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Practice comment

Nurses are vital in implementing the osteoporosis care manifesto

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Fracture liaison services and clinical audit are just two areas in which nurses can implement the National Osteoporosis Society manifesto, argues Julia Thomson

 Keywords: Osteoporosis, Fracture, Long-term conditions


 The National Osteoporosis Society (NOS) recently launched a manifesto outlining steps to eradicate unnecessary fractures. There are four versions, one for each of the UK’s four nations.

It focuses on five areas: managing falls, fragility fractures and osteoporosis; clinical guidance; assessing clinical performance; primary care services; and public awareness and education.

While the manifesto is aimed primarily at politicians and policymakers, its adoption relies on buy-in from practitioners working at the coalface. What, then, is nurses’ role in ensuring their challenges are met?

Establishing effective fracture liaison services (FLSs) lies at the heart of the manifesto. These services are usually provided by a dedicated nurse specialist, working in orthopaedics under the guidance of a specialist in bone health.

Nurse specialist role

The nurse specialist is responsible for establishing care systems to ensure that every patient over 50 with a fracture is identified, recorded and offered a one-stop-shop fracture risk assessment.

Such specialist nurses can also practise in primary care, ensuring that patients with fragility fractures who are not identified in acute care, or who do not even go to hospital following a fracture, are assessed and given treatment, where appropriate, to reduce the risk of a future fall or fracture.

Identifying patients at risk of fragility fracture can occur across nursing disciplines. High-risk people can present anywhere. Nurses are ideally placed to identify such patients and refer them on to FLSs if they have a history of fracture, or to report any risk factors such as corticosteroid use.

Adequate education is therefore essential, not just in the obvious disciplines of orthopaedics and rheumatology, but as an essential element of every nurse’s core training.

The need for guidance

The manifesto also calls for coherent, adequate guidance for the prevention, diagnosis, treatment and care of falls, fragility fractures and osteoporosis.

Despite constructive involvement by the NOS since 2002, NICE has so far failed to produce workable clinical guidance on managing and preventing fragility fractures. Its two latest technology appraisals on osteoporosis, published in 2008, are unfair to some patient groups, unworkable and overly complex.

The importance of mechanisms to assess clinical performance is another key feature of the manifesto. Auditing the care given to those at risk of falls and at risk of or with fragility fractures is important in ensuring that examples of best practice are identified and areas for improvement are highlighted.

Nurses often have an integral role in clinical audit. A good understanding of the importance of these processes in assuring quality is essential.

A focus on osteoporosis in primary care is vital if we are to reduce the number of fragility fractures.

To make this happen, it is important that incentives are given to PCTs to identify and treat those with or at risk of fragility fractures. The most effective means of doing this would be by including osteoporosis in the GP Quality and Outcomes Framework (QOF).

Including the condition in the QOF would allow community-based nurses to become much more involved in promoting bone health and include awareness-raising as part of their service.

The final element of the manifesto outlines the importance of measures to improve understanding of bone health among people of all ages, including positive messages being communicated in schools.School nurses have an important role in promoting bone health and the NOS urges local authorities and school boards to ensure they receive training in the field.

The manifesto has many implications for nurses, not only in the emergence of exciting new roles in fracture liaison but also in providing opportunities for us all to become more aware of at-risk patients who we see in our daily practice.


Julia Thomson is osteoporosis nurse and helpline adviser for the National Osteoporosis Society


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