care for the older adult with hip fracture are to maximise mobility and preserve optimal function [1, 2]. Psychosocial factors, however, must be incorporated into a holistic approach to care, helping patients to find motivation to rehabilitate [1, 13].

Emergency departments (EDs) are often noisy, busy, overstimulating care settings, with inappropriate care environments for vulnerable older people in a state of personal and physical crisis. These conditions can expose patients to a risk of acute delirium (Chap. 12). Reducing the impact of this requires consideration of the following three principles [14]:

  • Timeliness—avoid unnecessary and unwanted delay in the ED with rapid transfer to a definitive care environment.

  • Effectiveness—aim for optimal outcomes using the best available evidence.

  • Patient-centredness—provide care that is respectful of and responsive to individual needs.

Patients should fast for up to 6 h before the operation and must not drink for up to 2 h before the operation (both depending on local guidance). It is important that patients do not fast for an unnecessarily long time and are offered clear liquids (preferably containing sugar and protein) up to 2 h before the operation [15, 16]. Some patients will have been lying on the floor at home for a long time after their fall. Consequently, they are at risk of dehydration and other complications of a ‘long lie’ after the fall including pressure ulcers/injuries, incontinence, compartment syndrome and rhabdomyolysis (release of toxins from muscle damage into the bloodstream). In accordance with local guidelines, intravenous fluid therapy should be commenced soon after admission to the ED [17]. EKG/ECG and initial blood tests should include, as a minimum, BAC test (blood typing, antibody screen and computer control test), fluid and electrolyte balance and haemoglobin. Identification of signs of a urine infection such as pyrexia, frequency, cloudy/foul-smelling urine and incontinence may instigate a urine sample being sent for microbiology.

Providing emergency care to older people following trauma must follow the same principles as for all age groups, using the ABCDE approach. The normal and abnormal changes of ageing, compounded by active comorbidities, mean that morbidity and mortality are increased concerns. Examples of physiological considerations relating to ageing include the following [18]:

Airway—ageing causes degeneration of the physiological airway, and musculoskeletal pathology, such as osteoarthritis, can reduce neck and spine flexibility, making airway management difficult. Any pre-existing dysphagia increases the risk of aspiration and pneumonia. Hypostatic pneumonia is an increased risk due to immobility and limited coughing reflexes.

Breathing—depleted respiratory resilience leads to loss of hypoxic reserve and potential hypoventilation with oxygen administration; oxygen therapy is still needed but requires closer monitoring in recognition of this. Older people are more at risk of respiratory failure because of the increased work of breathing.

Circulation—reduction in cardiopulmonary reserve means that there is increased risk of fluid overload when administering intravenous fluids (particularly colloids), requiring closer monitoring. Normal heart rate and blood pressure are not a guarantee of normal cardiac output and use of beta-blockers, and antihypertensive agents can mask the signs of deterioration. Blood loss from the fracture site can vary from a few millilitres for an un-displaced intracapsular fracture to over a litre for a multi-fragment or subtrochanteric fracture. All patients should have intravenous saline from the time of presentation, with the rate of infusion adjusted according to the estimated blood loss and degree of dehydration. Older people have an increased risk of heart failure, so infusion needs to be carefully prescribed and monitored.

Disability—prolonged inactivity and disuse limit final functional outcome and impact survival.

Exposure—skin and connective tissue undergo extensive changes with ageing, resulting in diminished thermoregulation, increased risk of infection, poor wound healing and increased susceptibility to hypothermia. Prevention of these risks should begin from arrival in the ED. The patient’s skin should be examined from head to toe to identify any skin damage or redness and recorded in the patient record (see Chap. 9 for further information about pressure ulcer/injury prevention). A pressure-redistributing mattress should be in place on the trolley/bed; older people who are suspected to have hip fracture should preferably be immediately admitted to a hospital bed (rather than ED trolley) with a pressure-relieving/redistributing mattress. Clothing should be replaced with a gown as soon as possible so that zippers or buttons do not create pressure, leading to skin injuries [15, 19]. Adequate pain assessment and management should be in place to enable position changes.The admission to the ED is the point at which comprehensive geriatric assessment (CGA) should begin (see Chap. 6). A full and comprehensive history should be taken that includes relevant comorbidities, medication history and previous functional ability as well as personal and social history. This will form the initial CGA assessment to be built on in the following hours and days. Further detailed assessment can then take place following hospital admission and surgery. It is important to get an overview of the patient’s overall history from various sources on arrival at the ED. Many older people, with and without cognitive impairment, are unable to provide an accurate history in this stressful situation so the history should also be sought from a relative, caregiver or general practitioner [20, 21].

7.4.1 Pain Management

A hip fracture is very painful, but good pain management is a frequently neglected aspect of care. Unresolved pain contributes to worse outcomes for the patient. Good collaboration among the orthogeriatric team is essential for achieving good pain management, particularly so that mobilisation can take place soon after surgery.

One significant reason for inadequate analgesia is poor assessment, particularly in those who have difficulty in or are unable to communicate [22]. Acute pain should be continuously assessed by the clinical care team at the time of presentation and then regularly throughout the care pathway so that effective pain management can be implemented. Every patient should receive frequent, accurate pain assessment using an evidence-based tool, beginning at the admission interview [23]. A review of health records should be conducted to detect pre-existing painful conditions and prescribed analgesia, noting its impact and any side effects and reporting these to the clinical team.

Common instruments used for pain assessment are the verbal rating scale (VRS) and the visual analogue scale (VAS) (particularly useful for patients with cognitive decline) [24]. Older people are often reluctant to acknowledge and report pain, so practitioners should be alert to signs of pain in older people including behavioural and autonomic signs of pain, e.g. facial grimaces/frowns; writhing or constantly shifting while in bed, moaning, whimpering or groaning; restlessness; or agitation.

Administration of nerve blocks preoperatively (including in pre-hospital care by paramedics in some countries) for patients with hip fracture is increasingly common as they have been shown to have a significant positive effect on the pain experience and minimise the need for opioid analgesics, which have multiple risk factors in older frail patients [25, 26]. Advanced and specialist nurses increasingly have a role in the administration of nerve blocks both in the ED and inpatient units [26].

Immediate analgesia should be offered to all patients presenting with suspected hip fracture, including those with cognitive impairment. The choice and dose of analgesia should be age-appropriate, with close monitoring for associated side effects. Analgesia should be sufficient to allow movements necessary for investigations (indicated by the ability to tolerate passive external rotation of the leg) and for nursing care. Multimodal analgesia can be used to maximise the positive effect of the selected medications while limiting the associated adverse effects [27]. Older people are more susceptible to adverse medication reactions. However, analgesics can be used safely and effectively when age-related differences in absorption and distributions of these medications are considered alongside individual risk factors [22]. Comorbidities, especially kidney disease, and polypharmacy must be considered, and pain management in those with cognitive difficulties is challenging because of communication problems.Attention to patient comfort using support and positioning is an additional element of pain management. Turning the patient with a hip fracture onto the affected side should be avoided until it has been surgically fixed; gently ‘tipping’ the patient may be unavoidable when performing care and checking the skin on the patient’s back. Pillows should be used between the thighs and knees to help manage pain. Adduction or rotation of the affected leg should be avoided. Changing the patient’s position should always be performed by two experienced nurses using good manual handling practice.

7.5 Post-operative Care

Post-operatively, orthogeriatric care aims to mitigate the effects of the fracture and surgery and remobilise, re-enable and re-motivate patients in preparation for discharge, ideally back to their place of residence before the fracture (Chaps. 8, 14 and 16). The fundamental principles of post-operative care include:

  • Early mobilisation

  • Management of pain

  • Post-operative hypotension management

  • Optimisation of hydration

  • Management of anaemia

  • Assessment for delirium

  • Nutritional optimisation

Mobilising the patient soon after surgery has proven to be beneficial in prevention of the complications of mobility and in assisting recovery (see Chap. 8 for more information about mobility, remobilisation and exercise following fragility fractures). The early post-operative phase is crucial, as delayed remobilisation is associated with prolonged hospital stay [11]. Following surgery, it should be standard practice to sit the patient out of bed for them to begin to stand on the day after surgery, providing that this is not medically contraindicated. Attention should be paid to the potential for the patient’s blood pressure to drop (orthostatic hypotension) on standing in the first few days. Progress thereafter varies considerably depending on the individual patient and the type of fracture or surgery. Patients with extracapsular fractures tend to take longer to remobilise than those with intracapsular fractures [4]. Initially, they may be afraid of weight bearing on the operated leg and should be motivated by the care team while ensuring effective pain management.

Creating good outcomes in rehabilitation after a hip fracture requires motivation, so understanding a patient’s anxiety, feelings of vulnerability and concerns for the future should be considered as barriers for recovery [28].

7.5.1 Pain Management

Pain assessment, evaluation, reassessment and appropriate administration of analgesia should be central to routine care and to promote rehabilitation. Most patients have constant pain in the days following surgery, which worsens when they move, so they want to lie still to avoid pain, increasing the impact of immobility. The same principles of pain assessment and pain management discussed earlier apply in the post-operative period. If pain is poorly controlled, mobilisation will be delayed, increasing the risk of the complications of prolonged immobility and leading to increased dependency and associated rise in the risk of delirium [29, 30]. Pain also inhibits the ability to receive and understand given information.

The highly variable nature of pain and an individual’s response to it make accurate assessment a central element in facilitating individualised pain management and monitoring. Many studies have shown that cognitively impaired and acutely confused patients receive less analgesia than their unimpaired counterparts. To help staff understand the individual needs of a person with dementia, the use of an assessment tool such as the ‘this is me’ tool [31] encourages relatives and carers to share individual information, characteristics and behaviour.

Paracetamol can be offered every 6 h unless contraindicated with additional opioids if paracetamol alone does not provide sufficient pain relief. Nonsteroidal anti-inflammatory drugs are often contraindicated in older adults and should only be considered in selected cases. Opioid analgesia is a key component in managing hip fracture pain, but there remains wide variability in individual need; opioid requirements decrease with ageing, and side effects can impede mobility, impair cognition and interfere with recovery. Other medications such as sedatives, anti-emetics and neuroleptics may increase opioid sedation, and adverse effects need to be considered when dosing and titrating opioids. It is essential to anticipate and monitor common side effects such as sedation, constipation, nausea and vomiting and instigate preventive treatment as appropriate [32]. Older people have increased risk of respiratory depression with opioids, so regularly monitoring sedation levels is recommended.

Non-pharmacological therapies are also an integral part of the treatment plan. A variety of options have been shown to be effective individually or in combination with appropriate medications [1]. Selecting strategies that the patient believes to enhance the effectiveness is helpful. Recommended therapies include, but are not limited to:

  • Ensuring that the patient feels warm using blankets

  • Cognitive-behavioural strategies: breathing exercises, relaxation therapy, humour, music therapy and socialisation/distraction

  • Repositioning regularly with supportive pillows, engaging the patient in decision-making about comfortable positions

  • Using an interdisciplinary approach: occupational therapists may provide custom seating, splints or adaptive devices; physiotherapists will assist in individual mobility, exercise and strengthening programmes

  • Physical activity to improve range of motion, mobility and strength (Chap. 8)

7.5.2 Preparation for Discharge

Discharge planning should be a coordinated effort between the patient, the patient’s family, the interdisciplinary team and staff in the destination setting, if the patient is to be discharged to another care facility (discharge and post-hospital care are considered in more detail in Chap. 16). This process should begin as soon as possible following admission.

Education of the patient and family or other carers is an important aspect of preparing for discharge both in terms of their continued recovery and rehabilitation and in relation to prevention for future falls (Chap. 4) and secondary fracture prevention (Chap. 5). This can be a challenge for healthcare providers because of decreasing lengths of stay and the need to deliver increasingly complex information. So, providing patients with alternative ways of receiving information is valuable. This may include printed written information and various forms of electronic information and education using mobile phone apps, for example. Providing patients with an information booklet or automated pictographic illustration of discharge instructions has been proven valuable [33,34,35]. Healthcare professionals can also support information and education for patients with a hip fracture using an app that accommodates different learning styles. This way of dissemination of health knowledge can be used by elderly hip fracture patients even if they are not used to technology [36].

There are numerous factors to consider when preparing the patient for discharge. The responsibility for the patient’s care after discharge from the hospital is often delegated to the patient and their family (Chap. 15) along with the general practitioner and, sometimes, community care staff. Therefore, the patient and their caregivers must be able to understand the discharge advice so that they can recall aftercare instructions and recognise that the information they require for their post-discharge care can be found in these (written or other) instructions. There are several reasons for supporting oral information or education with written or virtual illustrations: with ageing visual clarity and auditory acuity decreases, making it difficult for older people to assimilate information, and poor lighting, noise levels and room temperatures can inhibit the learning process. Managing multiple messages can be difficult for older people, and their personal perception of the severity of their injury and subsequent surgery will limit their ability to receive and understand information. Anticipation, anxiety and fear all contribute to diminished reception of knowledge. Fear and preconceived notions of the consequences of acquiring a hip fracture also block patients’ ability to take in information [6].

7.6 Fundamentals of Perioperative Care

Maintaining mobility, energy and participation in self-care during an older person’s hospital stay can help to maintain their independence, reduce the likelihood of falls and fall-related injuries and minimise loss of confidence due to fear of falling (Chap. 4). The underlying principle of high-quality care is empathy; this is a complex multidimensional aspect of the therapeutic relationship that involves understanding the needs, meanings, fears, priorities and perspectives of patients [37, 38] (Chap. 12).

Attending to comfort and hygiene is a fundamental care activity. This includes, for example, acknowledging that the patient often does not feel hunger or thirst and therefore may have a dry mouth, needing effective and frequent mouth care. Many other aspects of fundamental nursing care during the perioperative period are covered in other chapters including the following:

Cognitive impairment and acute delirium—The nursing team is most likely to recognise and act on the signs of altered cognitive function and/or signs of delirium. Interaction between care providers and a patient with cognitive impairment can be a source of stress, particularly if the individual with cognitive impairment resists the efforts of the care provider (Chap. 12).

Pressure ulcer/injury prevention—Pressure injuries are serious complications of immobility, hospitalisation and surgery and can affect up to one-third of hip fracture patients (Chap. 9).

Hydration and nutrition—Fluid management in older people can be difficult as they may reduce/self-regulate fluid intake to control incontinence or urinary frequency and to manage difficulties in accessing toilet facilities. Close monitoring of fluid balance is essential to prevent or identify renal injury. Often patients do not like or want to drink fluids or nutritional supplements. Nutrition is closely linked to all recovery outcomes. Although it is the responsibility of the whole team, the 24-h presence of the nursing team makes them central to adequate fluid and dietary intake (Chap. 11).

Constipation—Either acute or chronic constipation is a significant and common complication for patients following fracture and during periods of ill health and immobility. Prevention should be considered early in the care pathway; this should involve:

  • Regular assessment of bowel function including frequency and consistency of defecation

  • Titration of opioids as pain diminishes—opioid analgesia is a significant cause of constipation

  • Providing and encouraging a fibre-rich but palatable diet and sufficient oral fluid intake

  • Careful but early use of prescribed aperients

Nurses should also educate patients about how to diminish aperients after discharge according to their changed mobility, regained privacy and, eventually, regained appetite.

Healthcare-associated infection—Prevention, recognition and management of infection are the responsibility of the whole orthogeriatric team but are central to 24-h nursing care, which includes coordination of care provided by the other team members. Nurses in leadership roles can be instrumental in ensuring adherence of staff to infection prevention guidelines and monitoring rates of infection. Prevention of surgical site (Chap. 10), pulmonary and urinary tract infections and thromboembolism are also important in perioperative care.

Secondary fracture prevention—When preparing the patient for discharge, it is important to consider secondary prevention of the fracture. This is described in detail in Chaps. 2 and 5 and should be a focus during the entire patient’s stay in hospital. This includes referral for investigation and—when needed—treatment of osteoporosis together with assessment and prevention of fall risk (Chap. 4).

Summary of Key Points

  • The care of the orthogeriatric patient following hip fracture and subsequent surgery presents significant challenges for the healthcare team.

  • Effective evidence-based nursing care is crucial in optimising patient outcomes following hip fracture.

  • Nurses need to understand different types of hip fracture and their management so that they can deliver evidence-based acute and perioperative care to patients with hip fracture based on each person’s specific needs.

  • Much of the pre-, peri- and post-operative care of the patient in need of hip fracture surgery is aimed at maintaining safety and preventing and recognising the complications of the fracture and surgery.

  • Patients have existential concerns and worries about the future as they know that a hip fracture is a serious injury with complications that can be life-threatening or threaten their mobility.

  • Even once the patient has recovered from surgery, there remains the need to comprehensively prepare them for discharge.

7.7 Suggested Further Study and Ideas for Reflections

After reading this chapter, consider the following case example:

Mrs. Ito has been admitted to the ED in her local city hospital following an intertrochanteric hip fracture. You are the practitioner who receives her on arrival at the orthopaedic unit. Her daughter is with her.

Mrs. Ito is transferred from the ED trolley to a bed. She is clearly in pain, so you administer the pain medication she is due immediately. While you are making her comfortable, you chat with her about how she is feeling. At first, she seems a little uncertain in her answers, and you notice that she seems anxious.

  • What do you think may be going on in her mind? What might be her worries?

  • How might you find out more about what her experiences and worries are? And how can you comfort her?

The following day, after Mrs. Ito’s surgery for internal fixation of her fracture, you are responsible for her personal care.

  • Write a reflection about what you think is important for patients in their post-operative care.

7.7.1 General Suggestions for Further Reflection

  • Talk with your colleagues about what you have learned and the ways you could use this to address the problems identified. Have you noted any areas of good practice in this chapter that do not currently happen in your own area that you might consider implementing?

  • Reflect on your practice concerning pain management; which tools do you use? Do you reassess patients’ pain? And how do you react if the patient is still in pain?

  • Talk with patients and relatives and other health professionals about topics concerning the patient pathway such as preoperative care and pain management. Reflect on what you learn from these discussions, and make suggestions about how practice might be developed to improve satisfaction and encourage patient empowerment by involvement of patients and relatives in care.

7.7.2 Further Suggested Reading

7.8 How to Self-Assess Learning

To identify learning achieved and the need for further study, the following strategies may be helpful:

  • Examine local documentation of nursing care regarding hip fracture care and other outcomes, and use this to assess your own knowledge and performance. Fundamentally, nursing is a team effort, so consider this from your own individual perspective as well as that of the team.

  • Seek advice and mentorship from other expert clinicians regarding the issues raised in this chapter, e.g. pain specialists, anaesthetists, orthopaedic surgeons, geriatricians and physiotherapists. Have ‘learning conversations’ with specialists and other members of the team to keep up to date on new evidence and disseminate it to colleagues. These conversations can include any recent new knowledge or evidence.

  • Review indicators of good practice (e.g. incidence of complications, early mobilisation, regular pain assessment and evaluation), and regularly assess patient and carer views and satisfaction; satisfaction has been recognised as an independent indicator of nursing care quality.

  • Peer review by colleagues can be used to assess individual progress and practice but should not be too formal. There should be open discussion within the team. Weekly case conferences can identify nurse-focused issues and enable the exchange of expertise.

  • Collaborate with health professionals from other departments covering the patient pathway to undertake case evaluation.