The National Association of Orthopaedic Nurses (NAON) Scope and Standards of Orthopaedic Practice, 3rd Edition

Carol V. Harvey ▼ Jonathan David ▼ Diane R. Eckhouse ▼ Tina Kurkowski ▼ Cherie Mains ▼ Dottie Roberts

Background The NAON Scope and Standards of Orthopaedic Nursing Practice refl ect the following for the association: The fi rst version of the Standards of Orthopaedic Mission Statement: The mission of the National Nursing Practice was published jointly by NAON's pre- Association of Orthopaedic Nurses (NAON) is to decessor, the Orthopaedic Nurses Association (ONA), advance the art and science of orthopaedic care through and the American Nurses Association (ANA) in 1975. excellence in research, education, and nursing practice. The National Association of Orthopaedic Nurses (NAON) Value Statement: NAON promotes a culture of was established in 1980. In 1982, NAON conducted a professional collaboration among its members, other survey of its general membership to identify the original members of the team, and with other pro- standards of care, which were published in 1986 as fessional organizations, developed through trust, Orthopaedic Nursing Practice: Process and Outcome respect, integrity, and passion for the specialty of Criteria for Selected Diagnoses . Orthopaedic nurse certi- orthopaedics. fi cation was established in 1986 as a credentialing mech- Core Values: NAON believes in the core values of anism that validates profi ciency in orthopaedic nursing integrity, trust, vision, innovation, and stewardship. practice and enhances professional development. In Philosophy: NAON believes the specialty of ortho- 1989, a task force of NAON members created the Scope paedic nursing should set forth the highest standards of Orthopaedic Nursing Practice (1990), using a variety of nursing practice for optimum patient care. NAON of sources and expert opinions to defi ne the practice of believes in the concept of man as a total being having orthopaedic nursing and issues specifi c to this specialty. physical, psychological, cultural, social, emotional, The Scope of Orthopaedic Nursing was revised and and spiritual needs. The orthopaedic nurse, in collabo- standards were added for the 1996 publication of Scope ration with the patient and other members of the and Standards of Orthopaedic Nursing Practice . health team, utilizes this concept of man to assess, Revisions were made in 2001 to refl ect the changes in plan, implement, and evaluate a plan of patient care. health care and the nursing role. This document updates This is essential to assure that each these original documents to establish the current Scope patient achieves the highest possible level of health. and Standards for Orthopaedic Nursing Practice. NAON is committed to the advancement of the

Copyright 2013, National Association of Orthopaedic Nurses. All rights Reviewers reserved. No part of this publication may be reproduced or transmitted in Dorothy Pietrowski, MSN, RN, ACNP, ONC® any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system without the Pam Sapp, MN, RN, OCNS-C® written permission of the National Association of Orthopaedic Nurses. Marisa R. Swain, MSN, RN-BC, ONC® Reprinted with permission. Lauri Carpenter Tveit, MSN, RN, ONC® Published for NAON by: SmithBucklin, 401 N. Michigan Ave, Suite 2200, Michael Vansteel, MSN, RN-BC, ONC®, NE-BC Chicago, IL 60611–4267 ([email protected] ). Acknowledgments Editor This third edition of the Scope and Standards of Orthopaedic Nursing Carol V. Harvey, MSN, RN, ACNS-BC, ONC® Practice is based on the work of Dennis Ross, PhD, MAE, RN (editor of Authors the fi rst edition), as well as his work with Helen Taggart, DSN, RN, CS, Jonathan David, BSN, MSc, RN, ONC® on the second edition of this publication. Diane R. Eckhouse, MS, APN, OCNS-C® The authors received honoraria from the NAON for their work on the Scope and Standards. The authors have disclosed that they have no Tina Kurkowski, MS, RN, ONC, CNOR, ANP-C, ONP-C® other fi nancial interests to any commercial company related to this edu- Cherie Mains, MSN, RN, ONC®, CNOR-R cational activity. Dottie Roberts, MSN, RN, CMSRN, OCNS-C®, CNE DOI: 10.1097/NOR.0b013e3182920e7d

© 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2013 • Volume 32 • Number 3 139 Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

NNOR200394.inddOR200394.indd 139139 116/05/136/05/13 12:4212:42 AMAM profession of nursing. NAON believes that educational Infl uences on Orthopaedic programs that foster personal and professional growth will develop competence and excellence in nursing Nursing Practice practice for the orthopaedic nurse. NAON supports and encourages research and advanced clinical prac- H ISTORICAL PERSPECTIVE tice as the foundation for expertise in nursing practice. Since its inception as a profession through the efforts of NAON is a nonprofi t national and international Florence Nightingale, nursing has been an evidence- leader in identifying knowledge gaps and opportuni- based practice discipline directed toward health promo- ties for education of orthopaedic nursing practitio- tion and maintenance of self-care for individuals, fami- ners, promoting research, and encouraging effective lies, and communities. Dame Agnes Hunt, in the late communication between orthopaedic nurses and 19th century, is identifi ed as the founder of orthopaedic other groups with similar interests. NAON analyzes nursing as she established the fi rst orthopaedic hospital and makes defi nitive position statements with recom- for crippled children in England. Her focus was on fresh mendations on key clinical issues that have a strong air, good food, and happiness to help children, and thread to orthopaedic nursing and patient care. eventually adults, rehabilitate from musculoskeletal For these Scope and Standards of Orthopaedic disorders. In the early half of the 20th century, predom- Nursing Practice (3rd ed.), NAON defi nes patients in inant health problems were accidents or infections. the same broad sense, as humans who are health care However, the rapid development of medical and nursing consumers, who live within a family and community, sciences and technologies led to a more curative focus and for whom orthopaedic nurses provide holistic care for health care. In the latter half of the century, trauma that encompasses the entire spectrum of development and chronic diseases became the predominant health and lifespan. The ANA also considers the patient in this problems in the United States. The U.S. Department of broad sense by defi ning standards of care for the health Health and Human Services (DHHS) defi nes chronic care consumer who is “the person, client, family, group, conditions as those that limit activities of daily living community, or population who is the focus of attention and/or require ongoing medical attention for a year or and to whom the is providing services more. An example of this in orthopaedics is arthritis. as sanctioned by state regulatory bodies” (ANA, 2010, The DHHS identifi es that these conditions, especially p. 65). The Centers for Medicare & Medicaid Services along with diabetes, heart disease, and obesity, are cre- (CMS) defi nes the patient as an individual who is ating a signifi cant and increasing burden on the health receiving needed professional services that are directed of Americans (DHHS, 2010). Today, care for trauma vic- by a licensed practitioner of the healing arts toward tims and individuals with chronic musculoskeletal con- maintenance, improvement or protection of health, or ditions remain the focus of orthopaedic nursing. lessening of illness, disability, or pain (CMS, 2012b). This Scope and Standards of Orthopaedic Nursing C ONTEMPORARY ISSUES AND TRENDS Practice (3rd ed.) applies to orthopaedic nursing in clin- ical practice across all settings from acute and extended Advances in orthopaedic nursing practice have paral- or long-term care, ambulatory care centers, to home leled and facilitated advances in the prevention and and community settings. This publication includes the treatment of musculoskeletal conditions. As orthopae- scope of orthopaedic nursing practice, standards of dic nursing expands its body of knowledge through practice, and standards of professional performance of research and practice, nurses increasingly play integral orthopaedic nursing practice. roles in all aspects of orthopaedic care. The focus on While the American Nurses Association ANA prevention as well as acute care, chronic care, and reha- Nursing: Scope and Standards of Practice (2010) apply bilitation refl ects the current trends in orthopaedic to all professional nurses, these orthopaedic standards medicine and health care delivery in the United States. mirror the ANA and contain specifi c criteria for defi ning Musculoskeletal injuries often take place during a expectations and competent care associated with basic disaster. Orthopaedic nurses are key providers of care and advanced clinical practice of orthopaedic nurses. As for victims of disasters and participate with local and the nursing profession responds to the ever-changing national relief efforts. Orthopaedic nurses are part of needs and demands of health care, these standards and the military and provide essential care to military per- description of practice will require ongoing refi nement sonnel who are injured. Many breakthrough orthopae- as orthopaedic practice evolves. dic procedures and rehabilitation techniques have resulted from knowledge gained through these experi- ences. Purpose Orthopaedic patients are frequently asked to be base- The purposes of the Scope and Standards of Orthopaedic line subjects for research to defi ne parameters and Nursing Practice include: benchmarks for therapeutic intervention effectiveness. Orthopaedic nurses are involved in research and • defi ning orthopaedic nursing practice; research utilization particularly in areas such as pain • providing guidance for the professional growth and management and prevention of venous thromboembo- development of orthopaedic nurses; and lism and are contributing to evidence-based practice. • describing the basic responsibilities and areas of NAON members continue to advance the specialty accountability of orthopaedic nurses. and refi ne the standards of orthopaedic nursing practice

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NNOR200394.inddOR200394.indd 140140 116/05/136/05/13 12:4212:42 AMAM based on evolving work of the ANA, the National League improvement, informatics, and safety. Sets of KSAs for for Nursing (NLN), and the National Council of State each of the competencies were then created for use in Boards of Nursing (NCSBN). Additional resources for nursing prelicensure programs. the standards of practice are drawn from the Quality As with the QSEN project, NAON identifi es patient- and Safety Education for Nurses (QSEN) project in col- centered care as an essential element of orthopaedic laboration with the work from the Institute of Medicine nursing practice. As defi ned by the QSEN project (RWJF, (IOM) report, The Future of Nursing with funding by 2012c), patient-centered care recognizes “the patient or the Robert Wood Johnson Foundation (RWJF). National designee as the source of control and full partner in pro- issues surrounding health care reform and the Patient viding compassionate and coordinated care based on Protection and Affordable Care Act (DHHS, 2010) also respect for patient's preferences, values, and needs” infl uence standards of practice in terms of supporting (para. 1). Patient-centered care is achieved through access to quality care. teamwork and collaboration, marked by nurses’ ability to “function effectively within nursing and inter-profes- sional teams, fostering open communication, mutual National League of Nursing respect, and shared decision making to achieve quality Core Values patient care” (RWJF, 2012e, para. 1). A continuing focus Continuing dedication to evidence-based practice on safe practice allows orthopaedic nurses to minimize requires orthopaedic nurses to “integrate best current the risk of harm to patients and themselves through sys- evidence with clinical expertise and patient/family pref- tems and individual efforts (RWJF, 2012d). A critical erences and values for delivery of optimal health care” part of the culture of safety is the appropriate use of (RWJF, 2012a, para. 1). The four core values of the technology and informatics “to communicate, manage National League for Nursing (NLN, 2011, para. 1) also knowledge, mitigate error, and support decision mak- guide orthopaedic nursing practice: ing” (RWJF, 2012b, para. 1).

• Caring : Promoting hope, healing, and response to S AFETY AND QUALITY INITIATIVES the human condition • Integrity : Respecting the dignity and moral whole- Nursing practice is evolving constantly, with the goal of ness of every person without conditions or limita- continually improving the delivery of patient care. The tions Joint Commission (2012b) developed National Patient • Diversity : Affi rming the uniqueness of and differ- Safety Goals for improvement of patient identifi cation, ences among persons, ideas, values, and ethnicities communication, medication administration, infec- tions, and pressure ulcers, identifi cation of patient • Excellence : Creating and implementing transforma- safety risks; fall reduction; and prevention of wrong tive strategies with daring ingenuity site, wrong procedure, or wrong person surgery. These The IOM (2010) suggests that nurses play a vital role goals are essential to promote safe, quality orthopaedic in the future of health care in the United States and are patient care. In addition, The Joint Commission's pivotal to realization of the objectives of the Patient (2012c) Surgical Care Improvement Project (SCIP) pro- Protection and Affordable Care Act (DHHS, 2010) in vides a set of core measures for monitoring quality indi- light of the evolving health care system and changes in cators. These encompass standards to prevent surgical health care settings. Four key messages were developed site infection, maintain blood glucose and blood pres- by the IOM (2010, para. 3): sure, prevent urinary tract infections, maintain tem- perature regulation, and prevent venous thromboem- • Nurses should practice to the full extent of their edu- bolism in surgical patients. The ANA has also developed cation and training. the National Database of Nursing Quality Indicators • Nurses should achieve higher levels of education and (NDNQI®) to enable hospitals to collect and evaluate training through an improved education system that data concerning nursing-sensitive indicators reported promotes seamless academic progression. to a national database. The database provides research- • Nurses should be full partners, with physicians and based national comparative data on nursing care and other health care professionals, in redesigning health the relationship to patient outcomes. It serves as evi- care in the United States. dence for patient care quality improvement initiatives • Effective workforce planning and policy making (ANA, 2012b). All these measures are very important require better data collection and information infra- for monitoring and promoting positive orthopaedic structure. surgical patient outcomes. Musculoskeletal injuries are often the highest to take The RWJF has funded the QSEN project. The overall place during a disaster. Orthopaedic nurses are key pro- goal through all phases of QSEN is to address the chal- viders of care for victims of disasters and participate lenge of preparing future nurses with the knowledge, with local and national relief efforts. skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care sys- tems in which they work. In order to accomplish this H EALTH CARE REFORM goal, competencies are defi ned in the project. These The issue of health care reform in the United States has competencies include patient-centered care, teamwork been the subject of political debate since the early part and collaboration, evidence-based practice, quality of the 20th century. Health care reform (CMS, 2012a) is

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NNOR200394.inddOR200394.indd 141141 116/05/136/05/13 12:4212:42 AMAM a general rubric used for discussing major health policy myelomeningocele, scoliosis, oncologic disorders/ creation or changes that typically attempts to: bone cancer, and congenital or acquired conditions of pediatrics such as congenital hip dysplasia/clubfoot. • Broaden the population that receives health care cov- erage through either public sector insurance pro- Orthopaedic nurses also may be advanced practice grams or private sector insurance companies registered nurses (APRNs). NAON endorses the efforts • Expand the array of health care providers from of the NCSBN (2012) in developing the APRN Consensus which consumers may choose Model to standardize education, licensure, and practice • Improve the access to health care specialists across the United States and its territories. The NCSBN • Improve the quality of health care (2008, p. 7) states that an APRN is a nurse: • Give more care to citizens • who has completed an accredited graduate-level • Decrease the cost of health care education program preparing him/her for one of the four recognized APRN roles: certifi ed registered The Patient Protection and Affordable Care Act (DHHS, (CRNA), certifi ed nurse-midwife 2010) is a U.S. federal statute signed into law in 2010. The (CNM), clinical nurse specialist (CNS), or certifi ed law aims to provide a number of incentives over time for (CNP). individuals, not already subject to a designated qualifi ed • who has passed a national certifi cation examina- health benefi ts plan, or employers not currently offering tion that measures APRN role and population- their workforce such benefi t plans, to secure coverage via focused competencies and who maintains continued a framework of subsidies, tax credits, and/or fees. competence as evidenced by recertifi cation in the role and population through a national certifi cation D EMOGRAPHICS program; Orthopaedic nurses must address the needs arising • who has acquired advanced clinical knowledge from unique age, gender, cultural, spiritual, ethnic, and skills preparing him/her to provide direct care racial, sexual orientation, and socioeconomic back- to patients, as well as a component of indirect care; grounds in each care situation. In addition, the number however, the defi ning factor for all APRNs is that a of older adults is increasing, obesity is a major chal- signifi cant component of the education and practice lenge in America, and many economically disadvan- focuses on direct care of individuals; taged persons lack adequate health care. Orthopaedic • whose practice builds on the competencies of reg- nursing practice is enriched through this diversity and istered nurses (RNs) by demonstrating a greater the needs of society and refl ects respect for the unique depth and breadth of knowledge, a greater synthesis backgrounds of patients and families. of data, increased complexity of skills and interven- tions, and greater role autonomy; • who is prepared educationally to assume responsi- Roles of the Orthopaedic Nurse bility and accountability for health promotion and/ Orthopaedic nurses play a major role in the care of people or maintenance as well as the assessment, diagnosis, of all ages with orthopaedic injuries and conditions and management of patient problems, which across multiple settings. Orthopaedic nurses collaborate includes the use and prescription of pharmacologic with health care providers in many specialties. Injury pre- and nonpharmacologic interventions; vention, acute care, chronic care, and rehabilitation are a • who has clinical experience of suffi cient depth and major focus and include the following in orthopaedics: breadth to refl ect the intended license; and • Prevention strategies that include education of the • who has obtained a license to practice as an APRN public about issues such as osteoporosis, arthritis, in one of the four APRN roles. seat belt and helmet use, fall prevention in older Orthopaedic nurses may also be clinical nurse lead- adults, and sports injury prevention. ers (CNLs). The CNL is a role defi ned by the American • Acute care with injury that includes management of Association of Colleges of Nurses (AACN, 2007, 2012) as musculoskeletal injuries, such as fractures and sport an advanced clinician with education in a CNL master's injuries in the emergency setting, the inpatient area, degree program in nursing and who passes the CNL cer- as well as in the clinic and operating room. Acute tifi cation examination. The CNL is not an administrator care restorative procedures include joint replace- or a manager but collaborates with the health care team ments; tendon, muscle, and bone transplants and at the point of care. The American Nurses Association is transfers; bone and joint stabilization with internal addressing this role as it grows nationwide; however, and external devices as well as establishment and the role of the CNL is not part of the NCSBN (2008) maintenance of traction; and pain management in APRN Consensus Model. the hospital or the ambulatory care setting. NAON believes the orthopaedic nurse, in any role, • Chronic and/or rehabilitation interventions and must promote patient safety, quality care, communica- management include care for persons with condi- tion and collaboration among disciplines, and a healthy tions such as metabolic disorders/osteoporosis, environment. These are essential for achievement of degenerative disorders/osteoarthritis, infl ammatory positive patient outcomes. As noted in the 2010 posi- disorders/rheumatoid arthritis/lupus, neuromuscular tion statement, NAON promotes “a healthy work disorders/multiple sclerosis/cerebral palsy environment for all nurses. To optimize the safety,

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NNOR200394.inddOR200394.indd 142142 116/05/136/05/13 12:4212:42 AMAM effectiveness and productivity of nursing care, the work • New Knowledge, Innovation, and Improvements : environment must provide strong leadership, appropri- an organization's ethical and professional ate resources and a supportive milieu” (NAON, 2010b, responsibility to contribute to health care delivery, para. 2). the organization, and the profession. • Empirical Quality Results : organizations are in a Health Care Delivery Settings unique position to become pioneers of the future and to demonstrate solutions to numerous prob- Standards of Orthopaedic Nursing Practice refl ect the lems inherent in today's health care systems. spectrum of care delivery across the patient lifespan, Beyond the “What” and “How,” organizational lead- from pediatrics to end-of-life, and in all settings in ers must ask themselves what difference these which orthopaedic nurses may function. Orthopaedic efforts have made. nurses work in trauma care settings such as emergency transport, emergency departments, and urgent care facilities. Orthopaedic nurses work in all phases of the Scope of Orthopaedic Nursing perioperative experience, including preoperative set- Practice tings, the operating room, and postanesthesia care envi- ronments. Additionally, orthopaedic nurses work in O RTHOPAEDIC NURSE inpatient and outpatient facilities, clinics, physician The professional orthopaedic nurse is a competent reg- offi ces, homes, long-term care, assisted living, hospice istered nurse with entry-level educational preparation settings, and in the community. Short length of stay in and licensure whose practice focuses on the care of acute care settings has led to more acute patients in patients with orthopaedic conditions in a variety of set- rehabilitation or skilled nursing care facilities or even at tings. These include, but are not limited to, the areas of home. This impacts the need for orthopaedic nurses to administration, adult care, geriatric care, pediatric care, be involved in all aspects of care for effective transition, inpatient care, outpatient clinic, critical care, emer- and continuity, and includes the need for effi cient and gency department, education, informatics, home health focused patient and family education. care, long-term care, medical-, offi ce Health care changes have shifted many patients to practice, oncology, and/or perioperative care. ambulatory centers. Patients may no longer travel long Orthopaedic nurses must be licensed by his/her state distances for comprehensive orthopaedic centers but and practice in accordance with federal laws and regu- instead receive care in rural clinics or home settings lations, specifi c state Nurse Practice Acts, and position staffed by nurses. These changes in care delivery set- descriptions of health care agencies. tings create opportunities for education and expansion As outlined in the NAON Position Statement: Role of orthopaedic practice. Expanded care delivery settings and Value of the Orthopaedic Nurse (NAON, 2009, p. emphasize the need for consistent standards in ortho- 1), based on competency and specialty training, the pro- paedic nursing practice. fessional orthopaedic nurse: Accreditation standards for health care profession- • may work independently or collaboratively with a als also infl uence orthopaedic nursing practice. In par- multidisciplinary health care team (including ticular, many healthcare organizations are accredited patients and families) providing appropriate, effec- by The Joint Commission (2012). Health care settings tive, and effi cient care and education also may be accredited by the Det Nortske Veritas • is able to assess, identify nursing diagnoses and treat Healthcare Inc. (DNV, 2012), which uses the National patient conditions for which orthopaedic patients are Integrated Accreditation for Healthcare Organizations at risk, including, but not limited to, pain, impaired (NIAHO) standards in combination with the CMS regu- physical mobility, self-care defi cits, impaired skin lations to measure and ensure quality patient care and integrity, body image disturbance, and posttrauma outcomes. response In addition, many organizations and orthopaedic • bases clinical judgment and decision making on the nurses participate in the American Nurses Credentialing nursing process, , and research, as Center (ANCC) Magnet Recognition Program®. This well as specifi c orthopaedic knowledge program addresses the professional work environment, • performs holistic assessments of individuals and/or requiring Magnet-designated facilities to adhere to the families, with special focus on impact of musculosk- following model components (ANCC, 2012): eletal conditions on self-care needs, environmental • Transformational Leadership : to lead people where management, resources, and support systems they need to be in order to meet the demands of the • develops, implements, and continuously evaluates a future. plan of care, encouraging a multidisciplinary team • Structural Empowerment : structures and processes approach to making patient care decisions developed by infl uential leadership provide an inno- • maintains current orthopaedic knowledge and shares vative practice environment in which strong profes- that knowledge with other health professionals sional practice fl ourishes and the mission, vision, • participates in peer review to assure competent practice and values come to life to achieve outcomes believed • serves as an educator, mentor, and role model for to be important for the organization. nursing colleagues, students, and others • Exemplary Professional Practice : to demonstrate • participates in professional nursing associations that what professional nursing practice can achieve. promote educational and professional activities

© 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2013 • Volume 32 • Number 3 143 Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

NNOR200394.inddOR200394.indd 143143 116/05/136/05/13 12:4212:42 AMAM • applies research and evidence-based practice in the assessment and interventions that identify and enhance various clinical practice settings an individual's strengths and abilities to maximize well- • participates in/conducts clinical research and shares being and quality of life. Orthopaedic nursing practice fi ndings through presentation and/or publication predominantly facilitates the promotion of wellness and • maintains and promotes political awareness and is self-care, maintenance of health, and prevention of proactive concerning health care issues injury and illness in the care of individuals with muscu- loskeletal conditions. Advanced practice registered nurse (APRN) roles in Using evidence-based nursing practice knowledge orthopaedics include the CNS and the NP. The ortho- and technology, the orthopaedic nurse, at any level, paedic APRN may also be a CRNA; however, nurse ensures that the patient, family, health care team, com- anesthetists are certifi ed in the role rather than in the munity, and regulatory agencies are aware of and utilize orthopaedic practice specialty. The advanced practice the best practices available to affect positive patient orthopaedic nurse is prepared at the graduate level to care and outcomes. The NAON Scope and Standards of provide direct patient care and/or consultation, teach- Orthopaedic Nursing Practice contribute to the associ- ing, and coaching based on complex assessments to ation's commitment to the ideals of an altruistic and maximize patient potential and infl uence the best-iden- humanistic profession. These provisions promote tifi ed plan for positive patient outcomes. An APRN is orthopaedic nursing practice by identifying its specifi c autonomous in his/her practice. The orthopaedic APRN purposes, defi nition, levels of specialty practice, and enhances the abilities of others and effects positive functions of nurses who practice at various levels within change in health care organizations. The orthopaedic this specialty. APRN develops partnerships with other specialty pro- viders to work in multidisciplinary teams to drive posi- tive health outcomes. In addition, the APRN identifi es Orthopaedic Nursing Certifi cation gaps and develops areas for improvement through sci- Certifi cation as an orthopaedic nurse attests to the entifi c research processes. These processes promote attainment of a specialized body of knowledge beyond positive changes in practice and the APRN supports basic registered nursing licensure. The major goal of implementation of evidence-based practice solutions. specialty nursing certifi cation is to improve patient out- The APRN may also have prescriptive authority, use comes and promote the safety of health care consumers. procedures, referrals, treatments, and therapies in Certifi cation serves to promote quality patient care by accordance with state and federals laws and regula- providing a mechanism for nurses to demonstrate their tions as wells as position descriptions of health care profi ciency. Certifi cation documents the individual agencies. nurse's understanding of a body of information specifi c As outlined in the NAON Position Statement: Role to orthopaedic nursing and the standard of nursing and Value of the Orthopaedic Nurse (NAON, 2009, p. 2), practice, while providing expanded career opportuni- advanced orthopaedic nursing practice requires sub- ties. Certifi cation improves patient outcomes and pro- stantial theoretical knowledge and clinical expertise in motes the nursing profession and the knowledge base of orthopaedic nursing and at least a master's degree prep- the individual nurse on all levels. As stated in the NAON aration. The advanced practice orthopaedic nurse: Position Statement: Orthopaedic Nurse Certifi cation , “orthopaedic nurse certifi cation provides tangible evi- • incorporates all the above aspects of the professional dence that nurses have the knowledge required to pro- orthopaedic nursing role vide effective care to patients experiencing the complex • provides expert care to individuals diagnosed with problems associated with a musculoskeletal diagnosis musculoskeletal conditions at any stage of life” (NAON, 2010a, p. 2). • educates and supports community groups interested in health promotion and illness/injury prevention O RTHOPAEDIC NURSE CERTIFIED (ONC®) • may fulfi ll various roles including direct caregiver, ® consultant, educator, researcher, administrator, and/ The Orthopaedic Nurses Certifi cation Board (ONCB , ® or primary health care provider 2011) defi nes the ONC as a registered nurse who has suffi cient practical experience and knowledge to pass the certifi cation examination, indicating a level of Orthopaedic Nursing knowledge consistent with competent orthopaedic nursing practice. The ONC® may provide care to indi- Orthopaedic registered nursing practice is defi ned as vidual patients or supervise care delivered by orthopae- the protection, promotion, and optimization of health dic nurse generalists and other caregivers. The ONC® and abilities; prevention of illness and injury; alleviation also may function in supportive roles, such as patient/ of suffering through the diagnosis and treatment of staff educator, case manager, or manager/administrator. human response; and advocacy in the care of individu- In addition, an orthopaedic APRN may be certifi ed as an als, families, communities, and populations. The defi ni- ONC® and meet criteria set by an individual state Nurse tion mirrors Nursing's Social Policy Statement: The Practice Act to function as an APRN. Essence of the Profession (ANA, 2010). The musculosk- The ONCB (2011) describes the ONC® as a certifi ed eletal system can be affected by degenerative, traumatic, nurse who: infl ammatory, neuromuscular, congenital, metabolic, and oncologic disorders throughout the lifespan. • utilizes appropriate nursing theory as the foundation Orthopaedic nursing practice involves interactive for nursing practice;

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NNOR200394.inddOR200394.indd 144144 116/05/136/05/13 12:4212:42 AMAM • incorporates critical skills in addressing the health The following spheres of practice describe the certi- care needs of orthopaedic patients; fi ed advanced practice orthopaedic nurse (ONCB, 2011): • develops consistency in data collection to identify • Clinician/Practitioner : assesses, formulates nursing health problems in orthopaedic populations; diagnoses, and for the ONP-C® formulates medical • implements the plan of care and evaluates the effec- diagnoses, treats and evaluates quality nursing care, tiveness of care provided by the orthopaedic nursing and advocates health promotion and disease preven- team; tion • uses extensive clinical expertise to participate in the • Educator : participates in health promotion, disease care of patients with complex orthopaedic problems; prevention, teaching/coaching of patients, family, • collaborates with consumers and other members of and health care providers, and serves as a preceptor/ the interdisciplinary health care team to ensure com- mentor for health care professionals prehensive orthopaedic education and treatment • Manager : monitors and ensures quality of health programs are established and maintained for a vari- care practice ety of health care settings; • Consultant : serves as a consultant to nursing staff, • facilitates the education and professional growth of other disciplines, and the community regarding mus- members of the orthopaedic nursing team; culoskeletal health • serves as a consultant for orthopaedic nursing care to other nurse generalists, members of the interdisci- • Researcher : applies research fi ndings to direct nurs- plinary health care team, and the community; ing practice and conducts/participates in research • initiates/assists in development of program specifi c performance indicators in general • orthopaedics or special interest groups. Tenets of Orthopaedic Nursing • assists in development of disease specifi c program Practice for the orthopaedic unit/health care Five tenets characterize contemporary orthopaedic • organization and achieving recognition status by nursing practice and are modeled after the ANA Scope regulatory bodies and Standards of Practice (ANA, 2010): • ensures the continuity of care through utilization of orthopaedic nursing standards of care and evidence- • Orthopaedic nursing practice is individualized. based practice; Orthopaedic nursing respects diversity and care is • keeps abreast of current trends that impact ortho- individualized to meet the unique needs of the patient paedic nursing practice through involvement in or situation. The patient is defi ned to be a health care local, regional, national, and international profes- consumer who is person, client, family, group, com- sional organizations; munity, or population who is the focus of attention • updates orthopaedic practice knowledge through and to whom the orthopaedic nurse provides muscu- continued involvement in educational requirements loskeletal care as sanctioned by state regulatory bod- of recertifi cation; and ies. • participates in initiatives for political reform of • Orthopaedic nurses coordinate care by establishing health care systems. partnerships. The orthopaedic registered nurse establishes partnerships with persons, families, sup- port systems, and other providers, utilizing in-person and electronic communication to reach a shared goal Certifi ed Advanced Practice of delivering quality musculoskeletal health care. Orthopaedic Nurse Effective collaborative interprofessional team plan- The certifi ed advanced practice orthopaedic nurse, as ning is based on recognition of each discipline's defi ned by the ONCB (2011), holds a graduate degree value and contributions, mutual trust, respect, open (master's or doctorate) in nursing with emphasis and discussion, and shared decision-making. certifi cation as either an Orthopaedic Clinical Nurse • Caring is central to the practice of the orthopaedic Specialist–Certifi ed (OCNS-C®) or an Orthopaedic registered nurse. Professional nursing promotes Nurse Practitioner–Certifi ed (ONP-C®). The advanced healing and health and is fostered by a trusting rela- practice orthopaedic nurse may be eligible for advanced tionship between nurse and patient. Conscious car- practice licensure or recognition based on individual ing is exemplifi ed in concrete acts, and effective state Nurse Practice Acts and the APRN Consensus interpersonal, verbal and nonverbal communication Model (NCSBN, 2008). Advanced practice orthopaedic techniques. The nurse additionally promotes self- nurses are tested for certifi cation in the roles of clini- care as well as care of the environment and society. cian/practitioner, educator, consultant, researcher, and • Orthopaedic nurses use the nursing process to plan manager (ONCB, 2011). The advanced practice ortho- and provide individualized care to their health care paedic nurse assesses, formulates diagnoses, identifi es consumers. Orthopaedic nurses use evidence-based expected outcomes, develops a plan of care, and evalu- knowledge of human experiences and responses, as ates clinical and nonclinical orthopaedic nursing prac- well as theoretical knowledge, to collaborate with tice for patients with complex musculoskeletal prob- patients to assess, establish nursing diagnoses, iden- lems. The advanced practice orthopaedic nurse uses tify outcomes, plan, implement, and evaluate care. theory, research, and evidence-based practice as a basis The overall goals are to prevent harm and produce for clinical decision-making and for guiding practice. benefi cial effects that contribute to quality outcomes.

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NNOR200394.inddOR200394.indd 145145 116/05/136/05/13 12:4212:42 AMAM Identifi ed outcomes are the basis for nurses to evalu- These standards mirror the ANA (2010) Standards of ate the effectiveness of their care. Critical thinking, Professional Nursing Practice . NAON, and the ANA, problem solving, and decision making underlie each use the nursing process, which includes the compo- step of the nursing process. The nursing process is nents of assessment, , outcomes iden- universally applicable, dynamic, cyclical, and most tifi cation, planning, implementation, and evaluation as of all interpersonal and collaborative. the framework for defi ning the standards of practice. • A strong link exists between the professional work Accordingly, the nursing process encompasses signifi - environment and the orthopaedic registered nurse's cant actions taken by orthopaedic nurses and forms the ability to provide quality health care and achieve foundation of nurses’ decision making toward positive optimal outcomes. Evidence indicates that an orthopaedic patient outcomes. The Standards of unhealthy work environment contributes to medical Orthopaedic Nursing Practice should be interpreted as errors, ineffective delivery of care, and confl ict and applicable only to those actions within the scope of the stress among health professionals. Unsafe conditions individual nurse's license and do not require the nurse or a negative and/or a demoralizing environment to engage in any action which is outside the scope of his also contribute to a poor work environment. The pro- or her license or competency, or to perform actions vision of quality health care occurs only in an envi- assigned to other members of the health care team. ronment dedicated to constantly maintaining and improving orthopaedic care. Orthopaedic nurses S TANDARD 1. ASSESSMENT have an ethical obligation to promote a healthy work The orthopaedic nurse collects comprehensive data per- environment by striving to maintain a professional, tinent to the patient's health and/or situation in order to safe, and collaborative health care environment. make clinical decisions and positively impact outcomes for those with actual or potential orthopaedic conditions. Competencies for assessment data collection include Standards of Orthopaedic Nursing identifi cation of holistic/individualized data in a sys- Standards of professional nursing practice are authori- tematic and ongoing manner while respecting values, tative statements through which the profession outlines preferences, knowledge, and needs; involvement and the responsibilities that all nurses are expected to per- respect for the health care consumer and family; col- form competently (ANA, 2010). These standards are laboration with other health care providers; identifi ca- comprised of Standards of Orthopaedic Nursing tion of barriers to effective communication; prioritiza- Practice and Standards of Orthopaedic Nursing tion of data based on immediacy of the condition; use of Professional Performance. evidence-based assessment methods; synthesis of data NAON believes the specialty of orthopaedic nursing to identify patterns and variances; application of ethi- should establish the highest standards of nursing prac- cal, legal, and privacy guidelines; and documentation of tice for optimum patient care. Quality health care is a relevant data in a retrievable manner. primary responsibility of its practitioners. These stan- For the advanced practice orthopaedic nurse, compe- dards provide a framework to which orthopaedic nurses tencies for comprehensive assessment also include ini- should be held accountable. They describe the minimal tiation and interpretation of consults, diagnostic tests, competence level of professional nursing care or activ- and procedures relevant to the patient's current status, ity common to all nurses who care for patients with and assessment of the effect of interactions among indi- actual or potential orthopaedic conditions. viduals, family, community, and social systems. The standards may serve as the foundation for: S TANDARD 2. DIAGNOSIS • databases of orthopaedic nursing practice; • regulation of orthopaedic nursing practice; The orthopaedic nurse analyzes the assessment data to • quality improvement programs; determine the diagnoses or issues for persons with • outcome criteria for health care reimbursement or actual or potential orthopaedic conditions. fi nancing; Competencies for determination of diagnosis • creation or measurement of nursing care delivery include the derivation of the diagnoses or issues from systems or organizational design; the assessment data; validation with the patient, family, • certifi cation programs; and other health care providers; identifi cation of risks • position descriptions or evaluations; to safety or barriers to health from interpersonal, sys- • educational programs; tematic, or environmental circumstances; use of stan- • orthopaedic ; and dardized classifi cation systems and clinical decision • policies, procedures, and protocols for health care support tools; and documentation of diagnoses or agencies. issues to facilitate determination of the expected out- comes and plan. For the advanced practice orthopaedic nurse, com- Standards of Orthopaedic Nursing petencies for the determination of diagnosis also include Practice systematic comparison and contrast of clinical fi ndings with normal and abnormal variations and developmen- Standards of Orthopaedic Nursing Practice describe a tal events; utilization of complex data and information competent level of nursing care as demonstrated by the via interview/obtaining a history, examination and critical thinking model known as the nursing process. diagnostic processes; and collaboration with health

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NNOR200394.inddOR200394.indd 146146 116/05/136/05/13 12:4212:42 AMAM care providers to develop and maintain competency in address identifi ed diagnoses or issues; and active partici- the diagnostic process. pation in the development and continuous improvement of systems that support the planning process. S TANDARD 3. OUTCOMES IDENTIFICATION The orthopaedic nurse identifi es expected outcomes for S TANDARD 5. IMPLEMENTATION a plan individualized to the patient's health and/or situ- The orthopaedic nurse implements interventions identi- ation with actual or potential orthopaedic conditions. fi ed in the plan of care to attain expected outcomes indi- Competencies for identifi cation of expected out- vidualized to the patient's health and/or situation with comes include involvement of the patient, family, health actual or potential orthopaedic conditions. care providers, and others in formulating expected out- Competencies for implementation of plans include comes; respect for cultural values and ethical consider- collaboration and partnership with the patient and health ations; consideration of associated risks, benefi ts, costs, care providers to implement the plan in a safe, realistic, scientifi c evidence, clinical expertise, and trajectory of effi cient, and timely manner; demonstration of caring the condition; inclusion of measurable goals with an behavior; utilization of technology to measure, record, appropriate time estimate for outcome attainment; and retrieve data; utilization of evidence-based interven- facilitation of continuity of care; and modifi cation of tions and treatments specifi c to the diagnosis; provision expected outcomes according to changes in the status of of and advocating holistic, sensitive care that addresses the patient or the situation. the needs of diverse populations across the lifespan; For the advanced practice orthopaedic nurse, com- application of appropriate knowledge to the health care petencies for the identifi cation of expected outcomes situation; application of health care technology to maxi- also include incorporation of scientifi c evidence and mize access and optimize outcomes; utilization of com- implementation of evidence-based practices with iden- munity resources; accommodation of different styles of tifi cation of expected outcomes; consideration of cost communication; integration of traditional and comple- and clinical effectiveness; patient satisfaction; and con- mentary health care practices; encouragement of an opti- tinuity among providers; and differentiation of out- mal level of participation and problem solving by the comes that require care processes from those that patient; and documentation of implementation and any require system-level interventions. modifi cation or changes in the identifi ed plan. For the advanced practice orthopaedic nurse, com- S TANDARD 4. PLANNING petencies for implementation of the plan also include facilitation of the use of systems, organizations and The orthopaedic nurse develops a plan that prescribes community resources; support for collaboration with strategies and alternatives to attain expected outcomes nursing and other health care providers; incorporation individualized to the patient's health and/or situation of new knowledge and strategies to initiate change if with actual or potential orthopaedic conditions. desired outcomes are not achieved; use of advanced Competencies for planning include the development communication skills to promote relationships among of holistic/individualized plans, while respecting values, nurses, patients, and other health care providers to beliefs, socioeconomic factors, environment, and avail- maintain open discussion of patient experiences to able technology; establishment of priorities with the improve outcomes; and active participation in the devel- patient, family, and others; inclusion of strategies that opment and continuous improvement of systems that address the identifi ed diagnoses which may include pro- support the implementation of the plan. motion and restoration of health and wholeness across the lifespan, prevention of illness, injury, or disease, alleviation of suffering, and support care of the dying. S TANDARD 5A. COORDINATION OF CARE Competencies also include provision for continuity of The orthopaedic nurse coordinates care delivery to care; a pathway or timeline; consideration of economic attain expected outcomes individualized to the patient's impact; integration of current scientifi c evidence, health and/or situation with actual or potential ortho- trends, and research; provision of direction to other paedic conditions. members of the health care team; exploration with all Competencies for coordination of care include orga- involved of suggested potential and alternative options; nization of the components of the plan; management of refl ection of current standards, rules, regulations, and care to maximize independence and quality of life; standards; documentation in a manner that uses stan- assisting the patient in the identifi cation of options for dardized language or recognized terminology; and mod- alternative care; communication during transitions of ifi cation of the plan according to the ongoing assess- care with the patient, family, and system; advocating for ment of the response and other outcome indicators. dignifi ed and humane care by the interprofessional For the advanced practice orthopaedic nurse, compe- team; and clear documentation of the coordination tencies for planning also include identifi cation of assess- of care. ment and diagnostic strategies with therapeutic interven- For the advanced practice orthopaedic nurse, com- tions that refl ect current evidence, research, literature, petencies for coordination of care also include leader- and expert clinical knowledge; selection or design of ship in the coordination of interprofessional health care strategies that meet multifaceted/complex patient needs; to integrate the delivery of services, synthesis of data, inclusion of the patient's holistic values and beliefs and information to modify surroundings if needed, and regarding therapies in the plan; leadership in the design prescribe necessary system and community support and development of interprofessional processes to measures.

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NNOR200394.inddOR200394.indd 147147 116/05/136/05/13 12:4212:42 AMAM S TANDARD 5B. HEALTH TEACHING AND HEALTH PROMOTION implement care individualized to the patient's health and/or The orthopaedic nurse employs strategies to promote situation with actual or potential orthopaedic conditions. health and a safe environment individualized to the Competencies for prescriptive authority and treat- patient's needs and/or situation with actual or potential ment include consideration of the patient's comprehen- orthopaedic conditions. sive health care needs with prescribing evidence-based Competencies for effective health teaching and pro- diagnostics, tests, treatments, therapies, and proce- motion include focus on healthy lifestyles, risk-reducing dures; prescription of pharmacologic agents based on behaviors, developmental needs, activities of daily liv- current knowledge of pharmacology and physiology ing, and preventive self-care; use of holistic methods according to clinical indicators, the patient's status, and appropriate to the situation and consideration of needs and results of diagnostic and laboratory tests; patient's values, beliefs, developmental level, language evaluation of therapeutic and potential adverse effects preference, learning needs, readiness and ability to of pharmacological and nonpharmacological treat- learn, and socioeconomic status; seeking opportunities ments; provision of information about intended effects for feedback and evaluation of the effectiveness of used and potential adverse effects of proposed prescriptive teaching strategies; use of information technologies to therapies; provision of information about costs and communicate health care information in a variety of alternative treatments and procedures; and evaluation settings; and provision of information about intended and incorporation of complementary and alternative positive effects and potential adverse effects of proposed therapy into education and practice. therapies. For the advanced practice orthopaedic nurse, com- S TANDARD 6. EVALUATION petencies for health teaching and health promotion also The orthopaedic nurse evaluates the progress toward include synthesis of empirical evidence about risk attainment of outcomes individualized to the patient's behaviors, learning, behavioral change, motivational health and/or situation with actual or potential ortho- theories, epidemiology, and others when designing edu- paedic conditions. cation information and programs; personalized teach- Competencies for evaluation include conduction of ing and counseling considering comparative effective- systematic, ongoing, and criterion-based evaluation of ness and research recommendations; design of health outcomes in relation to the structures and processes information and education appropriate to the patient's included in the plan of care and indicated timeline; col- values, beliefs, culture, developmental level, learning laboration with the patient and others involved in the needs, and readiness to learn; evaluation of information care or situation; evaluation in partnership with the resources, including the Internet, for accuracy, read- patient to determine the effectiveness of planned strate- ability, and comprehensibility to help the patient access gies in relation to the patient's responses; use of ongoing quality information; engaging consumer alliances and assessment data to revise the nursing diagnoses, out- advocacy groups in health teaching and health promo- comes, plan, and implementation as needed; dissemina- tion activities; and provision of anticipatory guidance to tion of results to the patient, and others involved, in individuals, families, groups, and communities to pro- accordance with federal and state regulations; partici- mote health and prevent or reduce the risk of health pation in assessing and ensuring responsible and appro- problems. priate use of interventions, to minimize unwarranted or unwanted treatment and suffering; and documentation S TANDARD 5C. CONSULTATION of the results of the evaluation. For the advanced practice orthopaedic nurse, com- The orthopaedic nurse facilitates appropriate consulta- petencies also include evaluation of the accuracy of tion between health care providers and the patient to diagnoses and the effectiveness of the interventions and promote attainment of expected outcomes individual- other variables in relation to the patient's attainment of ized to the patient's health and/or situation with actual expected outcomes; synthesis of results of the evalua- or potential orthopaedic conditions. tion to determine the effect of the plan on the patient's The advanced practice orthopaedic nurse provides family, groups, communities, and institutions; adapta- consultation to infl uence the identifi ed plan, enhances tion of the plan of care for the trajectory of treatment the abilities of others, and effects change individualized according to evaluation of responses; and use of the to the patient's health and/or situation with actual or results of evaluation to make or recommend process or potential orthopaedic conditions. structural changes including policy, procedure, or pro- Competencies for consultation include synthesis of tocol revision as appropriate. clinical data, theoretical frameworks, and evidence; facilitation of involvement by the patient and other stakeholders in decision making and negotiating role Standards of Orthopaedic Nursing responsibilities; and communication of consultation Professional Performance recommendations. Standards of Orthopaedic Nursing Professional Performance describe a competent level of behavior in S TANDARD 5E. PRESCRIPTIVE AUTHORITY AND TREATMENT the professional role, including activities related to eth- The advanced practice orthopaedic nurse uses prescriptive ics, education, evidence-based practice and research, authority, procedures, referrals, treatments, and therapies quality of practice, communication, leadership, collab- in accordance with state and federal laws and regulations to oration, professional practice evaluation, resource

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NNOR200394.inddOR200394.indd 148148 116/05/136/05/13 12:4212:42 AMAM utilization, and environmental health. These standards care professionals; and maintenance of professional mirror the ANA (2010) Standards of Professional records that provide evidence of competency and life- Performance . All orthopaedic nurses are expected to long learning. engage in professional role activities, including leader- For the advanced practice orthopaedic nurse, com- ship, appropriate to their education and position. petencies also include use of current health care Orthopaedic nurses are accountable for their profes- research fi ndings and other evidence to expand clinical sional actions to themselves, their patients, peers, pro- knowledge, skills, abilities, and judgment, to enhance fession, and ultimately, society. role performance, and to increase knowledge of profes- sional issues. S TANDARD 7. ETHICS The orthopaedic nurse practices ethically. Competencies S TANDARD 9. EVIDENCE-BASED PRACTICE AND RESEARCH for ethical performance include use of the ANA Code of The orthopaedic nurse integrates evidence and research Ethics for Nurses With Interpretive Statements (ANA, fi ndings into practice. Competencies for integration of 2001) to guide practice; delivery of care in a manner that evidence and research fi ndings into practice include uti- preserves and protects patient autonomy, dignity, rights, lization of current evidence-based nursing knowledge, values, and beliefs; recognition of the centrality of the including research fi ndings, to guide practice; incorpo- patient and family as core members of any health care ration of evidence when initiating changes in nursing team; upholding patient confi dentiality within legal and practice; participation, as appropriate to education level regulatory parameters; assisting in self-determination and position, in the formulation of evidence-based prac- and informed decision-making; maintenance of a thera- tice through research; and sharing of personal or third- peutic and professional patient–nurse relationship party research fi ndings with colleagues and peers. within appropriate professional role boundaries; contri- For the advanced practice orthopaedic nurse, com- bution toward resolving ethical issues involving the petencies also include contributions to nursing knowl- patient, colleagues, community groups, systems, and edge by conducting or synthesizing research and other other stakeholders; taking appropriate action regarding evidence that identifi es, examines, and evaluates cur- instances of illegal, unethical, or inappropriate behavior rent practice, knowledge, theories, criteria, and creative that can endanger or jeopardize the best interests of the approaches to improve health care outcomes; promo- patient; questioning health care practice when neces- tion of a climate of research and clinical inquiry; and sary, for safety and quality improvement; and advocat- dissemination of research fi ndings through activities ing for equitable health for all. such as presentations, publications, consultation, and For the advanced practice orthopaedic nurse, com- journal clubs. petencies also include participation in interprofessional teams that address ethical risks, benefi ts, and outcomes; S TANDARD 10. QUALITY OF PRACTICE and provision of information on the risks, benefi ts, and The orthopaedic nurse systematically evaluates and outcomes of health care regimens to allow informed contributes to the quality and effectiveness of nursing decision-making by the patient, including informed practice. Competencies for contribution to quality consent and informed refusal. nursing practice include documenting the application of the nursing process in a responsible, accountable, S TANDARD 8. EDUCATION and ethical manner; use of creativity and innovation to The orthopaedic nurse acquires and maintains current enhance nursing care; and participation in quality knowledge and competency in nursing practice. improvement. These activities may include identifi ca- Competencies for acquiring and maintaining standards tion of aspects of practice important for quality moni- of education-based performance include participation toring; use of indicators to monitor quality, safety, and in ongoing educational activities related to appropriate effectiveness of nursing practice; collection of data to knowledge bases and professional issues; demonstra- monitor quality and effectiveness of nursing practice; tion of a commitment to lifelong learning through self- analysis of quality data to identify opportunities for refl ection and inquiry to address learning and personal improving nursing practice; formulation of recom- growth needs; identifi cation of experiences that refl ect mendations to improve nursing practice or outcomes; current practice to maintain knowledge, skills, abilities, and implementation of activities to enhance the quality and judgment in clinical practice or role performance; of nursing practice. Competencies also include devel- acquisition of knowledge and skills appropriate to the opment, implementation, and evaluation of policies, role, orthopaedic specialty, setting, or situation; seeking procedures, and guidelines to improve the quality of formal and independent learning experiences to develop practice; participation in or leading interprofessional and maintain knowledge and clinical/professional skills; teams to evaluate clinical care or health services and identifi cation of learning needs based on nursing knowl- efforts to minimize costs and unnecessary duplication; edge, the various roles the nurse may assume, and the identifi cation of problems that occur in day-to-day changing needs of the orthopaedic population; partici- work routines in order to correct process ineffi ciencies; pation in formal or informal consultation to address analysis of factors related to quality, safety, and effec- issues in nursing practice as an application of education tiveness as well as organizational systems for barriers and knowledge base; sharing educational fi ndings, to quality patient outcomes; and implementation of experiences, and ideas with peers; contributions to a processes to remove or weaken barriers within organi- work environment conducive to the education of health zational systems.

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NNOR200394.inddOR200394.indd 149149 116/05/136/05/13 12:4212:42 AMAM For the advanced practice orthopaedic nurse, com- team members and the patient, and mentoring col- petencies also include taking the lead in the design and leagues in the acquisition of clinical knowledge, skills, implementation of quality improvements; design of abilities, and judgment. innovations to effect change in practice and improve health outcomes; evaluation of the practice environ- S TANDARD 13. COLLABORATION ment and quality of nursing care rendered in relation to The orthopaedic nurse collaborates with the patient, existing evidence; identifi cation of opportunities for family, other professional nurses, advanced practice research and applying evidence; obtaining and main- nurses, and members of the health care team in the taining professional certifi cation; and use of the results conduct of nursing practice. Competencies for effective of quality improvement to change nursing practice and collaboration include partnership with others to effect health care delivery systems. change and produce positive outcomes through the sharing of appropriate knowledge about the patient or S TANDARD 11. COMMUNICATION situation; communication with the patient and provid- The orthopaedic nurse and the advanced practice ortho- ers regarding health care and the nurse's role in the paedic nurse communicate effectively in a variety of for- provision of that care; promoting confl ict management mats in all areas of practice. Competencies for effective and engagement; participation in building consensus communication include assessment of communication or resolving confl ict in the context of patient care; format preferences of patients, families, and colleagues; application of group process and negotiation tech- assessment of personal communication skills; seeking niques with the patient and colleagues; adhering to continuous improvement of personal communication standards and applicable codes of conduct that govern and confl ict resolution skills; conveying information to behavior among peers and colleagues to create a work patients, families, the interprofessional team, and oth- environment that promotes cooperation, respect, and ers in communication techniques to promote accuracy; trust; cooperation in creating a documented plan questioning the rationale supporting care processes and focused on outcomes and decisions related to care and decisions when they do not appear to be in the best delivery of services that indicates communication with interest of the patient; disclosure of observations or the patient, and others; and engaging in teamwork and concerns related to hazards and errors in care or the team-building. practice environment to the appropriate level; mainte- For the advanced practice orthopaedic nurse, com- nance of communication with other providers to mini- petencies also include partnering with other disciplines mize risks associated with transfers and transition in to enhance patient outcomes through interprofessional care delivery; and contribution from a nursing perspec- activities, such as education, consultation, manage- tive in discussions with the interprofessional team. ment, technological development, or research opportu- nities; invitation for contributions by the patient and S TANDARD 12. LEADERSHIP team members in order to achieve optimal outcomes; leadership in establishing, improving, and sustaining The orthopaedic nurse demonstrates leadership in a collaborative relationships to achieve safe, quality variety of professional practice settings. Competencies patient care; and documentation of plan-of-care com- for effective professional leadership include oversight of munication, rationale for plan-of-care changes, and col- the nursing care given by others while retaining account- laborative discussion to improve outcomes. ability for the quality of care given to the patient ; abid- ing by the vision, the associated goals, and the plan to implement and measure progress of an individual S TANDARD 14. PROFESSIONAL PRACTICE EVALUATION patient or within the context of the health care organi- The orthopaedic nurse evaluates personal nursing zation; demonstration of a commitment to continuous practice in relation to professional practice standards lifelong learning and education for self and others; men- and guidelines, relevant statutes, rules, and regulations torship of colleagues for the advancement of nursing and is accountable to the public and profession. practice, the profession, and quality health care; treat- Competencies for professional practice evaluation ing colleagues with respect, trust, and dignity; develop- include provision of age-appropriate and developmen- ment of communication and confl ict resolution skills; tally appropriate care in a culturally and ethnically sen- participating in professional organizations such as sitive manner; engaging in self-evaluation of practice on NAON; communicating effectively with the patient and a regular basis, identifying areas of strength as well as colleagues; seeking ways to advance nursing autonomy areas in which professional growth would be benefi cial; and accountability; and participating in efforts to infl u- obtaining informal feedback regarding personal prac- ence health care policy involving the patient and the tice from the patient, peers, professional colleagues, profession. and others; participating in peer review as appropriate; For the advanced practice orthopaedic nurse, com- taking action to achieve goals identifi ed during the eval- petencies also include infl uencing decision-making uation process; providing the evidence for practice deci- bodies to improve the professional practice environ- sions and actions as part of the informal and formal ment and patient outcomes; providing direction to evaluation processes; interacting with peers and col- enhance the effectiveness of the interprofessional team; leagues to enhance personal professional nursing prac- promotion of advanced practice nursing and role devel- tice or role performance; and providing peers with for- opment by interpreting its role for the patient, families, mal or informal constructive feedback regarding their and others; modeling expert practice to interprofessional practice or role performance.

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NNOR200394.inddOR200394.indd 150150 116/05/136/05/13 12:4212:42 AMAM For the advanced practice orthopaedic nurse, com- supporting nurses in advocating for and implementing petencies also include engaging in a formal process environmental principles in nursing practice. seeking feedback regarding personal practice from the patient, peers, professional colleagues, and others. Summary S TANDARD 15. RESOURCE UTILIZATION The National Association of Orthopaedic Nurses Scope and Standards of Orthopaedic Nursing Practice refl ect The orthopaedic nurse utilizes appropriate resources to the mission of the association to advance the art and plan and provide nursing services that are safe, effec- science of orthopaedic care through excellence in tive, and fi nancially responsible. Competencies for research, education, and nursing practice. This NAON appropriate resource utilization include assessment of publication refl ects the beliefs of the members of the individual patient care needs and resources available to orthopaedic nursing profession and should be reviewed achieve desired outcomes; identifi cation of care needs, in conjunction with state Nurse Practice Acts. This doc- potential for harm, complexity of the task, and desired ument guides nurses in the application of professional outcomes when considering resource allocation; dele- skills and responsibilities; however, state laws, rules, gation of elements of care to appropriate health care and regulations govern the practice of nursing. providers in accordance with any applicable legal or These authoritative statements describe a competent policy parameters or principles; identifi cation of evi- level of behavior in the orthopaedic registered nursing dence when evaluating resources; advocating for professional role and the advanced practice registered resources, including technology, that enhance nursing nursing professional role. These include standards of practice; modifi cation of practice when necessary to professional nursing practice involving assessment, promote positive interaction between patients, care diagnosis, outcome identifi cation, planning, implemen- providers, and technology; assisting the patient and tation, and outcome evaluation. Standards of profes- family in identifying and securing appropriate services sional performance involve activities related to ethics, to satisfy needs across the health care continuum; and education, evidence-based practice and research, qual- considering costs, risks, and benefi ts in decisions about ity of practice, communication, leadership, collabora- orthopaedic treatment and care. tion, professional practice evaluation, resource utiliza- For the advanced practice orthopaedic nurse, com- tion, and environmental health. petencies also include utilization of organizational and community resources to formulate interprofessional plans of care; formulation of innovative solutions for patient care problems that utilize resources effectively REFERENCES and maintain quality; and design of evaluation strate- American Association of College of Nursing (AACN) . gies that demonstrate cost-effectiveness, cost benefi t, ( 2007 ). The education and role of the clinical nurse and effi ciency factors associated with orthopaedic nurs- leader. Retrieved from http://www.aacn.nche.edu/ ing practice. publications/white-papers/cnl American Association of College of Nursing (AACN) . S TANDARD 16. ENVIRONMENTAL HEALTH (2012 ). : Frequently asked ques- tions . Retrieved from http://www.aacn.nche.edu/cnl/ The orthopaedic nurse practices in an environmentally frequently-asked-questions safe and healthy manner. Competencies for environ- American Nurses Association (ANA) . (2001 ). Code for ethics mental health include attaining knowledge of environ- for nurses with interpretive statements . Washington, mental health concepts, such as implementation of DC : American Nurses Publishing. environmental health strategies; promotion of a prac- American Nurses Association (ANA) . ( 2010 ). Nursing: tice environment that reduces environmental health Scope and standards of practice ( 2nd ed. ). 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Retrieved from http://www. mote healthy communities. accreditationprofessional.org/accreditation_links. For the advanced practice orthopaedic nurse, com- cfm?topicϭ WS_AHP_LNK petencies also include creating partnerships that pro- Centers for Medicare & Medicaid Services (CMS) . ( 2012a ). mote sustainable environmental health policies and Health care reform for consumers . Retrieved from conditions; analyzing the impact of social, political, and http://www.cms.gov/Regulations-and-Guidance/ Health-Insurance Reform/HealthInsReformfor economic infl uences on the environment and human Consume/index.html?redirect ϭ /HealthInsReformfor health exposures; critically evaluating the manner in Consume/ which environmental health issues are presented by the Centers for Medicare & Medicaid Services (CMS) . (2012b ). popular media; advocating for implementation of envi- Welcome to the CMS innovation center . Retrieved from ronmental principles for nursing practice; and http://www.innovations.cms.gov/

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CALENDAR

Regional Offerings necessary to provide cutting-edge September 7, 2013–NAON Ortho- bone health care to patients in an pedic Nursing Comprehensive June 8 and June 9, 2013–NAON ONC evolving health care delivery environ- Review. Hock Plaza, 2424 Erwin Review Bone Up Course. SM UCLA ment. Register by May 1st to take Rd, Durham, NC 27705. For more Auditorium, UCLA Medical Center advantage of early bird pricing: NAON information: Pat Lester, 919-470-8548 Santa Monica, 1250 16th St., Santa members and Own the Bone site par- (phone). Monica, CA 90404. For more infor- ticipants: $100; Non-Members: $135. September 30-October 1, 2013– mation: Grace Liou, 424-259-8201 Link: http://bit.ly/11V4uJx. (phone). NAON’s Orthopaedic Nursing June 28, 2013–Orthopedic Nursing Comprehensive Review Course. June 14, 2013–Hot Topics in Bone Comprehensive Review Course. Presented by Catholi Health, Health & Post-Fracture Manage- Parker, CO. For more information: Appletree Business Park, Ste 8A, ment. This special program, co- Emily Stokes, 303-847-9545 (phone). 2875 Union Road, Cheektowaga, NY provided by the National Association August 23, 2013–NAON ONC Review 14227. For more information: Carol of Orthopaedic Nurses (NAON) and Course. 301 East 17th Street, NY, NY Caputi, [email protected] or the American Orthopaedic Association 10003. For more information: Maria 716-706-2541. (AOA), underscores the knowledge Cruz, 212-598-6788 (phone).

152 Orthopaedic Nursing • May/June 2013 • Volume 32 • Number 3 © 2013 by National Association of Orthopaedic Nurses Copyright © 2013 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

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