Journal of Orthopaedic Nursing (2007) 11, 38–42

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

Keeping practical orthopaedic nursing skills alive:Developing a photographic traction guide

Helen Ross Dip HE/RN, BSc (Hons) *, Jolyon Lockhart RGN, ENB219,DPSN, BSc (Hons)

Senior Staff Nurse, Evershot Ward, Poole Hospital NHS Trust, Longfleet Road, Poole BH15 2JB,United KingdomLecturer Practitioner, Trauma Unit, Poole Hospital NHS Trust, Longfleet Road, Poole BH15 2JB,United Kingdom

Summary This article describes the authors’ journey from observation of poor lev-els of knowledge and practice relating to the assembly and care of various forms oftraction in clinical practice, to the development of a photographic guide. The guideis intended to provide a step-by-step bedside teaching resource to be used at wardlevel, in the same way that a cookery book guides aspiring cooks through thesequential stages of food preparation. Other practitioners could use similar technol-ogy and methodology to create similar guides for their workplace.

�c 2007 Elsevier Ltd. All rights reserved.

KEYWORDSOrthopaedic;Trauma;Traction;Practice development

1d

Editor’s commentsNew technology has meant that producing educational resources is simpler and quicker than ever. This article describes how onehospital has produced their own traction manual as a source of professional development for health care professionals to ensurehigh standards of care are maintained. PD

Background

The UK government healthcare modernisationagenda emphasises the need for nurse leadershipand the development of interprofessional collabo-

361-3111/$ - see front matter �c 2007 Elsevier Ltd. All rights reseroi:10.1016/j.joon.2006.12.005

* Corresponding author. Tel.: +44 1202 448417.E-mail address: helen-ross@ntlworld.com (H. Ross).

ration (Pollard et al., 2005). Senior nurses have anexplicit professional imperative to advance clinicalpractice and education to enrich professionalpractice as a whole (UKCC, 1994), and to provideeducational and professional support to new andless experienced nurses (Jarvis and Gibson, 1985;Thomson, 1998). In addition, the principles of clin-ical governance require that healthcare unitsencourage a ‘learning culture’ so that quality in-

ved.

Keeping practical orthopaedic nursing skills alive: Developing a photographic traction guide 39

fuses all aspects of the organisation’s work (NHSExecutive, 1999). Nurses at every level are ex-pected to be ‘clinically effective’ by offering, inevery clinical situation, treatment and nursing careconducive to the best clinical outcome for thepatient, and are responsible for developing andmaintaining their skills at an optimum level (Castle-dine, 2004).

The last century saw an increasing emphasisand value being placed on the scholarly evolutionof nursing (Meleis, 1991), with an exploration andstudy of the meaning and theoretical base ofnursing providing support for the premise that itshould be regarded as a profession rather thana discipline (Fatchett, 1998), with concomitantemphasis on the development of academic skillsamong student and post-registration nurses (Cor-lett et al., 2003). However, it has been arguedthat these developments have led to a devaluingof practical skills and competencies among nurses(Bjork, 1995; Knight et al., 2000) with a subse-quent deficit in the teaching of the practicalskills that new nurses need to be able to workcompetently and confidently in their chosen disci-pline (Stevenson, 1996; Bjork, 1999; Best, 2005).These commentators’ views have been borne outby observation of many examples of poor prac-tice by the authors among nurses at all levels(Benner, 1984). Additionally, modern nurses workin a climate in which the amount spent on agencynurses has tripled since 1997 and one in tennurses leave the NHS every year (Buchan andSecombe, 2004). This means that a significantamount of health care is being provided by tem-porary and/or inexperienced staff who do notpossess the specialist skills and knowledge theirpatients need. It is therefore clear that skillsand practices that are rarely used are in dangerof being lost unless they can be enshrined in aclear, accessible and user-friendly format (Gaganand Hewitt-Taylor, 2004).

Two decades ago most orthopaedic wards couldshow examples of several different types of trac-tion at any one time and the majority of orthopae-dic nurses rapidly became skilled in its principlesand practice by means of working alongside andlearning from expert orthopaedic nurses (Royleand Walsh, 1992). The current management oforthopaedic patients is concerned with early fixa-tion and rehabilitation. The result of this changehas been that opportunities for nurses to becomeproficient in traction assembly skills are increas-ingly few in number. Consequently many nurseshave little or no knowledge or experience of trac-tion and are therefore unable either to demon-strate competence or to teach others.

Against this background, however, there are stillsome orthopaedic patients for whom there is nopracticable alternative to some form of traction,whether to control their pain, stabilise their frac-ture in the pre-operative period or, occasionally,as a definitive treatment. For orthopaedic traumanurses, therefore, traction assembly may be seenas a basic skill, essential for effective professionalperformance (Beattie, 1987). It is clear that thereis a need to explicate this traditional skill in anaccessible form for the benefit of new generationsof health care professionals and, of course, the pa-tients themselves. It has been proposed that nursesare as good as their last procedure, and that allprocedures and tasks should be regularly updatedand practised. Castledine (2005) highlights theneed for nurses of all levels of experience, not juststudents, to make sure that their skill base is cur-rent and well-honed.

Learning about traction

Teaching that engages more than one of the stu-dent’s senses, e.g. talking/listening accompaniedby practical work, backed up with written materialthat reinforces the heard and experienced learn-ing, is likely to be more effective than any whichincorporates only one or two modes (Bruner,1977). Mixed-mode teaching is particularly valu-able when it relates to a practical skill that involvesboth cognitive and motor aspects (Hampton, 1998).In determining how best to preserve and teachtraction skills, therefore, it was decided to rein-force practical tutorials on traction assembly witha pictorial guide, to serve as a reminder at a latertime and to provide an informational resource forany occasion when nurses find themselves unsureof how to proceed with traction-building. Studiesindicate that nurses are more likely than medicalcolleagues to refer to guidelines when they areunfamiliar with a procedure (Gabbay and Lemay,2004) and therefore an explicit guide with careinstructions seemed an appropriate development.The guide was designed to incorporate all thoseassemblies likely to be used, and featured, in addi-tion to the assembly guides, an illustrated glossaryof equipment utilised.

Various nursing texts already in print provideguidance on the general principles of various formsof traction (Royle and Walsh, 1992; Mallett and Bai-ley, 1996; Schoen, 2000), and the Royal College ofNursing has produced an excellent and detailed re-source (Jackson and Booth, 2002). However, whatnone of these texts can provide is a locally devel-oped, illustrated, step-by-step instruction of the

Os Calcis (Calcaneal) TractionYou will need:

• 1 Goalpost

• 1 Outrigger

• 2 Clamps

• 2 Pulleys

• 1 Braun Frame

• 2 Wide crepe bandages

• 8 Large safety pins

• Roll of gauze and cotton tissue (Gamgee)

• Elastoplast

• 2 Weight holders and prescribed weights.

• Length of Collar and Cuff

(approx 50cm or 18ins) and tie.

• Pair of Simonas swivels

• Traction cord

Figure 1 Title page of os calcis traction.

40 H. Ross, J. Lockhart

assembly of traction equipment using kit that isfamiliar and available to the user. Therefore thepractitioner trying to build traction from generalguidelines and line-sketches has to struggle toidentify which pieces, from the bewildering arraystacked in the storage cupboard, can be utilisedto achieve the desired result.

The traction guide opens each section with a listof the requisite components (see Fig. 1), each ofwhich can be found in the illustrated glossary.

This structured layout builds on a tradition ofnursing educational materials extending backthrough many decades – a guide to trolley layingdated 1941 utilised an illustrated glossary and usedphotographs to guide the reader (Castledine,2004). Thus the nurse can take the book to theequipment locker and assemble an appropriateset of parts, confident that each piece can be iden-tified from its photograph and knowing preciselyhow many of each component to collect.

Every stage of traction assembly was photo-graphed, using a digital camera so that the imagescould be electronically manipulated to best effect(Fig. 2).

Figure 2 Sequential pages illustrati

The experience of doing this reinforced theimportance of breaking activities down intosequential stages (Chandler, 1992), as some earlychapters were subsequently found to have incorpo-rated too many stages of construction into onephotograph, leaving the user confused as to whichshould be tackled first. This necessitated some re-design, and encouraged the authors to plan theirpicture sequences carefully.

The photographs include some cautionary pages,highlighting some common mistakes and problems,in order to preserve and promote good practice inthis traditional nursing skill. The choice of digitalphotography meant that it was simple to insert en-larged details as insets in order to illustrate smallcomponents such as swivel hooks and focus onthe finer points of construction such as a Pearsonknee flexion attachment (Fig. 3).

Another major benefit was that the book couldbe stored in electronic form for easy updatingand reprinting, and could also be made availablein CD form for postage and access via standardcomputer terminals throughout the hospital.

ng stringing for Hamilton Russell.

• In order to attach the knee flexion piece, dismantle the nut, bolt, and clampapparatus as shown.

• Slot the clamps over the side struts of the Thomas splint and fasten ensuring that black nut is outermost.

• It is important to have the circular hole of the clamp innermost otherwise the boltwill not thread through.

Figure 3 Detail of knee flexion piece assembly.

Keeping practical orthopaedic nursing skills alive: Developing a photographic traction guide 41

Since one of the driving principles of the guidewas that all the kit used in the photographs shouldbe available to the reader, the book was arrangedin loose-leaf folder format. Thus if any item ofkit is changed in the future, following variationsin supplier or new developments in technology, anew chapter can be designed and inserted withoutrendering the whole book obsolete.

Evaluation of the traction guide in practice hasshown it to be a useful tool. Guided by the step-by-step photographs, a newly qualified ‘novice’nurse (Benner, 1984) with no experience of build-ing, or caring for a patient in traction, was ableto assemble a functional, effective Thomas splint,thus providing the safe and competent care towhich his patient was entitled (NMC, 2002). An-other ‘competent practitioner’ nurse (Benner,1984) with, albeit infrequent, previous experiencestated that she found the guide to be a useful re-minder when putting up a Balkan beam assembly,as she did not prepare traction often enough to feelconfident of her ability. These examples, whichcorrespond to similar feedback from other usersof the guide, indicate that there is a role for thistype of explicit teaching aid at several levels ofnursing proficiency and fully justified the timeand effort expended in its creation. The users re-ported that their experiences allowed them to feelmore competent within their specialised field –and of course, their patients benefited from receiv-ing timely, appropriate care.

Bjork makes a powerful point when she statesthat patients expect to be met by mastery and effi-ciency when they are in need of practical nursingactions (Bjork, 1997).

Skilled orthopaedic nurses with a passion for com-municating their knowledgeand keeping nursing skillsalive could use the format of this guide as a model,and develop their own folder, using simple and acces-sible technology. By this means new generations ofnurses will be supported in their professionaldevelopment, and orthopaedic trauma patients willcontinue to receive optimum nursing care.

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