Practice of core competence training for orthopedic nurses in Hunan Province of China

The inclusion criteria were as follows: (1) nursing staff qualifications: participants must hold intermediate, senior, or chief professional ranks. Alternatively, nurses with junior professional ranks were eligible if they had a minimum of three years of orthopedic clinical experience; (2) training completion: individuals who completed the entire training program without any interruptions; (3) consent: volunteers who provided written informed consent.

The exclusion criteria were as follows: (1) nurses who terminated their participation prematurely; (2) individuals who did not participate in all required assessments and surveys.

The Hunan Provincial Training Base for Orthopedic Nurse Specialists is affiliated with the Department of Orthopedics at Xiangya Hospital of Central South University. Since its establishment in 2018, the base has trained nearly 350 orthopedic nurses specializing in orthopedic surgery.

The training requirements are divided into a theoretical teaching group, a clinical practice teaching group, and an education and management group.

The training program was developed based on the objectives of enhancing theoretical knowledge, professional skills, comprehensive practical competencies, and professional development capabilities. Accordingly, the curriculum was structured to include relevant training courses.

Training goal setting According to the core competence requirements of orthopedic nurses, the overall objectives of this training are as follows [7]: (1) Theoretical Knowledge Skills: To acquire a comprehensive understanding of the theoretical knowledge related to orthopedic diseases and nursing care. (2) Professional Skills: To master the assessment methods for orthopedic surgical techniques, key observation points, and treatment approaches for potential complications. (3) Comprehensive Practical Skills: To develop proficiency in applying nursing program thinking, organizing and coordinating work plans, and employing supervision and guidance techniques. (4) Professional Development Skills: To learn fundamental research methodologies, enhance skills in writing specialized academic papers, and acquire knowledge of orthopedic specialty teaching methods.

Curriculum Offering The training syllabus for orthopedic specialist nurses was developed based on core competency indicators and findings from our previous study of 5020 nurses across 342 hospitals [15], The syllabus also incorporated the Hunan Provincial Health Commission’s training manual. Following two rounds of Delphi expert consultation, the program was refined according to expert feedback.

The training content included both theoretical lectures and clinical practice (1 + 2 mode). The total training duration was three months, including one month of theoretical study (160 h) and two months of clinical practice (320 h). In terms of curriculum implementation, training was carried out in four dimensions of nurses’ core competencies (Table 1).

(1) Theoretical knowledge skills: A combination of intensive teaching and individual self-study. The content mainly includes knowledge of orthopedics (spine surgery, trauma surgery, bone and joint surgery, etc.) related to basic diseases, common orthopedic nursing techniques, practical application of advanced orthopedic concepts, evaluation knowledge of orthopedic patients, common orthopedic drugs and nursing, quality and safety management of orthopedic patients, perioperative management of orthopedic patients, observation and treatment of orthopedic critically ill patients, and bone care department patient management mode. At the same time, Hunan orthopedic experts were invited to give special lectures to expand professional knowledge for training objectives.

(2) Professional skills: According to the intention of the trainees, orthopedic specialties will be assigned, one-on-one clinical teaching will be adopted, and one chief instructor will be responsible for the whole process for each specialty. The content of professional skills training is arranged by the chief instructor of the department and the individual instructor of the trainee, including the collection of orthopedic patients’ medical records, patient assessment, observation and nursing care of various types of orthopedic patients, orthopedic operation skills, interpretation and treatment of patients’ abnormal indications, use of commonly used drugs in orthopedic surgery and treatment of adverse reactions, etc., which is aimed at integrating and applying theories in clinical nursing and cultivating the trainee’s ability in clinical practice.

(3) Comprehensive practical skills: the training subjects are freely grouped into groups of six, with a group leader. A small lecture is arranged once a month, and two case discussions, all in small groups, are arranged as a unit for PPT reporting, reporting cases selected by the training subjects under the guidance of the instructor.

(4) Professional development ability: Throughout the whole training process, experts in the province are invited to give lectures during the 1st to 4th weeks of theoretical study, which mainly include orthopedic specialty nursing quality monitoring and management methods, occupational safety and protection, nursing management skills, literature searching and reading skills, scientific research questionnaire design methods, dissertation writing skills, and subject declaration methods. In the 5th to 11th weeks of the clinical practice process, skills are utilized during the 5th ~ 11th week. In the 12th week, students write a review article on orthopedic diseases under the guidance of the research tutor.

To assess the effectiveness of the training program, this study used the four dimensions of Kirkpatrick model. A final grade of more than than 80 is considered a passing score.

The core competence evaluation scale for orthopedic nurses was designed and used to evaluate the core competencies of orthopedic specialty nurses by Luo et al. [7]. This questionnaire is divided into 4 dimensions, namely, theoretical knowledge (24 entries), professional skills (19 entries), comprehensive practice ability (14 entries), and professional development ability (15 entries). All of which are scored on a 5-point Likert scale ranging from 0–4 points in order from “complete ignorance” to “complete mastery”, with total scores ranging from 0-288 points, with 0–96 points for theoretical knowledge, 0–76 points for professional skills, 0–56 points for theoretical knowledge, 0–96 points for professional skills, 0–76 points for comprehensive practice ability, 0–56 points for professional development ability, and 0–60 points for professional development ability. A higher total score indicates greater core competency among orthopedic nurse specialists. The internal consistency Cronbach’s α coefficient in this study was 0.98.

The recruitment of study participants was conducted through the dissemination of the orthopedic specialist nurse training announcement on the official website of the Hunan Provincial Nursing Association and its WeChat official account. A total of 102 questionnaires were distributed in this study, and 102 valid questionnaires were recovered, for a recovery rate of 100%. The training subjects were all female (100%), with a mean age of 32.03 ± 3.55 years, of which 26 cases (25.5%) were between the ages of 20–29 years, 75 cases (73.5%) were between the ages of 30–39 years, and one case (1%) was 40 years old and above. A total of 99.2% of the training subjects had bachelor’s degrees, while those with a college degree or below and a master’s degree or above accounted for 7.8% and 1%, respectively. And 64.7% of the training subjects had more than five years of experience in orthopedics; 41 (39.2%) were nurses and nurse practitioners, 61 (59.8%) were supervisory nurse practitioners, and one (1%) was an associate nurse practitioner and above; 57.8% of the training subjects were from tertiary hospitals.

Table 2 shows the results of the evaluation assessment. After three months of training as orthopedic nurse specialists, the mean final score of the training participants was 89.01 ± 2.16. The Reaction level of the outcome had the highest score, with the training participants scoring full marks for both theory and practical daily attendance. The Behavioral level score was next highest (95.67 ± 1.89), followed by the Result level total score (89.13 ± 2.57) and the Learning level total score (84.75 ± 3.81).

Compared with those in the pretraining period, the total core competency scores and four-dimensional scores of 102 orthopedic nurses were significantly higher after training (Table 3).

All pretraining scores on the theoretical knowledge dimension were < 3, and in particular, the scores on imaging manifestations of common orthopedic diseases, spinal deformities, bone and soft tissue tumors, and congenital diseases related to congenital diseases were < 1.7. After training, more than 80% (24/29) of the entries for the theory dimension were greater than 3 points. However, nurses still scored less than 3 points for common orthopedic imaging manifestations, bone and soft tissue tumors, bone and joint infections, tuberculosis, bone and cartilage developmental and metabolic disorders, and congenital disorders (Table 4).

The professional skills dimension included orthopedic nursing assessment techniques and orthopedic specialty nursing operation techniques. Before the training, the average entry scores of the training subjects were the lowest in terms of neurological function assessment and joint mobility assessment, and after the training, the average scores of all the entries of the professional skill dimension improved (> 3 points), and the difference was statistically significant (P < 0.001), as shown in Table 5.

Table 6 shows the dimension of comprehensive skills and practical abilities. The training participants’ performance in the dimension of “effective combination of theory and skills” was the worst, and the scores of “sense of responsibility, prudence, and three-checking and seven-checking” before and after the training were all > 3 points. After the training, the average scores of all the items were greater than those before the training, and the difference was statistically significant (P < 0.001).

In the dimension of professional development ability shown in Table 7, the pretraining results revealed that orthopedic nurses performed the worst in “professional papers (0.77 ± 0.77)”, “research projects (0.93 ± 0.86)”, “academic communication (1.21 ± 0.78)”, “keeping abreast of the academic frontiers (1.54 ± 0.93)” and “mastery of academic frontiers (1.54 ± 0.93)”. After the training, the various professional development abilities of the training participants improved, and the difference between before and after the training was statistically significant (P < 0.001).

The training curriculum and practice program are formulated within the framework of the core competence of orthopedic nurses, which is validated by Hunan orthopedic, rehabilitation, therapeutic, and nursing experts, with a focus on the knowledge and technology of high morbidity and critical illnesses in the field of orthopedics and a focus on cultivating the core competence of trainees. The format of this training is diversified according to the different training courses, covering a variety of forms, such as theoretical lectures, lectures by experts, departmental rotations, operation exercises, and group discussions. The instructors are all orthopedic specialists in the clinical setting of Hunan tertiary hospitals, with solid theoretical knowledge and rich practical experience. Clinical practice adopts the tutor system, formulates a strict practical training plan, and correctly intervenes and guides trainees to carry out operation scenario drills. Trainees learn, share, and communicate under the one-on-one guidance of the mentor They internalize the knowledge with secondary understanding, reconstruct the knowledge framework, and expand the knowledge circle. In recent years, China has carried out specialized orthopedic nurse training in Beijing, Shanghai, Jiangsu, and other places. For example, Liu et al. [8] explored the application of the nursing outcome-oriented case management model in orthopedic nurse specialist training; Tong [9] explored the impact of orthopedic nurse specialist training on the development of orthopedic surgery in Jiangsu Province. However, previous training content has neglected the development of competencies for instance research [8, 9]. Research thinking and innovative consciousness are the conditions for conforming to the development trend of the times and are necessary components in the career planning of specialized nurses [6]. This training not only develops the professional knowledge and skills of orthopedic nurse specialists but also incorporates scientific research ability and management thinking into the scope of training, aiming to improve the core competence of orthopedic nurse specialists in all aspects and to enable orthopedic nurses to play an advantageous role in clinical work, scientific research and innovation, and teaching and management. The results of this study indicate that following the implementation of the training program for orthopedic specialist nurses, there were statistically significant improvements in theoretical knowledge, professional skills, comprehensive practical abilities, and professional development capabilities (P < 0.001). These findings suggest that the training program not only augmented the professional knowledge base of the nurses but also underscored the importance of integrating theoretical knowledge with clinical practice. Furthermore, the program enhanced participants’ abilities in critical areas, including clinical observation and analytical thinking, emergency problem-solving, and research and learning skills.

The evaluation system is an important basis for measuring the quality of training, which can directly reflect the degree of fulfillment of the training objectives [16]. The evaluation content of specialized nurse training in China is mostly formulated by hospitals or various specialties according to their own needs, lacking a continuous evaluation mechanism, and the comprehensiveness and effectiveness of the evaluation are insufficient [17]. This study adopted the widely-used Kirkpatrick model to establish a standardized evaluation for orthopedic nurse specialist training. It comprehensively assesses training effects, meets diverse needs, and is practical and feasible [12, 18]. In addition, among the top 10 most frequently published research articles on nurse specialist training, “core competencies” is an important indicator for measuring the level of specialization of nurse specialists [19]. This study also combined the core competencies for the comprehensive evaluation of training effectiveness [19]. The evaluation and feedback mechanism effectively promotes the continuous improvement of the training quality of orthopedic specialist nurses, promotes the healthy and orderly development of orthopedic therapeutic specialties, and lays a solid foundation for the establishment of a specialized training system for orthopedic specialist nurses.

After the training of specialized nurses, the overall competence of the trainees has improved, but there are still some entries with scores lower than 3 after the training, such as the “imaging manifestations of common orthopedic diseases” in the orthopedic basics in the dimension of theoretical knowledge, indicating that the trainees’ ability to learn and update theoretical knowledge needs to be improved. Previous studies have shown that most specialist nurses have assumed the role of only clinical workers, whereas their ability to act as educators, researchers, administrators, and consultants has been weakened and neglected [20], which is consistent with the results of this study. In this study, trainees’ professional development abilities, such as “mastering the academic frontier”, “academic communication”, “professional papers” and “scientific research projects”, were low before and after training. This is related to the fact that the majority of the trainees who participated in this training had college or undergraduate degrees. Most of them had a weak scientific research foundation. This highlights the importance of writing specialized textbooks for orthopedic nursing and offering elective courses in nursing schools. It also shows that the development of the research capacity of orthopedic nurse specialists is a long way to go and requires a longer period before significant results can be seen. Therefore, improving theoretical and professional development skills is the focus of future training. In the future, a presurvey on the current level of nursing research and training needs of trainees will be carried out to clarify the needs and improve the relevance of the contents of the lectures and the effectiveness of the training.

Focus on layered training and tracking the effects of forward training. The minimum educational requirement for most orthopedic practice nurses in the United States is a master’s degree in nursing [19]; in comparison, our country has lower educational access requirements for specialized nurses, which is one of the reasons for their lower theoretical foundation and research capacity. In the future, a precise tiered training system can be developed and taught according to nurses’ academic qualifications, giving full play to the maximum development potential of nurses at each tier. Highly educated nurses have high academic and practical skills to adapt to complex healthcare environments, participate in or develop policies, and make recommendations for the healthcare system. Nurses at lower academic levels but with more clinical experience enhance their operational thinking for clinical quality improvement and are encouraged to file patent inventions and promote their use.

In addition, there should be a focus on longitudinal follow-up of trained orthopedic nurse specialists. Fan et al. [20] investigated the current status of the job management of orthopedic specialist nurses in 28 provinces, cities, and autonomous regions across the country and reported that 74.64% of nurses whose jobs did not change after training and that most orthopedic specialist nurses were less likely to carry out advanced nursing practice work and were still dominated by routine nursing practice. If the training is followed by no active practical application, the purpose of the training is lost. Some provinces in China are encouraging clinical nurse specialists to provide long-term care for chronically ill patients after discharge from hospitals in a variety of ways, for example, by setting up specialist care clinics in primary healthcare organizations. However, the issue of how to transfer quality resources to primary care organizations, communities, and nursing homes still deserves extensive research [21].

Although the training faculty included in this study were experienced clinical cadres in orthopedics, there may have been bias in their selection due to the current lack of a uniform faculty certification system. In addition, the establishment of research awareness and improvement in competence is a gradual process, so it is difficult to see significant progress in 3 months of training, and the development of trainees’ competence will be further tracked in the future.