Vol. 18 • Issue 7
• Page 37
Nurse practitioners have always provided healthcare to patients with orthopedic problems - in settings ranging from primary care practices to urgent care clinics. Traditionally, orthopedic care by providers who are not physicians has been predominantly provided by physician assistants. But as the nurse practitioner population expands, more NPs are entering this subspecialty. During my 12 years of orthopedic practice, I have noticed more NPs entering orthopedics as well as other subspecialties. The American Academy of Nurse Practitioners estimates that approximately 2% of NPs now practice in orthopedics and sports medicine.
Growing NP interest in orthopedics is evident in the frequent scheduling of orthopedic lecture topics at national NP conferences. In addition, organizations are attempting to meet the special interests of NPs working in orthopedic settings. These include the Pediatric Orthopedic Practitioners Society and the National Association of Orthopedic Nurses (NAON). The NAON recently introduced an orthopedic nurse practitioner certification examination. Details are available at www.oncb.org.
My path to orthopedic practice was somewhat serendipitous. Many orthopedic NPs have had prior exposure to and experience in orthopedics as an RN first assistant (RNFA) or as a nurse in an orthopedic clinic. For them, the move into orthopedics as an advanced practice nurse seems like a natural career progression.
For others, like me, the entry into orthopedics was a leap into the unknown that turned out to be a fantastic career choice. My career experience as an RN was predominantly in the emergency department and intensive care unit. Like many nurses, I had some general exposure to orthopedic problems but no dedicated orthopedic specialty experience. While pursuing my NP education at Syracuse University, I focused on primary care and cardiology. When I could not find the right position for me in cardiology or primary care, I accepted an available position in orthopedics, which I thought would be temporary. Fortunately, my collaborating physician was willing to mentor me.
I found my new practice area of orthopedics to be extremely interesting. My experience as an ED and ICU nurse prepared me better than I had anticipated for my new career path. My passion for orthopedics was truly ignited when I had my first opportunity to assist in surgery. For me, a man who enjoys tools and woodworking, the chance to saw, hammer and drill to repair living tissue was exciting.
For many years, my practice focused on the outpatient care of general orthopedic patients. While working in general orthopedics, I had opportunities to work with many fellowship-trained subspecialists, including foot and ankle, spine, sports medicine, joint reconstruction, hand and trauma surgeons. The experience that I obtained by working alongside these subspecialists is invaluable to me and my career. As a result of my clinical exposure to these subspecialty areas, the practice I have gravitated toward is orthopedic spine practice. In addition to assisting with spine surgery, the treatment of outpatient back pain and injury is a particular passion for me.
I believe the opportunities for a nurse practitioner in orthopedics are limitless. A nurse practitioner can practice in general orthopedics or any of its numerous subspecialties, taking care of patients with disorders or injuries to any joint or extremity. Some subspecialty areas to consider include joint reconstruction, spine surgery, foot and ankle surgery, hand surgery, sports medicine or orthopedic oncology. NPs can focus on pediatric or adult patients or treat patients across the lifespan. The choice of practice setting is varied: outpatient clinic, acute care setting, surgery and more. Some NPs practice across multiple settings, often rounding on patients and taking call.
The typical patients treated by orthopedic nurse practitioners vary depending on the practice setting. For NPs who are assisting with surgical cases, the types of surgeries may be dictated by the needs of the surgeon and the practice, as well as the patient's insurer. An NP can assist with just about any surgery. Assistant services decrease anesthesia time and potentially improve outcomes. But an insurer may not pay for the assistant's services or time. Typical orthopedic surgical cases an NP may expect to assist with include joint arthroplasty, fracture repair, vertebral fusion and anterior cruciate ligament reconstruction.
In a general outpatient orthopedic setting, patient presentations are quite varied. In these settings, nurse practitioners evaluate and manage arthritis, sprains, strains, tendonitis, bursitis and fractures. Other common patient problems include neck or low back pain, shoulder impingement syndrome, meniscus tears, carpal tunnel syndrome, and tendon or ligament ruptures.
If you are interested in practicing in orthopedics, spend time with an orthopedic surgeon, NP or PA in an outpatient orthopedic clinic, an inpatient orthopedic unit or in the operating room. NP students should seek clinical rotations in these settings.
A few formal training opportunities are now available for a nurse practitioner to develop expertise in orthopedics. A post-master's certificate program for orthopedic advanced practice nurses exists at the University of Massachusetts in Lowell, and several others are being developed across the country. At least four orthopedic residencies exist for PAs, but only one orthopedic NP fellowship: at the University of North Carolina Medical Center in Chapel Hill. This year-long, full-time program accepts a limited number of licensed NPs annually for paid training in orthopedics.
When entering orthopedic practice, study orthopedic texts and obtain as much continuing education as you can. If you have access to orthopedic rounds at a medical center, take full advantage of the learning opportunity.
The nurse practitioner in orthopedics needs to learn many new and specialized physical examination techniques. Although some basic musculoskeletal exam techniques are taught in an NP's physical examination course, most techniques used in clinical orthopedic practice are not. Several textbooks about musculoskeletal examination are available. Seek a mentor and take time to practice examination techniques with a skilled clinician.
In addition to supplementary physical examination techniques, new clinical skills are needed for orthopedic practice. Many NPs learn these skills through experience with their collaborating surgeon or mentor. Continuing education courses are available to acquire psychomotor skills. The orthopedic nurse practitioner must be competent in the application of a wide variety of casts, splints, braces and orthotics. Fracture and dislocation reduction techniques are also essential. The orthopedic NP also requires skill in injection techniques for joints, trigger points, tendon sheaths and soft tissue. Some additional skills to learn include diagnostic joint aspiration, nail removal, suturing, incision and drainage, and foreign body removal. In the area of patient education, the orthopedic NP should be confident in teaching general stretching and strengthening exercises to patients.
The interpretation of diagnostic test results is an essential skill for orthopedic practice. In other settings, diagnostic tests ordered by NPs prompt a report of findings from a radiologist or lab. In outpatient orthopedic practice, it is common to have the capability to take x-rays in the office at the time of the patient visit. A radiologist may not be present to interpret the images. Some offices also have a dual energy x-ray absorptiometry scanner, a magnetic resonance imaging device, a computed tomography scanner or fluoroscopy. In these situations, it is the responsibility of the NP to read and interpret the imaging study, consult with the collaborating orthopedic surgeon as needed, and make treatment decisions.
Even if a certain imaging study is interpreted by a radiologist, many orthopedic providers view and interpret the images themselves. There are a few basic reasons for this. You as the clinician have had the luxury of taking the history and examining the patient. This gives you additional guidance for viewing the images; the radiologist typically does not have this background information. You are able to correlate image findings to your physical examination. Subtle findings are sometimes missed by radiologists because they have no contact with the patient. Lastly, many orthopedic providers feel an ethical obligation to their patients to view the images. They do not want to offer surgical or nonsurgical treatment decisions if they have not interpreted the images themselves and confirmed the radiologist's interpretation.
The practice barriers that exist for orthopedic nurse practitioners are the same for all nurse practitioners. The inability to be credentialed and paid by many insurers has long been an issue for our profession. Although some healthcare systems have fully embraced NPs, many NPs are still struggling to be recognized and credentialed by hospitals to admit, discharge, assist in surgery and round on patients.
Most NP students do not perform clinical rotations in the operating room or in orthopedic practice. In PA programs, however, most students spend some clinical time in the operating room and obtain some surgical skills prior to graduation. In addition, some states, such as New York, do not recognize assisting at surgery to be within the scope of practice for the nurse practitioner. To overcome these barriers to practice, the NP may choose or be required to obtain additional training as an RNFA. Some first assist programs are specifically geared toward NPs.
Another barrier I have encountered is generated by referring physicians. Throughout my career, I have met resistance from referring physicians who disagree with their patients being evaluated and treated by a nurse practitioner. Some physicians have expressed concern that they are referring patients to a lower level of care. A practice can react in one of two ways: appease the referral sources and limit NPs to the evaluation and follow-up of patients with an established diagnosis, or allow NPs to function within their scope and potentially open access to care for patients who might be waiting weeks for an appointment with a surgeon. The latter choice comes at the risk of losing some patient referrals, at least initially. The model that the practice chooses to accept is, in the end, a business decision.
Doctor of Nursing Practice
The doctor of nursing practice (DNP) degree is poised to be the entry requirement for NP practice starting in 2015. For me, a doctoral degree was both a personal choice and a career requirement because I teach nurse practitioner students. I chose the Case Western Reserve University DNP program for its focus on clinical leadership. The orthopedists that I practiced with during my doctoral studies were supportive, enthusiastic and proud to have a doctorally prepared NP working alongside them.
I believe my DNP education has improved my abilities as an educator and as healthcare provider. I have been able to directly apply the knowledge obtained from organizational leadership and practice management courses to my clinical setting. This allows me to better understand, discuss and participate in the business aspects of a practice. The experience gained from research courses and defending a doctoral thesis helped me better understand, evaluate and apply the evidence available to support our practice. While performing my doctoral research, I investigated occupational back injuries. The direct application of this research to my clinical practice solidified my enthusiasm for back pain as a clinical interest.
Putting It Into Practice
In orthopedic practice, I have found a fulfilling career niche. Nurse practitioners in orthopedics can work effectively with physician and physician assistant colleagues to increase access to care. We can also be valuable members of a surgical team.
I am excited to be part of a growing number of nurse practitioners who are choosing orthopedic practice as a career path. The box printed with this article provides a few resources for NPs who are interested in orthopedics.
Michael Zychowicz is an adult nurse practitioner who specializes in orthopedics and has earned a doctorate in nursing practice. He is an associate clinical professor and the director of the adult NP program at Duke University in Durham, N.C.
Resources for Orthopedic Specialization
Fellowships and Certificate Programs
The American Academy of Nurse Practitioners offers several orthopedic sessions at annual conferences, and recently launched an annual specialty conference for NPs with one conference track in primary care orthopedics: www.aanp.org
Advances in Orthopaedic Care: seminar titled "It's Not Just Broken Bones": www.pesihealth care.com/
National Association of Orthopedic Nurses: continuing education available for NPs through the annual conference as well as through online continuing education at www.orthonurse.org/
Pediatric Orthopedic Practitioners Society: www.popsociety.org/
Crowther CL. Primary Orthopedic Care. 2nd ed. St Louis: Mosby; 2004.
Mercier LR. Practical Orthopedics. 6th ed. St Louis: Mosby; 2008.
Griffin LY. Essentials of Musculoskeletal Care. 3rd ed. Rosemont, Ill.: American Academy of Orthopedic Surgeons; 2005.
Hoppenfeld S. The Physical Examination of the Spine and Extremities. Norwalk, Conn.: Appleton & Lange; 1976.