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A s healthcare reform is continuing to advance and more focus is being placed on value, shared decision making (SDM) is gaining momentum within the delivery of patient-centered care

(PCC). Patient-centered care serves to empower and en- gage patients in ways that promote SDM among patients, caregivers, and the healthcare team as a whole. Shared decision making takes into account the findings from current evidence-based practice, in addition to the patient’s values, desires, and preferences. As innovative care delivery and alternative payment models continue to expand, nurses should be familiar with the important role SDM plays.

The purpose of this article is to educate nurses on the phases and various aspects of SDM and how SDM relates to the specialty of orthopaedics.

Shared Decision Making Shared decision making is one of the hallmark compo- nents of PCC that encourages and empowers patients to play a proactive role in the self-management of their health (Agency for Healthcare Research and Quality [AHRQ], 2015a). The process of SDM is collaborative in nature and encourages patients and healthcare provid- ers to work together when making healthcare decisions (Informed Medical Decisions Foundation, 2015). A suc- cessful SDM process involves patient engagement through patient education, which arms the patients with the necessary knowledge needed to make informed decisions regarding their health. Possessing an ade- quate knowledge base of their medical conditions al- lows the patients to ask pertinent questions and choose sound treatment options that correlate with their own desires and preferences while being fully aware of the risks and benefits. This also allows healthcare providers to feel more confident in the plan of care they establish

(Informed Medical Decisions Foundation, 2015). Studies from almost two decades ago have shown that patients desire more educational information, in addi- tion to more collaborative involvement with their healthcare providers when it comes to decision making regarding the plan of care, and this trends is even more popular today (Deber, Kraetschmer, & Irvine, 1996).

The Dartmouth-Hitchcock Center for Shared Decision Making (2015) defines SDM as collaboration between clinicians and patients in which they come to an agreement about healthcare decisions and is benefi- cial when there are no obvious “best” treatment options available. For SDM to take place, there are specific as- pects that must exist jointly between both the patient and the clinician during the decision-making process. These joint aspects include active involvement in the plan of treatment, sharing of information, expressing preferences, and mutual agreement of the plan of treat- ment (Hoffmann et al., 2014). The specific aspects of SDM encourage patient-centeredness by engaging pa- tients in a way that will involve them in their own care. Table 1 lists the benefits of SDM.

SDM and PCC The discussion of SDM would not be complete without highlighting PCC, especially because SDM is considered to be one of the integral building blocks of many PCC models. The history of PCC can be traced back to the 1960s during the American era of civil and human rights, followed by the development of Planetree health- care facilities, and now with the recent plethora of healthcare literature that supports the positive effect of PCC in a variety of settings (American Academy of Orthopaedic Surgeons, 2015). The term “patient- centered care” originated in 1988 by the Picker/ Commonwealth Program for Patient-Centered Care with the purpose of highlighting the charge for health- care providers, staff, and systems to shift their focus from diagnosis and management of diseases to the

Shared decision making (SDM) is gaining momentum within the delivery of patient-centered care. Shared decision mak- ing takes into account the findings from current evidence- based practice, in addition to the patient’s values, desires, and preferences. This article reviews the phases of SDM: patient engagement, discussion, and decision, in addition to the role SDM plays in the specialty of orthopaedics.

The Role of Shared Decision Making in Patient-Centered Care and Orthopaedics

Mary Atkinson Smith

Mary Atkinson Smith, DNP, NP-C, ONP-C, CNOR, Board Certified Nurse Practitioner and RNFA, Starkville Orthopedic Clinic, Starkville, MS; and Assistant Professor and Assistant Program Director, South University Online, College of Nursing and Public Health, Savannah, GA.

The author has disclosed no conflicts of interest .

DOI: 10.1097/NOR.0000000000000243

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needs and desires of patients and their families (Picker Institute, 2016). The PCC concept produces patient-cen- tered outcomes (PCOs), which are derived from a part- nership among healthcare providers, patients, and fam- ily members that focuses on patient preferences, needs, education, and support in a way that enhances informed decision making and participation in self-management among patients (Institute of Medicine [IOM], 2001a).

In 1999, the IOM, known now as the National Academy of Medicine, published a report addressing patient safety, titled To Err Is Human: Building a Safer Health System, and giving rise to a greater focus on im- proving quality in healthcare. Another IOM report fol- lowed in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, that defined PCC as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (IOM, 2001b p. 3). It was in this report in which PCC was identified as one of the six integral elements that constitute high-quality healthcare.

In 2007, The Institute of Healthcare Improvement (IHI) developed the Triple Aim framework with the pur- pose of improving the healthcare delivery experience, the health of the population as a whole, and reducing the cost of healthcare (IHI, 2015). The IHI refers to PCC as person- and family-centered care that puts patients and their family members at the center of each decision and empowers them to be active partners in their health- care (IHI, 2015). Nurses should be aware that PCC also means guiding patients in a way that includes complete and unbiased details about available options, in addi- tion to the potential benefits and risks. According to the IHI (2015), the next 5 years will reveal novel patient and family engagement models with a shifted focus from the patient’s problems to the patient’s preferences.

In 2011, the National Quality Strategy (NQS) was es- tablished as a result of the Patient Protection and Affordable Care Act with the intention of improving the aspects of healthcare delivery, patient outcomes, and population health nationwide, with SDM being one of the avenues to addressing these aspects (AHRQ, 2015b). The NQS is directed by the AHRQ with support from the U.S. Department of Health and Human Services (DHS). The NQS was developed with collaborative input from more than 300 public and private stakeholders in an ef- fort to better align quality measures and improvement strategies. This collaborative input produced three over- arching aims that align with the IHI Triple Aim along

with six priorities to guide healthcare improvement nationally. The three aims of the NQS include better health, better care, and lower costs. Patient-centered care is the focus of the better care aim along with two of the priorities that address patient- and family-centered care and patient engagement through effective commu- nication and care coordination (AHRQ, 2015b). It is within the patient- and family-centered care priority that the process of SDM is identified as a long-term goal of the NQS (AHRQ, 2015b).

SDM Phases Shared decision-making process comprises three inter- related phases: patient engagement, discussion, and de- cision (Chow, Teare, & Basky, 2009). These three phases consist of many interworking principles that support the overall concept of SDM, with patient engagement being the initial phase of the process. After the patient engage- ment phase is initiated, there is continued advancement into the discussion phase, with the decision phase being the final focus. Once the decision phase has been reached, the SDM process may move back and forth from the discussion and patient engagement phases. These phases of SDM work together to foster empower- ment and activation among patients and promote effec- tive communication between patients and healthcare providers. Shared decision-making phases encourage collaboration and generate synergy among healthcare providers, organizations, and stakeholders in a way that positively enhances patient care experiences (Prince, 2015). Figure 1 liststhe interrelated phases of SDM.

Patient engagement Phase According to Worden (2013), the lack of a standardized, formal, and detailed definition of patient engagement creates challenges when it comes to implementing and improving the process of patient engagement. There are many broad definitions of patient engagement in cur- rent literature. In 2012, the National eHealth Collaborative (NeHC) surveyed stakeholders regarding the particulars of patient engagement. This survey re- vealed that three fourths of the stakeholders feel that patient engagement is a key component in the success transformation of healthcare. However, their responses varied greatly regarding the definition of patient en- gagement. The responses included descriptions such as patients using online educational material to learn more about their health, patients sending e-mails to their healthcare providers to ask questions, patients schedul- ing appointments online with their healthcare provid- ers, patients discussing health-related questions face to face with their healthcare providers, and patients com- municating with healthcare providers in a timely fash- ion regarding changes in their health (NeHC, 2012).

Patient engagement in SDM may also be considered a form of information exchange between patients and their healthcare providers (Chow et al., 2009). The Center for Advancing Health (2010) describes a patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services avail- able to them” (p. 2). This definition highlights the health

table 1. benefits of shared decision making Patient engagement

Increased satisfaction among patients and providers

Patient education

Encourages patient self-management of health conditions

Promotes patient–provider discussions

Allows patients to play a proactive role in their plan of care

Plan of care parallels patient preferences and desires

Leads to more positive patient-reported outcomes

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behaviors of individuals in a way that parallels with their health status from the standpoint of health out- comes, instead of focusing on the activity of healthcare providers or institutional policies. Participation in en- gagement indicates that individuals are taking part in activities that allow them to blend accurate and detailed information with their preferences, needs, and capabili- ties in a way that assists them in health-related modali- ties pertaining to prevention, self-management, and res- toration (Center for Advancing Health, 2010).

The patient engagement phase in the process of SDM serves to involve patients in their own care to promote more positive patient outcomes and self-involvement in care coordination. These points are why increasing pa- tient engagement is one of the main goals for the Centers for Medicare & Medicaid Services ([CMS], 2013) and one of the six priorities for the NQS (AHRQ, 2015b). The engagement of patients and family members is one of the leading objectives of the electronic health record (EHR) Incentive Program, also known as Meaningful Use (MU), that is being implemented by the Health Resources and Services Administration (HRSA) sup- ported by the DHS’s health information technology and quality improvement initiatives (HRSA, 2015). To qual- ity for participation in the EHR Incentive Program, healthcare providers must use an EHR that has been certified to meet MU objectives and measures.

In orthopaedic settings, certified EHR technology can promote SDM within patient engagement by pro- viding patients with copies of their health-related infor- mation so that it may be shared with multiple health- care providers and reviewed by the patient themselves to encourage patients to self-monitor their health and identify mistakes in their health record (HRSA, 2015). Nurses can also encourage patients to obtain education and other tools through the certified EHR technology so that patients are better informed when making health- care-related decisions. Patients who are engaged in this manner are more likely to take a proactive role in managing their own health and participate in self-man- agement activities on a routine basis (HRSA, 2015).

discussion Phase The process of SDM continues with the discussion phase, which may be considered a focused and detailed derivative of patient engagement. The discussion phase consists of direct verbal communication between the healthcare provider and the patient. The nurse may view this phase of SDM as a form of counseling that fo- cuses on available treatment options, patient prefer- ences, and healthcare provider recommendations.

The discussion phase is considered a two-way form of communication between the treating clinician and the patient. Prior to the beginning of the discussion phase, the treating clinician may review current litera- ture pertaining to a specific condition or course of treat- ment to support evidence-based practice. The patient may review information gathered during the process of patient engagement and make a list of preferences based on the condition-pertinent information he or she has obtained. The nurse should empower the patient to ask about the efficacy of available and recommended treat- ment options, to include the risks and benefits, during the discussion phase of SDM.

Nurses might play an involved role in the discussion phase of the SDM process through decision support that involves the use of counseling, health coaching, and de- cision aids to better educate and inform patients. The use of decision aids may serve to enhance health literacy, promote patient empowerment, increase patient satis- faction, improve the patient experience, and positively support the overall SDM process. Health coaches teach and mentor patients so that they will possess the neces- sary skills, understanding, and knowledge base needed to empower and encourage patients to make healthcare- related decisions based on their own desires and prefer- ences (Legare et al., 2011). Decision support applied in a strategic multidisciplinary approach has been proven to improve outcomes among patients (Legare et al., 2011).

Orthopaedic practices and hospitals can work to- gether to create the discussion phase of SDM in which patients are educated on various aspects related to their specific condition. An example of this would be creating

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figure 1. Interrelated phases of shared decision making. Shared decision making begins with the first phase of patient engage- ment and progresses into the second phase of discussion and in the final and third phase of decision. Once the final phase of decision has been reached, there may be progression back into the discussion and patient engagement phases.

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a preoperative program for patients desiring elective total knee arthroplasty (TKA). Experienced orthopaedic nurses can oversee the preoperative TKA program and deliver individualized education that serves to empower patients in a way that will allow them to confidently enter into the decision phase of SDM.

decision Phase The decision phase encourages patient and provider ac- tivation in a way that supports a mutual agreement per- taining to the plan of treatment (Chow et al., 2009). The beginning of the decision phase may involve determin- ing the availability of recommended or desired treat- ment options. The decision phase may then progress into negotiating details of the plan of treatment. The decision phase may also include choosing when and where to receive care pertaining to the plan of treat- ment. The clinician might not always be in agreement with the patient during the decision phase. However, the goal of the decision phase is to develop the plan of care so that it reflects the patient’s preferences, values, and desired health outcomes (Chow et al., 2009).

Orthopaedic nurses will play a vital role in the deci- sion phase when it comes to determining the availability of treatment options. Orthopaedic practices may opt for employing a case management nurse during the decision phase to oversee the plan of care and ensure the patient’s preferences and desired outcomes are addressed in de- tail. The case management nurse can also serve as a me- diator between the clinician and the patient.

Successful Application of SDM The successful application of SDM may require educat- ing patients and healthcare providers about the SDM process. Nurses and patients can increase their knowl- edge base of SDM through education and learning, which can lead to a greater capacity for embracing change, minimize feelings of vulnerability, and build trust (Bunker, 2014). A collaborative interdisciplinary approach to SDM allows for a team-based approach that encourages effective communication among all healthcare providers involved in meeting the healthcare needs of the patient (Chow et al., 2009). It is important for the nurses to be aware of this when a patient is being treated and managed by multiple healthcare providers due to the presence of multiple chronic conditions.

The Future of SDM and PCOs Shared decision making will contribute to the future growth and promotion of PCOs. Patient-centered out- comes emerged from Section 6301 of the Patient Protection and Affordable Care Act and have guided the development of the Patient-Centered Outcomes Research Institute ([PCORI]; U.S. Government Accountability Office, 2010). For the future of SDM, the PCORI will serve to incorporate patient input in a way that guides research and policy agendas to gather infor- mation on outcomes that matter the most to patients and these outcomes can be used to guide effective pa- tient decision aids and SDM tools. This will serve to

ensure that quality of life and patient preference out- comes are better reflected in the research by producing data that will promote better informed patients, health- care providers, payers, and policy makers regarding the use of more effective treatments and minimization of wasteful healthcare spending (PCORI, 2014).

The Partnership to Improve Patient Care ([PIPC], 2013) recommends that SDM tools be developed and tested with input from patients, which will ensure that patients are being empowered to play a proactive role in their healthcare. This means that future development of SDM tools will focus on both clinicians and patients and a broad range of topics that influence the quality of care provided to patients such as medical testing and treatments, care planning, and cost of care. Data pro- duced from comparative clinical effectiveness research must be easily accessible and understandable to pa- tients through the availability of SDM tools that patients can use to personalize their own care preferences and decisions to avoid a “one size fits all” approach to care decisions. There will be incentives through healthcare payment and delivery systems that encourage the use of SDM tools in a way that promotes more individualized treatment decisions by both clinicians and patients (PIPC, 2013).

As SDM becomes more commonplace in healthcare, innovation will present more avenues to promote SDM tools. The use of constantly evolving EHRs is an excel- lent example of innovative technology that will serve to further support SDM tools. The National Quality Forum (2015) has an innovative tool called the Patient Passport that assists patients with clearly communicating their desired preferences to healthcare providers to improve the process of SDM and develop the plan of care. As the concept of SDM continues to grow in popularity, more innovative tools will emerge. The push for SDM through- out healthcare will serve to transform the role of care coordinators, case managers, social workers, allied health professionals, and physicians. The influence SDM will have on third party payers from the stand- point of payment reform should also be considered.

Application of SDM to Orthopaedics Shared decision making will not be appropriate in all areas of healthcare. From the standpoint of orthopaedic surgery, SDM will not be appropriate in emergency sit- uations but it is applicable from the standpoint of elec- tive surgical procedures or rehabilitation. For example, the SDM process is ideal for patients opting for proce- dures such as a total joint replacement or a rotator cuff repair. These surgical procedures require explicit and detailed pre- and postoperative planning and informed consent prior to surgery for which the SDM process is ideal. The process of SDM allows orthopaedic patients to communicate their health-related preferences and desires during the preoperative phase (Page & Moulton, 2014). With healthcare reform’s push for PCOs, SDM in orthopaedics can encourage patient expectations that are more realistic and in line with the patient’s prefer- ences, which can further enhance self-reported patient outcomes. (Page & Moulton, 2014).

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Nurses should also keep in mind how SDM applies to the determination of care and payment model re- form in orthopaedics. One example of this is the recent recommendation of the Comprehensive Care for Joint Replacement (CJR) model by the CMS that is due to take effect April 1, 2016 (CMS, 2016). The aim of the CJR model is to promote improved care and increased efficiency of care among patients undergoing hip and knee replacements by holding participating hospitals accountable for the aspects of quality and costs and provides incentives for enhanced care coordination among providers, hospitals, and post-acute care facili- ties (CMS, 2016). As the CJR model is implemented in hospitals nationwide, nurses will play an instrumental role in the integration of SDM into the CJR model. The process of SDM may serve to promote efficiency and effectiveness of the CJR model in ways that support positive PCOs.

Conclusion The SDM process will grow in popularity as PCC contin- ues to promote patient engagement, in addition to pa- tient and healthcare provider discussions that deter- mine the plan of treatment. Shared decision making serves to positively influence patient outcomes and the patient experience. It is vital for SDM to be fully under- stood by nurses, treating clinicians, and patients prior to implementation. Shared decision making in ortho- paedics can prove to be beneficial when it comes to pro- moting positive outcomes for elective surgical proce- dures such as a total joint replacements. Patients, healthcare providers, healthcare organizations, and payers all stand to benefit from the use of SDM.

references Agency for Healthcare Research and Quality. (2015a).

Shared-decision making. Retrieved from https://cahps. ahrq.gov/quality-improvement/improvement-guide/ browse-interventions/Communication/Shared- Decision-Making/index.html

Agency for Healthcare Research and Quality. (2015b). National Quality Strategy: Overview. Retrieved from http://www.ahrq.gov/workingforquality/nqs/overview .htm

American Academy of Orthopaedic Surgeons. (2015). Patient-centered care. Retrieved from http://www6. aaos.org/member/pemr/COAP/pcc.cfm

Bunker, K. (2014). Responses to change: Helping people manage transition. Silver Spring, MD: American Nurses Association.

Center for Advancing Health. (2010). A new definition of patient engagement: What is engagement and why is it important? Retrieved from http://www.cfah.org/pdfs/ CFAH_Engagement_Behavior_Framework_current .pdf

Centers for Medicare & Medicaid Services. (2013). Stage 2: Engaging patients in their health care. Retrieved from https://www.cms.gov/eHealth/ListServ_Stage2_ EngagingPatients.html

Centers for Medicare & Medicaid Services. (2016). Comprehensive care for joint replacement model. Retrieved from https://innovation.cms.gov/initiatives/ cjr

Chow, S., Teare, G., & Basky, G. (2009). Shared decision making: Helping the system and patients make quality health care decisions. Saskatoon, Saskatchewan, Canada: Health Quality Council. Retrieved from http:// hqc.sk.ca/Portals/0/documents/Shared_Decision_ Making_Report_April_08_2010.pdf

Dartmouth-Hitchcock Center for Shared Decision Making. (2015). Decision-making help: What is shared-decision making? Retrieved from http://www.dartmouth-hitch- cock.org/medical-information/decision_making_help. html

Deber, R., Kraetschmer, N., & Irvine, J. (1996). What role do patients wish to play in treatment decision making? Archives of Internal Medicine, 156(13), 1414–1420.

Health Resources and Services Administration. (2015). Health information technology and quality improve- ment: Introduction. Retrieved from http://www.hrsa. aquilentprojects.com/healthit/toolbox/HealthITA doptiontoolbox/MeaningfulUse/intro2meaningfuluse andpatientandfamily.html

Hoffmann, T., Legare, F., Simmons, M., McNamara, K., McCaffery, K, Trevena, L., …Del Mar, C. (2014). Shared decision making: what do clinicians need to know and why should they bother? Medical Journal of Australia, 201(1), 35–39.

Informed Medical Decisions Foundation. (2015). What is shared decision making. Retrieved from http://www .informedmedicaldecisions.org/what-is-shared-deci- sion-making

Institute of Healthcare Improvement. (2015). Person and family-centered care. Retrieved from http://www.ihi.org/ Topics/PFCC/Pages/Overview.aspx

Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved from http://iom.nation- alacademies.org/∼/media/Files/Report%20Files/1999/ To-Err-is-Human/To%20Err%20is%20Human%20 1999%20%20report%20brief.pdf

Institute of Medicine. (2001a). Envisioning the national health care quality report. Washington, DC: National Academies Press.

Institute of Medicine. (2001b). Crossing the quality Chasm: A new health system for the 21st century. Retrieved from http://iom.nationalacademies.org/∼/media/Files/ Report%20Files/2001/Crossing-the-Quality-Chasm/ Quality%20Chasm%202001%20%20report%20brief .pdf

Legare, F., Stacey, D., Briere, N., Desroches, S., Dumont, S., Fraser, M., …Aube, D. (2011). A conceptual frame- work for interprofessional shared decision making in home care: Protocol for a feasibility study. BioMed Central Health Services Research, 11(23). doi:10.1186/ 1472-6963-11-23

National eHealth Collaborative. (2012). National eHealth Collaboration (NeHC) stakeholder survey results. Retrieved from www.nationalehealth.org/ckfinder/ userfiles/files/2012%20NeHC%20Stakeholder%20 Survey%20Results%20FINAL.pdf

National Quality Forum. (2015). Promoting high-quality care for patients with advanced illness. Retrieved from h t t p : / / w w w. q u a l i t y f o r u m . o r g / P r o m o t i n g _ H i g h Quality_Care_for_Patients_with_Advanced_Illness.aspx

Page, A., & Moulton, B. (2014, December). Shared deci- sion making in orthopaedics. AAOS Now, 8(12). Retrieved from http://www.aaos.org/news/aaosnow/ dec14/clinical4.asp

Partnership to Improve Patient Care. (2013). The issues: Shared decision making. Retrieved from http://www .pipcpatients.org/issues.php?tab=3

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Patient-Centered Outcomes Research Institute (PCORI). (2014). Why PCORI was created. Retrieved from http:// www.pcori.org/about-us/why-pcori-was-created

Picker Institute. (2016). Picker principles of patient-centered care. Retrieved from http://cgp.pickerinstitute. org/?page_id=1319

Prince, M. (2105). Corporate collaboration: Generating synergy for positive patient care experiences. CMSA Today, 4, 25–26.

U.S. Government Accountability Office. (2010). Subtitle D—Patient-centered outcomes research. Retrieved from h t t p : / / w w w. g a o . g o v / a b o u t / h c a c / p c o r _ s e c _ 6 3 0 1 .pdf

Worden, I. (2013). The path to increased patient engagement lies in the definition. Retrieved from http://www.better- patientengagement.com/2013/03/03/the-path-to-in- creased-patient-engagement-lies-in-the-definition/ Index

For more than 150 additional continuing nursing education activities on orthopaedic topics, go to nursingcenter.com/ce.

planned that are free to members and several advanced practice webinars that have a small fee for both mem- bers and nonmembers.

Speaking of value, I am very excited about this year’s Congress, because of the signifi cate value to one’s prac- tice that has been added. Each year I am amazed at the quality of the speakers and relevance of the informa- tion presented that attendees can then take back to their place of employment. What challenges are you facing in your practice? Congress is your chance to look for solutions to those challenges, whether from information gathered from podium presentations, posters, or round table discussions or through net- working with other professional colleagues. Personally, I am looking forward to some of the new events such as Saturday Night at the Webinar and the ability to earn extra continuing educations before and after Congress through our new Extended Learning Webinars.

At the close of Congress last year in Nashville, then President Julie Twist (JT) said these words as she passed to me the presidency of NAON:

I entrust in you with the mandate of the member- ship—to guard the interests of the association and its members—with a level head, a strong sense of re- sponsibility and commitment. We have the faith that you will lead NAON well. On behalf of the entire membership, I pledge you our support as you and the executive board lead the association toward its goals.

To our incoming President Colleen Walsh, this is our pledge to you. I must admit during the change of leadership at Congress I missed some of the words as JT was talking. It was a nervous time, the bright stage lights are on you, you are standing in front of a large audience, and you are preparing to address your col- leagues, family, and friends for the fi rst time as the new President. I later went back and read what JT had said and as you can see the responsibility of is both simple and complex, to guard the interests of the as- sociation and its members. Use what you have learned as a nurse when looking at the budget or issues. The fi ve steps of the nursing process—assess, gather data, diagnose, plan, and implement the fi nal evaluation— can be adapted to the boardroom to help you make decisions.

Nurses in general and orthopaedic nurses specifi - cally, they are part of a special group, and it has been my honor to represent you during my year as your president. What other profession do we get to see peo- ple, the patient, in some of life’s most intimate mo- ments; nurses are there from birth to death. We are there encouraging our patients when they are in de- spair, rejoicing in their accomplishments, and being their voice when they are not able to speak. As President of NAON, I’m proud to be in that exceptional circle with you, the orthopaedic nurse. Thank you for the privilege of being the 36th President of NAON.

Orthopaedic Nursing is an international journal providing continuing education for orthopaedic nurses. Focusing on a wide variety of clinical settings - hospital unit, physician’s office, ambulatory care centers, emergency room, operating room, rehabilitation facility, community service programs, the client’s home, and others – Orthopaedic Nursing provides departmental sections on current events, organizational activities, research, product and drug information, and literature findings.

Call for Papers

Articles should reflect a commitment to professional development and the nursing profession as well as clinical, administrative, academic, and research areas of the orthopaedic specialty.

The journal is seeking contributions through its online submission site: www.editorialmanager.com/onj.

For more information please visit the journal’s website: www.orthopaedicnursing.com

NATIONAL ASSOCIATION OF ORTHOPAEDIC NURSES

OrthopaedicNursingThe International Leader in Practice and Education

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