Specialized training helps nurses take the lead in patient management within an FLS

Josée Delisle World Osteoporosis Day

Read our World Osteoporosis Day interview with Josée Delisle, Clinical Nurse Specialist, researcher, and internationally recognized Fracture Liaison Service expert.

On the occasion of World Osteoporosis Day, IOF interviewed Josée Delisle, RN, BScN, MSc (experimental surgery.). A Clinical Nurse Specialist and researcher with internationally recognized expertise in Fracture Liaison Service development, she is a Medical Research Consultant with D.P.R.M Medical Inc., Medical Research Protocol Development. She has been a dedicated educator in the field, having published research papers on FLS management, and having lectured at special symposia for IOF and SICOT, among others. We thank Josee for providing her important insights in this interview.

From your point of view, what are the main challenges for osteoporosis management in Canada?

One of the biggest challenges for osteoporosis management in Canada is certainly the fact that it is difficult to get funding to subsidize an FLS coordinator. Also, major barriers are non-referral from orthopaedic surgeons and staff and the patients’ refusal to participate. Challenges to success reside in implementing an institutional policy for optimal screening, standardized algorithms of care, and order sets. (1)

Based on your experience, do you find that patients are well aware of their disease and the need to take treatment to avoid future fractures? 

Unfortunately, patients are not well aware of the disease and their risks of future fracture. We find a lot of denial from patients when we approach them for their fragility fracture management. Which often leads to the refusal of treatment to prevent future fractures. I have seen patients returning with another fracture and, only then, were they ready to initiate treatment.

Can you state, based on your experience, why FLSs are essential to make a difference to the patient’s experience?

An FLS identifies patients at risk of future fracture, coordinates care for patients to initiate treatment and maintains long-term treatment adherence. An FLS is essential in helping to close the osteoporosis care gap. Low medication adherence is associated with poorer outcomes in osteoporosis and a greater risk of re-fracture. An FLS provides vital education that can empower patients in their fragility fracture management.

Are there any special skills a Nurse should have to work in an FLS? Or can you share experiences of  any challenges that need to be met daily in an FLS setting?

We implemented an order set in our institution.  The order set is pretty straightforward and easy to apply. Nurses received training sessions on fragility fracture, FLS, and management. The coordinator is always available for knowledge transfer, should any questions arise. This has proven to be safe and efficient. We demonstrated that nurses alone can manage 74% of fragility fracture patients (2). 
An FLS improves the identification rate of fragility fracture and their management, contributing to closing the care gap in our institution (3).

As a Nurse in an FLS; what would you say is most important when it comes to collaboration within the multidisciplinary team?

Collaboration with the multidisciplinary team serves to increase long-term treatment adherence (4). It keeps the patient in the loop of subsequent fracture prevention and helps identify if there is a need to adjust prevention strategies. Ultimately, it decreases the subsequent fragility fracture rate. 


1. Senay A, Delisle J, Banica A, Laflamme GY, Leduc S, Mac Thiong JM, Ranger P, Rouleau DM, Fernandes JC. Barriers to the identification of fragility fractures for secondary fracture prevention in an orthopaedic clinic-based Fracture Liaison Service. A prospective cohort study. Current Orthopaedic Practice. 2018 Nov; 29(6):574-578.

2. Senay A, Delisle J, Raynauld JP, Morin SN, Fernandes JC.  Agreement between physicians' and nurses' clinical decisions for the management of the fracture liaison service (4iFLS): the Lucky Bone™ program. Osteoporos Int. 2016 Apr;27(4):1569-76. doi: 10.1007/s00198-015-3413-6. Epub 2015 Nov 24.

3.Senay A, Delisle J, Giroux M, Laflamme GY, Leduc S, Malo M, Nguyen H, Ranger P, Fernandes JC.The impact of a standardized order set for the management of non-hip fragility fractures in a Fracture Liaison Service. Osteoporos Int. 2016 Dec;27(12):3439-3447

4.Senay, A., J. C. Fernandes, J. Delisle, S. N. Morin, S. Perreault. Persistence and compliance to osteoporosis therapy in a Fracture Liaison Service: a prospective cohort study. Archives of Osteoporosis. 2019 14:87. Doi: 10.1007/s11657-019-0633-y.