Competencies for advanced clinical practice (ACP) hand therapists in first-line management of closed hand fractures: Results of a United-Kingdom (UK) stakeholder consensus study

Abstract

Introduction

In the United Kingdom [UK], Advanced Clinical Practice (ACP) roles are being developed to improve access to high-quality patient care, where healthcare services are struggling to meet steadily increasing service demands. Increasingly, ACP hand therapists are assessing and treating acute closed hand fractures. However, the knowledge and skills required of these roles has not been identified or standardised.

Methods

Consensus recommendations were developed from an expert panel of medical doctors and hand therapists using an electronic Delphi process. Participants were recruited from purposive and snowball sampling. Delphi questions were developed from a literature review and clinician survey and included rating of items open text responses. Consensus was defined as ≥75% agreement. Summary feedback was provided after each round.

Results

There were 20 panellists (12 medical doctors and 8 hand therapists), of which 18 (90%) completed all rounds. 23 competencies were consistently identified as very important; there was less agreement on how to evidence these competencies.

Conclusion

These findings can be used to develop ACP hand therapist roles and provide a framework to guide individual therapists to base their own learning and development. They underpin safe, efficient and costeffective patient care.

Introduction

Hand fractures represent around 7% of all emergency department attendances and, as most occur in working age people, ¹ have high healthcare and productivity costs due to reduced ability to work. ² In the UK, healthcare austerity has made meeting national standards of care ³ for treatment of patients with hand fractures challenging. Globally, professionals from a wide range of backgrounds are encouraged to work at an advanced level to address the growing supply-demand imbalance and workforce shortages. ⁴ Extra costs and staff shortages worsened by the COVID-19 pandemic have accelerated this agenda. In England, this has been reflected in the development of a multi-professional framework for advanced clinical practice (ACP) with formal accreditation. ⁵ ACP practice, regardless of clinical setting, is characterised by a high degree of autonomy and complex decision-making evidenced by core capabilities in clinical practice, leadership, education, and research, with defined standards for practitioners working in these roles. ⁶ In the UK, pioneering hand therapists began providing first line management (i.e. clinical assessment, diagnosis and choice of treatment) of closed hand fractures over 20 years ago. ⁷ However, a recent survey ⁸ highlighted that only 6% of the British Association of Hand Therapists (BAHT) members are routinely providing this service.

Over 80% of closed hand injuries are treated non-surgically, ⁹ primarily requiring therapist-led care such as the provision of custom-made orthotics and/or instruction in early active motion. Earlier assessment and definitive treatment from an ACP hand therapist enables earlier mobilisation and thus reduces complications associated with prolonged immobilisation.^10,11 Furthermore, hand therapists are well placed to discuss prognosis and topics of concerns for patients, such as time to recovery, managing pain and recovery of function. ¹² Published reports on the effectiveness of similar pathways have reported a quicker time from assessment to treatment and subsequently earlier return to function,^7,13 fewer visits to hospital per patient, ¹³ high patient satisfaction^13,14 and increased hand surgeons’ clinic capacity.^7,13,14

Treatment decision (i.e. surgical or non-surgical intervention) for patients with closed hand fractures has traditionally been made by doctors despite there being no recognised scope of practice. Although the multi-professional framework for advanced clinical practice defines a level of practice and competencies for therapists to undertake such scope of practice, it fails to define the required specific clinical knowledge and skills. ⁶ There is scarce published evidence concerning the knowledge and skills required for the proficient first line care of adults with closed hand fractures. ¹⁵ In traditional healthcare models, complex hand fractures are treated by medical doctors from two specialities, orthopaedic and plastic surgery, with differing experience and treatment preferences.^16,17 Consistently, published reports of hand therapists providing first line management of adults with closed fracture demonstrate variation in experience, knowledge and skills underpinning these roles. ¹⁵

Given the increasing number of therapists involved in first line assessment and management of hand fractures and the absence of standardised competencies, there is an urgent need to clearly define this practice. The aim of this work was to undertake a stakeholder Delphi consensus process to develop an agreed set of competencies for ACP hand therapists providing first line management of hand fractures.

Methods

Study design

Delphi surveys are defined as “...a group facilitation technique designed to transform opinion into group consensus”. ¹⁸ The process aims to organise and agree information on a topic about which little is known by a panel of diverse experts. ¹⁹ This study was conducted electronically using Microsoft Forms for ease of asynchronous completion by busy clinicians and to facilitate a geographically diverse panel of experts. Questions were developed from the findings of a literature review ¹⁵ and a clinician survey ⁸ and grouped in four competency themes: clinical assessment, imaging, treatment decision, and general. For each theme, participants rated the importance of specific knowledge and skills and were invited to add any additional comments (Figure 1). Items were rated on a 9-point Likert scale but divided in three categories: very important (7-9), moderately important (4-6) and not important (1-3) (Table 1). If ≥ 75% of participants rated an item as not important (1-3), it was removed from further rounds. If ≥ 75% of participants rated an item as moderately important (4-6), the item was brought to the next round. Where ≥75% of participants rated the item as very important (7-9), the item was included in the competency list, and where ≥75% rated an item as not important, it was removed. Prior to dissemination, the Delphi questions were reviewed for content and clarity by the study Steering Committee and peer reviewed by the British Association of Hand Therapists (BAHT) Clinical Evidence Committee. The role of the study steering committee was to provide guidance and oversight on the project including contributing to the design of the Delphi questionnaires and feedback on preliminary analysis of the results. It comprised of geographically diverse, experienced hand surgeons, radiologists, hand therapists, clinical academics with expertise in hand fracture management and participation in consensus generation methods and four people with lived experience of hand fractures. The study protocol was published online on Open Science Framework for transparency. ²⁰

Figure 1.

Illustration of the Delphi process.

Table 1.

Pre-defined percentage threshold consensus criteria for Delphi study^21–23.

Consensus status		Required ratings thresholds
Very important	Consensus	≥75% of participants rated the item 7-9
Moderately important	Brought to next round	≥75% of participants rated the item 4-6
Not important	Removed from further rounds	≥75% of participants rated the item 1-3

Eligibility criteria and recruitment

Participants were recruited to the Delphi panel using both purposive and snowball sampling. ¹⁸ Clinical experts were identified through the clinician survey, conference presentations, publication records and colleague recommendations. Adapting previous work from Tang and Giddens, an “Expert” was defined as a highly experienced clinician with in-depth knowledge of the assessment and/or treatment of hand fractures, contribution to the development of this field by either training clinicians, developing pathways of care or clinical guidelines, lecturing or publishing in this field. ²⁴ Each potential participant filled an expression of interest form including demographic data on level of expertise, profession and geographical location. We aimed to recruit 16-20 participants from the specialties of emergency medicine, radiology, hand surgery (plastic and orthopaedic surgeons) and hand therapy (occupational therapists and physiotherapists). This number was set to allow inclusion of participants from various stakeholder groups, geographical regions and to allow a sufficient sample size with an estimated 70% response rate. ²⁵ We limited participation to UK clinicians as advanced practice is likely to have significant international variations. Throughout the Delphi process, participants were blinded to the identity of other panellists. We sent two reminders for each round to increase the response rate.

Data management

Responses were analysed using descriptive statistics. All open text responses were discussed with the steering group and categorised for inclusion in subsequent rounds. After the first and second rounds, anonymised summary feedback was provided as part of the subsequent round.

Governance and approvals

The study received approval by the Imperial College Healthcare NHS Trust Therapies Service Improvement Group (registration number 1097) and approved for distribution by the BAHT Clinical Evidence Committee. Study reporting followed the ACCORD guideline (Supplementary Data 1). ²⁶

Results

Delphi panel demographics

Twenty-four clinicians registered their interest to participate in the Delphi study. Two pairs of hand therapists worked in the same hospital and each pair was asked to nominate one to participate in the study to maintain professional and geographical variety resulting in a Delphi panel of 22. Two invited panel members did not respond, yielding a final panel number of 20 (Table 2 and Figure 2). Response rate was 100% for the first round and 90% for the second and third rounds.

Table 2.

Delphi panel characteristics.

Delphi panel characteristics (n = 20)	n (%)	Number of respondents per Delphi round
Profession		Round 1	Round 2	Round 3
Occupational therapist	7 (35)	7	7	7
Physiotherapist	5 (25)	5	4	4
Orthopaedic surgeon	5 (25)	5	5	5
Plastic surgeon	2 (10)	2	2	2
Emergency medicine	1 (5)	1	0	0
Experience treating hand fractures (years)
0-5	1 (5)
11-20	8 (30)
>21	13 (65)

Figure 2.

Geographical location of study participants (n = 20).

Competencies

All proposed competencies except one were rated as very important in the first round and therefore these were included in the final competency list (Table 3). The competency which failed to reach agreement was “skills related to closed fracture manipulation/ring block and knowledge of the associated governance processes” with a median rating of 7 in the first round and 6.5 in the second round.

Table 3.

Final competency list (rated as very important by ≥ 75% of participants).

	Median rating 1st round (IQR)
Clinical assessment (Patient-related subjective and objective measures)
Knowledge and skills related to the general observation (signs) including the assessment of finger bruising, swelling and alignment (deviation, rotation, scissoring)	9.0 (1)
Knowledge and skills related to the clinical assessment of pain, joint stability, range of motion and neuro-vascular function	9.0 (0.25)
Knowledge and skills in assessing the influence patient factors (i.e. dominance, health, occupations, social factors) in the choice of treatment and potential functional outcomes	8.5 (1)
Skills in the assessment of the patients’ goals	8.0 (2)
Imaging (requesting and interpreting radiology findings)
Knowledge and skills related to imaging interpretation	9.0 (1)
Knowledge and skills in measuring fracture patterns and in assessing the fracture stability (likely displacement patterns)	9.0 (1)
Knowledge of the appropriate imaging modality to request (X-ray vs USS vs MRI) relative to the injury and how to order these investigations	9.0 (1)
Knowledge of the ionising radiation (medical exposure) regulations	9.0 (2)
Treatment planning (analysis of factors leading to surgical vs non-surgical treatment decision making and communication of the plan to the patient)
Knowledge of red flags for cases requiring surgery	9.0 (0)
Knowledge of factors affecting the decision for non-surgical vs surgical treatment	9.0 (0)
Knowledge of the risks and benefits of each treatment option	9.0 (0)
Knowledge of best immobilisation / protection methods for non-surgical treatment	9.0 (1)
Knowledge of anticipated outcome for treatment options	8.5 (1)
Skills in joint decision making when recommending surgical or non-surgical options	8.5 (1.25)
Self-awareness, both of biases and skill sets for success with different options	8.0 (1.5)
Knowledge of surgical techniques and associated benefits and risk	8.0 (2)
General competencies
Self-awareness of performance	9.0 (1)
Knowledge and skills related to hands surgery/therapy	9.0 (1)
Actively seeking view of others for the management of complex cases	9.0 (1.25)
Knowledge and skills in applying research to practice	8.0 (2.25)
Knowledge and skills related to extended scope practice in closed hand fractures	7.0 (1)
Knowledge of the ACP development	7.0 (1.25)
Knowledge and skills in auditing practice	7.0 (1.25)

There was agreement in the rating of competencies by professional background. Both therapists and medical doctors rated similarly (+/− one point) with two exceptions: “Knowledge and skills related to imaging interpretation” (median rating therapists = 9; medical doctors = 7) and “knowledge and skills in applying research to practice” (therapists = 8; medical doctors = 6).

There was less agreement on how to evidence competencies. However, 11 items were rated as very important (Table 4) and 19 were rated as moderately important (Table 5). Two items were similar and therefore amalgamated (“supervised assessment” and “supervised treatment”). Items brought forward to the second round were rated in a similar way. Only one evidence of competency was rated as not important and removed after the first round: “attendance on a surgical fracture fixation course”.

Table 4.

Final evidence of competencies list (rated as very important by ≥ 75% of participants).

	Median rating 1st round (IQR)
Completion of the ionising radiation (medical exposure) regulation (IRMER) training	9.0 (0)
Yearly continuous development in treatment and outcomes of hand fractures	8.0 (2)
Regular case discussions in supervision, multi-disciplinary team or peer supervision	8.0 (2)
Regular 360 assessment by the multidisciplinary team	8.0 (2.25)
Participation in department treatment guidelines and patient information material	8.0 (1.25)
Formal course on image interpretation	8.0 (2.25)
Number of supervised assessment/treatments of patient with closed hand fractures	7.5 (1.25)
Regular audit of treatment outcomes	7.5 (2)
Evidence of integration of new evidence in treatment planning	7.0 (1.25)
Evidence of experience in audit and participation in research	7.0 (1.25)
Review of a set number of imaging request and interpretation	7.0 (1.25)

Table 5.

Competencies (n = 1) * and evidence of competencies rated as moderately important.

	Median rating 2nd round (IQR)
Skills in closed fracture manipulation/ring block and knowledge of the associated governance processes*	6.5 (2.75)
Review of the reliability of assessing fracture stability and pattern with the multidisciplinary team	7.0 (1)
Regular attendance to imaging multidisciplinary meeting	7.0 (2)
Number of hours of observation of clinical assessment of patients with closed hand fractures in emergency department and / or fracture clinic	7.0 (1)
Formal ACP accreditation or working towards the accreditation	7.0 (1)
Audit of imaging requests and interpretation	7.0 (1)
Evidenced of skills by patient assessment of satisfaction with the explanation of treatment options	6.0 (2)
Log book of fractures assessed to ensure wide variety of type of fractures assessed	6.0 (2.5)
Experience evidenced by a number of years of practice in hand therapy	6.0 (1)
Number of case study reflections	6.0 (1)
Number of annual continuous professional development activities related to imaging	6.0 (1.75)
Evidence of patient involvement in the development and planning of service	6.0 (2)
Number of notes reviewed by another practitioner	6.0 (2)
Log book of image interpretation (set number of image interpretation practice)	6.0 (2)
Number of hours of observation of image interpretation in radiology	6.0 (2.75)
Evidenced of knowledge of treatment planning by review of notes	6.0 (2)
Number of years of practice with patients with closed hand fractures	6.0 (2)
Experience evidenced by working at a specific pay band scale	5.0 (2.75)
Observation of a set number of hand fracture surgeries	5.0 (0)

As ratings in the first and second rounds were similar the focus of the third round was altered to refine some of the evidence of competencies to assist their implementation in clinical settings. To evidence yearly continuous development in the treatment and outcomes of hand fractures, “log of key articles in hand fractures” and “presentations at in-service training” were rated the highest. “Participation in journal club”, “literature review”, “participation in research”, “reflective practice of audit of poor outcomes” and “attendance at national conferences” were also mentioned. Eighty-three percent of the participants recommended 6-15 supervised cases and 72% recommended this to be completed yearly or every few years, rather than once or twice after induction. The frequency of case discussion was more variable, but 89% believed it should happen between weekly to every 2-3 months. Similarly, there was no agreement on the frequency of the 360-degree multidisciplinary team assessments. Most (61%) thought that 0%–20% of the caseload should be audited yearly. Image interpretation courses such as Radiopedia online courses (https://radiopaedia.org/), e-Learning for healthcare on clinical imaging (https://www.e-lfh.org.uk/programmes/clinical-imaging/), and the British Association of Hand Therapist Level 2 course on fractures and radiographic interpretation were all recommended. Finally, there was no agreement on the number of imaging requests and interpretations which needed to be reviewed but 44% thought that 11-20 would be sufficient.

Discussion

To our knowledge this study is the first attempting to define competencies for Advanced Clinical Practice (ACP) Hand Therapists providing first line management of closed hand fractures in UK. The selection of competencies for inclusion was achieved in a single Delphi round, highlighting shared experiences across the professional groups. There was greater variability in views regarding how to evidence these competencies.

Competencies

There is currently no mandatory regulation of ACP roles in the UK, nor protection of titles, ²⁷ and inconsistencies have occurred in ACP implementation across different centres. ²⁸ ACPs develop a portfolio of evidence showing they are clinically competent to complete their role safely; however, it does not identify tailored, specialty learning outcomes to work towards. ²⁷ The Chartered Society of Physiotherapists have highlighted the need to define post-qualification skills and training in different specialities as a research priority in 2024. ²⁹

In the field of hand therapy, Ellis et al. ³⁰ conducted a Delphi study on the role parameters and requirements of general extended scope practice in hand therapy in 2005. The top five highest rated competencies/training were: “at least 3 years of experience in the relevant field”, “the ability to work autonomously”, “the ability to recognise weaknesses in clinical knowledge and competencies”, “in-house formal training in extended tasks” and “ability to practice and lead practice development”. Master’s modules, generic courses on extended practice, and shared learning with junior doctors were rated as the least important training. The emphasis on therapist characteristics (self-awareness) and in-house training mirrors our results. This is likely to be due to an element of practicality: the competencies can be assessed quickly and at little cost. This reflects comments by panel members that competencies should remain practical and a “realistic” exercise in busy clinical settings.

Evidence of competencies

Whilst all but one proposed competencies reached consensus, only 11 items suggested to evidence these competencies (37%) reached the consensus threshold. However, 16 evidence of competencies (55%) with moderate agreement only narrowly failed to reach consensus with median ratings one point or less below the threshold. It is likely that some items, for example skills related to closed fracture manipulation/ring block or regular attendance to imaging multidisciplinary meeting are related to differences in pathways or local systems. This highlights that competencies and evidence thereof must be adapted to the individual clinical context and will likely vary somewhat between organisations.

Of interest, “overall years of experience” or “pay scale” which is defined by specific banding in the UK (Band 5-8) failed to reach consensus as evidence of knowledge and skills. Furthermore, these items received the most open comments. There was a balance between comments explaining that banding and years of experience did not equate to clinical reasoning and ability, versus those stating that experience helped improving fracture pattern recognition and skills and offered an easy way of quantifying competencies. Observation and scrutiny from a mentor with personal skills such as motivation, attitude to work, attitude to risk and reflection skills were valued higher than years of experience/pay banding by panel members. Wong et al. ³¹ found that years of experience was a factor in treatment choice variation by ACP hand therapists in the first line management of metacarpal neck fractures. Three participants questioned if anyone with less than 5 years’ experience had the ability, confidence and credibility to work as ACP. In the authors’ opinion, competencies should be based on personal attributes of therapists as well as their other clinical skills in line with the competencies described in Table 3. Salary banding and years of experience in isolation were seen as insufficient evidence of competency in this setting.

Five open comments stressed that competency development should remain a realistic task in busy clinical settings and not a long “tick box” exercise. Several comments highlighted the importance of the qualification/standard/attributes of the person signing off competencies (mentor, supervisor, peers, MDT) to ensure quality over quantity. The need to assess and reflect on outcomes was highlighted as a measure of the impact of these competencies, especially for those with poorer outcomes.

Strengths and limitations

Competencies brought forward in a preliminary clinicians’ survey ⁸ were similar to those in this Delphi. This, along with the rapid consensus, strengthened the finding of this study. Our panel was diverse, and attrition rate was low. We failed to recruit a participant from radiology and had only one participant from emergency medicine who failed to complete round 2-3. This is likely to be related to the fact that they did not rate themselves an expert in the assessment and treatment of hand fractures. A separate survey on each theme sent to different professional groups may have been better at identifying competencies in each theme.

Applications

The results of this study will inform training for therapists, junior doctors, and other clinicians working with adults with closed hand trauma. By categorising the competencies into four themes based upon the pre-existing literature ¹⁵ and clinician survey input, ⁸ we present a robust framework which can serve as a syllabus for education.

We recommend that the list of competencies and evidence is made available to therapists on the BAHT Web site with the suggestion that they are adapted to local practice. They also provide a framework to guide individual therapists to base their own learning and development. The key factors underpinning the competencies is self-awareness of limitations, openness regarding outcomes and signing off competencies by a recognised mentor/supervisor. The litigious nature of medicine in the UK draws extra scrutiny where practice has been poor. Further to Lord Carter’s report in 2016, ³² the Getting It Right First Time (GIRFT) programme was introduced in the UK, seeking to improve productivity, efficiency and capacity to benefit the patient through more equity of access to high quality care and ultimately to improve outcomes. ³³ The incorporation of ACP roles in hand therapy working within the identified competencies and within a supportive multidisciplinary team aligns well with GIRFT; and will help in the drive towards a safer, more effective and cost-efficient provision of services for our patients with hand injuries in the UK and worldwide.

Ethical statement

Ethical approval

Research ethical approval was not required. Imperial College Healthcare NHS trust Therapies Service Improvement Group approved and provided project oversight.

Informed consent

Not applicable.

ORCID iDs

Katia Fournier https://orcid.org/0009-0000-0105-5706

Lisa Newington https://orcid.org/0000-0001-6954-2981

Alexia Karantana https://orcid.org/0000-0003-3742-5646

Ryan W Trickett https://orcid.org/0000-0002-0688-0630

Donna L Kennedy https://orcid.org/0000-0002-7415-4761