Optimising Fracture Outcomes: A Nursing Clinical Pathway Approach

INTRODUCTION

Fractures are among the most frequently treated injuries on a global scale. Open reduction and internal fixation (ORIF) is the preferred intervention for complex fractures; it involves the repositioning of bones using plates, rods, or screws.^[1] Nevertheless, the recovery of patients is significantly influenced by the quality of nursing care, which is inconsistent as a result of the absence of structured care pathways.^[2] Clinical Pathway Management Programmes (CPMPs) resolve this issue by standardising evidence-based nursing interventions. Their integration into routine care has enhanced outcomes in high-income countries; however, they are underutilised in low and middle-income settings.^[3]

Standardised nursing care is frequently absent in India due to patient overload and staff shortages. Many nurses are inadequately trained in evidence-based postoperative care, despite the fact that tertiary care centers perform intricate procedures such as ORIF.^[4] In Mangalore, preliminary surveys indicate that nurses frequently fail to adhere to structured practices and lack essential knowledge.^[5] This investigation is noteworthy for its implementation of a structured CPMP that is tailored to the needs of orthopaedic nursing in resource-constrained environments.^[6]

The intervention seeks to decrease postoperative complications in ORIF patients and develop foundational competencies by focusing on early-career nurses who have had limited exposure to evidence-based care models.^[7] The results are anticipated to enhance the quality and consistency of orthopaedic nursing practice, with implications for broader healthcare systems that are confronted with comparable challenges.^[8]

This investigation assesses the effect of a CPMP that is specifically designed for nurses who are responsible for ORIF cases. It examines the enhancements in knowledge and practice that occur because of structured training.^[9]

MATERIAL AND METHODS

This quasi-experimental study was conducted at two tertiary care hospitals in Mangalore (2019-2020) and utilised a non-equivalent pre-test post-test control group design. Institutional permissions and ethical approval (YEC2/494) were obtained. Participants were required to provide informed consent. A purposive sample included 60 staff nurses who were involved in orthopaedic care. They were randomly assigned to experimental and control groups. The effect size was 0.80, the significance level was 0.05, and the power was 0.80. A 15% attrition rate was incorporated into the calculation of the sample size using G Power. The inclusion criteria were as follows: nurses who were willing to participate, directly involved in ORIF care, and working in orthopaedic wards. Nurses who were not engaged in ORIF care or were on extended leave were excluded. The following tools were utilised: (1) a demographic proforma; (2) a structured knowledge questionnaire (20 multiple-choice questions, score range: 0–20); and (3) an observational checklist (70 items spanning six care domains). A panel of five experts determined the content validity. Cronbach’s alpha was 0.82 for the questionnaire and 0.95 for the checklist. Data collection was conducted in three phases: pre-test, intervention, and post-test, subject to the receipt of ethical approval and administrative consent. Eligible nurses were identified and informed about the study, and their consent was obtained. Nursing practices were observed using a checklist, and knowledge questionnaires were administered during the pre-test. The experimental group subsequently participated in interactive sessions for one week as part of the CPMP training program. The post-test was administered to both groups using the same tools one week later, and the data were analysed using SPSS.

RESULTS

Effectiveness of the clinical pathway programme on knowledge

The pretest evaluation indicated that 73.3% of participants in the experimental group possessed fair knowledge, 3.3% exhibited poor knowledge, and 23.3% showed good knowledge. The control group exhibited a comparable pattern, with 53.3% demonstrating fair knowledge and merely 3.3% attaining an excellent knowledge score. Post-implementation of the clinical pathway management program, the experimental group exhibited notable enhancement in knowledge levels. Post-test data indicated that 76.7% of individuals possessed fair knowledge, whereas 23.3% exhibited excellent knowledge. The average knowledge score rose significantly from 9.366 (±2.141) to 14.166 (±1.723) (p = 0.001). The control group had negligible enhancement.

Figure 1 depicts the comparison of average knowledge and practice scores between control and experimental groups, both prior to and following the intervention. In the control group, the mean knowledge score exhibited a slight increase from 10.1 to 10.83, while the mean practice score experienced a marginal decrease from 47.8 to 46.86, indicating no significant change (p > 0.05). The experimental group exhibited a notable enhancement, with the mean knowledge score increasing from 9.36 to 14.16 (p 0.01) and the practice score ascending from 46.06 to 51.2 (p 0.001). The findings indicate that the clinical pathway management program significantly improved nurses’ knowledge and practice concerning ORIF.

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Figure 1:

Assessment of knowledge and practice within the groups.

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The independent t-test findings indicate that there was no statistically significant difference between the control and experimental groups in the pretest scores for knowledge (mean = 10.1 ± 3.241 vs. 9.366 ± 2.141; p = 0.305) and practice (mean = 47.8 ± 7.255 vs. 46.066 ± 5.064; p = 0.288), confirming that both groups were comparable at baseline. However, a statistically significant difference emerged between the groups in the post-test phase. The experimental group showed a significantly higher mean knowledge score (14.166 ± 1.723) than the control group (10.833 ± 3.052) with p = 0.001***, indicating a strong effect of the intervention on knowledge enhancement. Similarly, post-test practice scores were significantly better in the experimental group (51.2 ± 6.855) than in the control group (46.866 ± 6.941), with a p-value of 0.018*, reflecting a notable improvement in practical application due to the intervention. These results demonstrate that the educational intervention had a positive impact, enhancing both cognitive and behavioural outcomes among participants and offering hope for future interventions [Table 1].

Table 1: Comparison of knowledge and practice scores between groups (n=30+30)

Variable	Test	Group	Mean± SD	t-value	p value
Knowledge	Pretest	Control group	10.1 ± 3.241	1.034	0.305
		Experimental group	9.366 ± 2.141
	Post test	Control group	10.833 ± 3.052	-5.208	0.001***
		Experimental group	14.166 ± 1.723
Practice	Pretest	Control group	47.8 ± 7.255	1.073	0.288
		Experimental group	46.066 ± 5.064
	Post test	Control group	46.866 ± 6.941	-2.433	0.018*
		Experimental group	51.2 ± 6.855

t: Independent t-tests *: Statistically significant, ***: Very highly significant

DISCUSSION

The impact of a CPMP on enhancing the clinical expertise and knowledge of nurses caring for patients undergoing Open Reduction and Internal Fixation (ORIF) was assessed in this study. The results demonstrated statistically significant gains in the experimental group’s knowledge and practice scores, confirming the importance of organised, research-based interventions in nursing education and clinical practice.^[10]

The findings are consistent with previous research demonstrating that clinical pathways improve patient outcomes, lower care variability, and increase nursing competency. The evaluation of CPMP’s efficacy was reinforced by the use of a practice checklist and a validated knowledge questionnaire, which guaranteed accurate outcome measurement.^[11] Crucially, despite having less than a year of orthopaedic experience, the majority of the nurses in this study were early-career professionals who demonstrated notable improvements following the intervention. This demonstrates how well the CPMP fills basic training gaps in high-turnover settings, such as orthopaedic units.^[12]

Age, gender, level of education, and place of employment did not significantly correlate with the results, indicating that the intervention was widely applicable to a variety of nurse profiles. The CPMP model appears to be scalable and adaptable for a variety of clinical settings, as evidenced by the consistency in improvement, which implies that it could be used successfully regardless of the participants’ backgrounds.^[13]

Clinically speaking, CPMP’s incorporation into nursing workflows provides a standardised framework for post-operative orthopaedic care management, guaranteeing that crucial duties like mobilisation, pain management, wound care, and neurovascular assessments are methodically handled. This improves patient safety and recuperation while lowering the chance of complications.^[14]

The study also emphasizes the implications for education and administration. CPMPs can be used by nurse educators and hospital administrators to improve staff clinical competency, decrease care delivery variability, and promote an evidence-based practice culture. Staff confidence and care quality may improve over time if CPMP training is incorporated into induction programs or continuing education initiatives.^[15]

Limitations

Nonetheless, it is necessary to recognise certain limitations. The findings’ generalisability is restricted by using purposive sampling and a comparatively small sample size. Additionally, evaluation of long-term knowledge retention and sustained behaviour change is not possible due to the brief follow-up period. Longer follow-up times, multi-center trials, and randomised controlled designs should all be considered in future research. Additional information about the clinical impact of CPMP would be obtained by including patient-level outcomes, such as satisfaction ratings and complication rates.

CONCLUSION

In summary, the CPMP intervention was a successful tactic to improve nurses’ expertise and practice in the orthopaedic field. Its well-organised layout, usefulness, and encouraging results point to a high likelihood of integration and replication in other comparable healthcare settings. In high-demand clinical settings, CPMPs can be an essential tool for enhancing nursing care and improving patient outcomes with the right support and adaptation.