1. Altmiller, Gerry


For the last decade, quality and safety have been the ardent focus of healthcare improvement. Many agencies provide resources to healthcare providers to assist their endeavors. The Quality and Safety Education for Nurses (QSEN) Collaboration developed competencies that define the concepts of quality and safety in relation to nursing practice and education. These concepts are not new to orthopaedic nursing; they are better defined through the QSEN competencies so that nurses can develop practice behaviors that ensure quality and safety for the patients they care for. The QSEN competencies guide the processes that support the Orthopaedic Core Competencies: Across the Lifespan. Together, they enhance the orthopaedic specialty by deepening the focus on patient safety and high-quality care. Preceptors are in a unique position to influence new nurses and those transitioning into orthopaedic nursing to adopt these practices as they develop skills to meet the requirements of the specialty.


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To meet the many challenges of healthcare today and to prepare future workers for interdisciplinary teamwork so that they can provide high-quality, safe, patient-centered care, national organizations are leading the way providing data, guidance, and support. The Institute of Medicine (IOM, 2000) initiated the call for change in the way that healthcare is provided with the landmark report To Err Is Human. In this report, it was identified that as many as 98,000 persons die each year in hospitals as a result of medical error. Reports followed that outlined mandates for competencies to protect patients, ensure safety, and improve the overall quality of the care rendered to them.


Many agencies and healthcare organizations provide information and resources to address quality and safety (see Table 1). One such national organization that undertook the challenge of addressing the IOM mandates was the Quality and Safety Education for Nurses (QSEN) Collaboration. Funded by the Robert Wood Johnson Foundation, this group set out to change the way that nurses are educated by developing six competencies that mirrored the IOM mandates for change. They identified the knowledge, skills, and attitudes needed by nurses to meet the competencies, which emphasized patient-centered care, collaboration with other members of the healthcare team, evidence-based practice, quality improvement and safety, and the integrated use of informatics (Cronenwett et al., 2007). Now partnered with the American Association of the Colleges of Nursing, they provide support for those on the front lines of healthcare as well as faculty and students in their initiatives to improve quality and ensure patient safety.

Table 1 - Click to enlarge in new windowTable 1. Resources for Quality and Safety

The QSEN Competencies (see Table 2) provide a framework focused on improving healthcare that is applicable to all nursing specialties. They transparently overlap the Orthopaedic Core Competencies (National Association of Orthopaedic Nurses, 2007) and enhance the role of the orthopaedic nurse by increasing the focus on quality and safety across the lifespan. The Orthopaedic Core Competencies (see Table 3) address pertinent topics in orthopaedic care including subspecialties of pediatrics, geriatrics, and palliative care. The competencies recognize three levels of nursing practice, competent, experienced/proficient, and senior practitioner/expert, which can be applied to advanced practice nursing. Each level requires orthopaedic knowledge, skills, and attitudes that blend well with the QSEN competencies and support safe, high-quality care. The experienced and expert-level orthopaedic nurse frequently assumes leadership and preceptor roles, which increase opportunities to share information and demonstrate nursing practice that supports quality and safety. These core competencies can be used within the expanded practice of the orthopaedic specialty as guidelines for preceptors as they oversee the nursing orientation of new-to-practice nurses as well as for facilitating the transition of seasoned nurses into orthopaedic patient care services.

Table 2 - Click to enlarge in new windowTable 2. QSEN Competencies
Table 3 - Click to enlarge in new windowTable 3. Topics Included in the Orthopaedic Nursing Core Competencies

Each level recognized in the Orthopaedic Core Competencies builds on the expertise achieved at the previous level. At the level of a competent nurse, the practitioner assesses and monitors for physical comfort, patient preferences, and family involvement. The competent nurse functions as a member of the team, understanding safety principles that guide practice, and integrating information and technology to achieve consistent positive patient outcomes. At the level of experienced and proficient nurse, the practitioner assesses, plans, and manages care of patients with complex needs, incorporating interventions based on evidence. The experienced nurse mentors peers and works within the team to develop strategies that improve care delivery processes and correct system design errors that create threats to patient safety. At the level of a senior practitioner and expert nurse, the practitioner provides leadership in the care of patient groups, reinforces patient-determined goals, and assists in solving problems at the point of care. The expert nurse models an attitude of partnership with other team members, acknowledging the contribution that each discipline makes to meeting the patient needs and helping the patient achieve his or her best possible state of wellness. Recognizing the knowledge, skills, and attitudes required for this specialty, the Orthopaedic Core Competencies dovetail with the implementation of the six QSEN competencies, creating an increased emphasis on quality and safety in orthopaedic patient care. The following will review the six QSEN competencies and connect them to the orthopaedic nursing specialty.


Patient-Centered Care

The first QSEN competency focuses on patient-centered care and recognizes the patient as the source of control in his or her care based on individual preferences. In orthopaedic nursing, one of the highest priorities of patient-centered care is pain management. During orientation, the orthopaedic nurse preceptor demonstrates the institution's emphasis on patient-centered care through the deliberate focus on pain management. For example, the competent nurse encourages patients to report pain being experienced, acknowledging that pain management is highly individualized, particularly where perceptions are widely varied among patients such as seen during recovery and rehabilitation following a total knee arthroplasty. The experienced nurse incorporates nonpharmacologic interventions such as music therapy, relaxation, or guided imagery into the plan of care for pain based on patient preferences. The expert orthopaedic nurse has the knowledge and skill to implement individual and population-based care that directly affects patient outcomes by developing protocols that address pain management and by evaluating their effectiveness.


Patient-centered care includes identifying population-based patient safety threats and addressing them. Osteoporosis is a serious health threat for older individuals and orthopaedic nurses play an important role in identifying those at risk and connecting them to treatment. The 2 Million Is 2 Many project is a national awareness program initiated by the National Bone Health Alliance (2012). It supports nursing's effort to protect patients from osteoporosis-related bone breaks. To support the program's goal to reduce the incidence of fractures 20% by 2020, nurses caring for patients aged 50 years or older who experience a fracture can request a test for osteoporosis to identify those with the condition so that appropriate care can be implemented.


Another way the orthopaedic nurse emphasizes patient-centered care is by demonstrating to new staff the importance of acknowledging individual patient goals. In example, preceptors can emphasize patient-centered care through an initiative to use a white board in each patient room to list the patient's daily goal. Developing the goal provides an opportunity for the nurse to collaborate with the patient and recognize his or her priorities. This process acknowledges the value of patient input and allows the goal to be personal and important to the individual patient, supporting the values of respect and understanding that exemplify this competency. Through initiatives such as this, preceptors demonstrate that empowering the patient promotes communication, acknowledges the priorities of the individual, and increases patient satisfaction.


Teamwork and Collaboration

The teamwork and collaboration competency requires working effectively with nurses and team members from other disciplines through open dialogue, mutual respect, and shared decision making to provide high-quality patient care that results in consistent positive outcomes. Competent nurses huddle with team members to identify concerns and priorities. They use established communication practices such as SBAR (situation, background, assessment, recommendation) to support effective teamwork and clear communication during hand-offs or during transitions between care phases such as from surgery to recovery to rehabilitation. Experienced nurses cross monitor team interactions, listening and confirming information, which allows for corrections to be made immediately. They influence the practice of new staff by modeling appropriate delegation techniques and assigning responsibilities on the basis of scope of practice. Expert nurses provide leadership and model effective communication during high stress team efforts such as managing care of a patient with a fat embolism or supporting staff during resuscitations.


Preceptors model an attitude of partnership with other team members by acknowledging the contribution each discipline makes to supporting and improving the patient's health status. The complexity of caring for orthopaedic patients demands this. Consider the care of a patient admitted for lower extremity amputation, whose care is complicated by age, diabetes, and long-standing cardiac disease. The orthopaedic nurse coordinates the care of multiple disciplines including a surgical team, a medical team, a physical therapist, an occupational therapist, and a nutritionist, all focused on optimizing the patient's health status. Preceptors demonstrate that strong communication skills and use of effective communication strategies to ensure safety are required when so many are involved in the patient's care. Safety is supported through the use of strategies such as the check-back or read-back, which is repeating back orders and directions to confirm accuracy. The two-challenge rule ensures that concerns are noted by restating them a second time if needed. Using this strategy, if a concern is brought forward and it is not acknowledged by other team members, the nurse has an obligation to bring it forward a second time to be sure that it is considered and addressed. In this way, the preceptor demonstrates skills in patient advocacy.


When an error occurs, frequently it is discovered afterward that someone in the room was concerned that the error was impending but was not comfortable speaking up. The use of critical language allows individuals to draw attention to a situation in which they believe an error may occur. Critical language is an established phrase within the institution that when it is used, all involved should stop and clarify actions. For instance, in the case of a patient being prepared for a procedure on the wrong side, the concerned individual would say "I need some clarity" and the group would proceed to review what the procedure is, identifying correct patient and correct side, even if it has already been done earlier. If a patient was about to receive a blood transfusion or treatment that was intended for another patient, the concerned individual would say "I need some clarity" and the group would review the treatment and the intended patient. Critical language provides the vehicle that allows the team to stop errors before they occur. The Agency for Healthcare Research and Quality's (AHRQ's) TeamSTEPPS (2005a, 2005b), a program to promote teamwork and communication, provides short videos to demonstrate some of these and other techniques that can be utilized by preceptors as teaching tools to improve communication skills of new staff.


Evidence-Based Practice

The third QSEN competency focuses on the knowledge, skills, and attitudes needed for integrating evidence-based practice with clinical expertise to provide current and expert patient care. The competent orthopaedic nurse follows standardized practices based on evidence to promote consistency and safety such as those used for early mobilization. The experienced nurse works on committees to determine best practices for common orthopaedic concerns such as transfusion after knee replacement or protocols for deep vein thrombosis prophylaxis. The expert nurse serves as a resource for others through the use of evidence-based practice. An example is in promoting safe patient handling and movement to prevent healthcare workers' musculoskeletal injuries from lifting and moving patients (Nelson, 2006) in high-risk orthopaedic tasks such as moving and turning the postoperative total hip replacement patient (Sedlak, Doheny, Nelson, & Waters, 2009). The expert nurse also has the opportunity to teach about safe clinical practices supported by evidence such as in the use of cryotherapy (the use of continuous cold flow units) after knee replacement surgery (Markert, 2011).


Preceptors can help new staff understand how evidence-based projects are identified. They can help them develop knowledge and skills to search for information and navigate evidence-based practice resources like AHRQ's National Guideline Clearinghouse (n.d.-a). The expert nurse can help competent and experienced nurses weigh the current evidence, determine appropriate recommendations, and share information so that clinical protocols can be developed on the basis of knowledge of the most current scientific information. By encouraging involvement in professional organizations, preceptors help new nurses connect to resources and information that support the adoption of best practices to provide safe, high-quality, evidence-based care.


Quality Improvement

The competency of quality improvement entails using data to monitor outcomes of care and using improvement methods to design and test changes in an effort to continuously improve the quality and safety of the current system. Not only is it important for the competent nurse to understand the required nursing care, but he or she must be able to continually analyze and evaluate that care so that it can be improved upon. The National Database of Nursing Quality Indicators from The American Nurses Association provides benchmarked data for hospitals that enroll and participate. Preceptors can show new staff how current trends for nurse-sensitive indicators within the institution compare nationally to outcome measurement data at similar institutions. Some important nurse-sensitive indicators for orthopaedic care include data on surgical site infections, pain assessment, information regarding falls, and pressure ulcer development. A complete list of indicators that are tracked can be found on the American Nurses Association (2012) website.


Experienced nurses realize that quality and safety cannot be attributed to knowledge and carefulness of individuals alone; hence, they use data to optimize system-based solutions to protect patients. Threats to quality and safety where investigation or improvement may be warranted can be identified through interaction with patients and through discussions with peers. Debriefing, a discussion that can be led by the experienced or expert nurse, provides an opportunity for review and feedback after care is delivered. The debriefing should focus on what was done well, what was done poorly, and what could be done better in the future.


As preceptor, the orthopaedic nurse contributes to the overall quality within the organization by assisting the nurse's transition to orthopaedic care and promoting retention of competent personnel. By providing constructive feedback, preceptors help others grow professionally and narrow the gap between current performance and desired performance. Feedback is most effective when it focuses on the task, the process used, or on self-regulation (the ability to identify one's errors and self-correct) and should always be followed with options for improvement (Hattie & Timperley, 2007). It is least effective when focused on the individual. Whether positive or negative, feedback should always be an unbiased account of what occurred and should lead to discussion of evidence-based practice so that quality can be improved (Clynes & Raftery, 2008).


In addition, orthopaedic nurses are involved in quality improvement on a national level. Own the Bone is a quality improvement program developed by the American Orthopaedic Association (2011) to address the treatment gap for osteoporosis and provide prevention strategies for secondary fragility fractures. This clinically proven program provides a web-based patient registry and offers 10 prevention measures along with tools that healthcare institutions can use to establish a fracture liaison service. An experienced or expert nurse functions in the important role of a care coordinator of the fracture liaison service to ensure that postfracture patients are identified and receive the appropriate care including evaluation, diagnosis, and treatment for osteoporosis under the supervision of their primary healthcare provider, orthopaedic surgeon, or osteoporosis specialist.



The competency of safety aims to minimize risk of harm through system effectiveness and through individual performance. Orthopaedic nurses minimize risk by upholding standards and working with other disciplines to develop strategies that support high reliability processes that contribute to consistent positive outcomes for patients. For example, the competent nurse prevents injury by maintaining range of motion for patients' joints and conducting neurovascular assessments to ensure adequate circulation. Falls-prevention techniques are a high priority with this population. Prompt removal of urinary catheters act to decrease the risk of infection. The experienced nurse recognizes the complexity of care for patients with complications such as malunion, pin track infection, or compartment syndrome. Through careful observation, the expert nurse identifies unintended effects or complications and acts quickly to provide remedy that will contribute to a favorable outcome. Expert nurses support a culture of safety rather than a culture of blame and encourage team members to be forthcoming about errors and near misses so that systematic problems that contribute to error can be addressed to reduce risk. They are familiar with error-reporting agencies such as the Institute for Safe Medication Practices (n.d.), which promote sharing information regarding errors so that agencies can improve care based on the experiences of others.


Expert nurses familiarize themselves with and share the many resources for patient safety information, standards, and strategies such as the National Patient Safety Goals from The Joint Commission (n.d.), the AHRQ Patient Safety Network (n.d.-b), and Open School at the Institute for Healthcare Improvement (n.d.). The Open School provides online courses focused on quality and safety. Registrants can earn contact hours as they complete the modules, which are free to those registering as students.


Preceptors recognize that stressful situations may interfere with effective, professional communication, placing patients at risk. Communication was identified by The Joint Commission as the root cause of 66% of the sentinel events between l995 and 2005 (AHRQ, n.d.-b). Experienced nurses respond to aggressive communication with de-escalation techniques that bring the focus of the interaction back to patient-centered care. Preceptors are in an excellent position to teach new staff assertion techniques such as cognitive rehearsal or the language of safety to use during difficult communications. Cognitive rehearsal (Griffin, 2004) uses rehearsed statements as responses when under duress to keep emotions in check, helping the individual stay focused on the problem at hand. The language of safety encourages effective communication by providing tools for advocacy. An example is the CUS strategy, an acronym for the words concerned, uncomfortable, and safe. Using these words, the nurse conveys that he or she is concerned with an aspect of care, he or she is uncomfortable with the patient presentation or the treatment, and he or she doesn't believe it is safe for the patient. Preceptors are in a unique position to counsel new staff as they assume their role on the interdisciplinary team and can teach these techniques to help them establish effective communication patterns to maintain patient safety.



The final QSEN competency focuses on the use of technology to communicate, manage knowledge, prevent error, and support decision making. The competent nurse maintains a hands-on ability to safely operate the complex equipment used in the day-to-day care of patients such as machines to provide continuous passive motion or smart pumps to deliver accurate medication dosages. The introduction of new technologies and patient care devices may be accompanied by resistance due to knowledge deficits for safe operation and accurate interpretation of data (Zuzelo, Gettis, Whitekettle, & Thomas, 2008) so experienced and expert nurses are expected to build consensus for their use among staff and participate in the evaluation process. Preceptors have the additional responsibility of providing clear instruction as well as continuous monitoring for new staff as they develop skills and confidence in their abilities to operate unfamiliar equipment safely.


In addition, as many facilities move to electronic health records, nurses are required to have proficient knowledge and skills in using and retrieving information from databases such as Orthogate (2011), a database where healthcare professionals can retrieve information about rare orthopaedic conditions. The competent nurse is able to navigate the information system used by the institution and maintain accurate records. The experienced nurse may serve as a resource for complex or specialized charting and is able to search for specific information regarding treatments or specialized equipment needed for patients. Expert nurses demonstrate skills in effectively retrieving information from national quality and safety resources to integrate safety strategies into system changes that promote safe practice, protect patients from unintended effects, and enhance communication among caregivers.



The QSEN competencies guide the processes that support the Orthopaedic Core Competencies Across the Lifespan. They enhance the orthopaedic specialty by deepening the focus on patient safety and high-quality care. The knowledge, skills, and attitudes that are the underpinnings of the QSEN competencies encourage the nurse, regardless of level of practice, to focus on patient-centeredness, work as an effective member of the team, to provide high-quality care based on current evidence, utilize information and technology, and keep the patient safe from harm. These concepts are not new to orthopaedic nursing; they are better defined through the QSEN competencies so that nurses can develop practice behaviors that ensure quality and safety for the patients they care for. Because of nurses' specialized abilities to contribute to the plan of care, carry out orders to support the plan of care, attend to the patient's and family's concerns regarding preferences, and coordinate care between members of the team, they remain active stakeholders in supporting quality and safety practices. Preceptors are in a unique position to influence new nurses and those transitioning into the specialty to implement quality and safety practices as they develop skills to meet the Orthopaedic Core Competencies. Their distinct knowledge of the orthopaedic specialty, intertwined with their knowledge of quality and safety practices, provides them with the skills to initiate change based on evidence and to evaluate the impact of that change on patient outcomes within their own organizations as well as the impact that change has on nursing practice, advancing the cause of increased quality and safety for patients.




Agency for Healthcare Research and Quality. (n.d.-a). National guideline clearinghouse. Retrieved from


Agency for Healthcare Research and Quality. (n.d.-b). Patient safety network. Retrieved from


Agency for Healthcare Research and Quality. (2005a). TeamSTEPPS fundamentals course: Module 1. introduction: Instructor's slides. Retrieved from


Agency for Healthcare Research and Quality. (2005b). TeamSTEPPS. Retrieved from


American Nurses Association. (2012). National database of nursing quality indicators. Retrieved from


American Orthopaedic Association. (2011). Own the bone. Retrieved from


Clynes M. P., Raftery S. E. C. (2008). Feedback: An essential element of student learning in clinical practice. Nurse Education in Practice, 8, 405-411. [Context Link]


Cronenwett L., Sherwood G., Barnsteiner J., Disch J., Johnson J., Mitchell P., Warren J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 112-131. [Context Link]


Griffin M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 3(6), 257-263. [Context Link]


Hattie J., Timperley H. (2007). The power of feedback. Review of Educational Research, 77(1), 81-112. [Context Link]


Institute for Healthcare Improvement. (n.d.). Open school. Retrieved from


Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press. [Context Link]


Institute for Safe Medication Practices. (2010). Homepage. Retrieved from


Markert S. E. (2011). The use of cryotherapy after a total knee replacement. Orthopaedic Nursing, 30(1), 29-36. [Context Link]


National Association of Orthopaedic Nurses. (2007). Orthopaedic nursing core competencies: Across the lifespan. Chicago, IL: Author. [Context Link]


National Bone Health Alliance. (2012). 2 million is 2 many. Retrieved from


Nelson A. (2006). Evidence-based practices for safe patient handling and movement (updated reprint from The Online Journal of Issues in Nursing, September 2004). Orthopaedic Nursing, 25(6), 366-379. [Context Link]


Orthogate. (2011). Orthopaedic rare conditions internet database. Retrieved from[Context Link]


Sedlak C., Doheny M., Nelson A., Waters T. (2009). Development of the National Association of Orthopaedic Nurses guidance statement on safe patient handling and movement in the orthopaedic setting. Orthopaedic Nursing, 28(2S), S2-S8. [Context Link]


The Joint Commission. (n.d.). Homepage. Retrieved from


Zuzelo P. R., Gettis C., Whitekettle Hansell A., Thomas L. (2008). Describing the influence of technologies on registered nurses' work. Clinical Nurse Specialist, 22(3), 132-140. [Context Link]


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