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- 1. A Day in the Life of.._.pdf A DAY IN THE LIFE OF ... 456 Volume 35 | Number 8 www.homehealthcarenow.org A Day in the Life of a Home Health Wound Care Nurse DONNA MORROW, RN, WCC, DWC, OMS I am a Registered Nurse and Wound and Ostomy Nurse Manager with an organization that provides an alternative to hospitalization for clients with acute care needs. For me, no 2 days are the same. On the surface, my role may seem like a standard management role. In running our Wound Department, I schedule home visits; review
- 2. all consults, care, and treatment recommendations; work with other managers and assist in de- veloping treatment plans for our patients. I work on scheduling patient visits across the state of Massachusetts for a team that includes four other wound nurses. I meet periodically with product representatives to keep abreast of new products and treatment options. I also coor- dinate trialing those products to determine which may best suit our patients. As the wound nurse manager, I regularly con- duct audits of our program and meet with our nurses to ensure
- 3. we maintain high standards of care for our patients. However, the population we work with often requires us to look at care through a different lens. Our team works primarily with patients who have acute mental healthcare needs and are cared for in their place of residence. One of the most cru- cial aspects in treating a wound care patient who also suffers from a mental illness—whether it is depression, addiction, schizophrenia, or posttraumatic stress disorder—is establishing a strong and trusting relation- ship. Without a strong bond
- 4. patients may feel like the work you’re doing with them has little chance of success—or that it will actually harm them. In psychiat- ric care, these relationships are often the only way to develop a continuum of care. The relation- ships I am able to build with my patients provide me greater knowledge of their background and insight into their recovery process that other medical pro- fessionals who see them less fre- quently may not be privy to. A critical step in caring for patients living with mental ill- ness is providing them with the dignity and respect that is often
- 5. left out of other aspects of their lives. By taking the time to un- derstand their needs and goals, someone in my position can more effectively work with pa- tients and lead them to be the driver of their own care plan. Whether I’m treating a burn, pressure ulcer, a general skin condition, or something more serious, like an ostomy, care must be provided in a holistic manner, with the patient’s en- tire well-being put into consid- eration. I once treated a woman in her 50s living with a multitude of health issues—both physi-
- 6. cal and psychiatric—who had the same wound for more than 3 years when I took on her case. When I walked into her home, she essentially asked me to leave, which is not uncom- mon with this population. She stated there was no way I could help her. It was clear how dis- couraged she had become from past experiences. However, after a long conversation with her, in which I listened to her story and concerns, I gained a better understanding of where she was coming from. I told her I was determined to figure out why her wound wouldn’t
- 7. heal, find the right treatment ap- proach, and work closely with her to make sure the problem was solved. It was then that she understood I was there for her and that I would closely follow her progress and stick with her through any setbacks. Throughout my career, I’ve learned how important it is that a patient feels supported and trusts you are sticking around. When care plans are built on a strong foundation, the patient One of the most crucial aspects in treating a wound care patient who also suffers from a mental illness—
- 8. whether it is depression, addiction, schizophrenia, or PTSD—is establishing a strong and trusting relationship. A B K / B S IP Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. September 2017 Home Healthcare Now 457 on call. My family knows that what I do is more than just a job; it’s who I am. The most valuable lesson I’ve learned throughout
- 9. my career is that wound care within complex populations, like those living with acute men- tal illness, is never an A-B-C-D process. Breakthroughs don’t happen overnight, and often in- cludes two steps back for every step forward. But, there is noth- ing more rewarding than going on this journey with my patients as they work to take control of their own care. At the end of the day, you need persistence and faith and to know that you have helped make a positive dif- ference—no matter how big or small—in someone’s life. Donna Morrow, RN, WCC, DWC, OMS, is
- 10. the Wound Ostomy Nurse Manager, Wound Care Division, Nizhoni Health, Somerville, Massachusetts. The author declares no conflicts of interest. Address for correspondence: Donna Morrow, RN, WCC, DWC, OMS, Nizhoni Health, 5 Middlesex Ave. #404, Somerville, MA 02145 ([email protected]). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI:10.1097/NHH.0000000000000587 tion due to past experience with painful dressing changes. The patient had six open wounds on his left leg and a previous right leg amputation. Not wanting to risk his left leg, our team worked together to come up with a re- alistic, long-term solution. We found a dressing we knew would not be painful to change and
- 11. began educating our patient on what to expect. By listening to his fears and doubts, and really hearing him out, a relationship was formed. He began to believe we were on his side and that our most important goal was achiev- ing a positive outcome. Once the bandages were applied, his persistent pain was significantly reduced, which led to long-term compliance. The patient no longer feared a painful dress- ing change and his six previ- ously persistent wounds healed in approximately 3 months. All of us on the team, including the patient, his physician, and the
- 12. wound clinic, were greatly re- lieved that no amputation was necessary. As a manager I work through the night and am almost always When care plans are built on a strong foundation the patient is not only driving their care but is also invested in their health, greatly increasing the chance for a successful outcome. is not only driving their care but is also invested in their health, greatly increasing the chance for a successful outcome. Part of this relationship includes educating a patient about their wound. Wound care patients liv- ing with mental illness often do not understand how a wound
- 13. developed or why a specific product is being used in their care. By sitting down with a patient and exploring behav- iors and/or lifestyle factors that have led to their health prob- lems, the patient’s mistrust of the healthcare system slowly dissipates and they can map out how to avoid detrimental choices that have led them to where they are now. Although much of what I do is centered on education and relationship-building, we also collaborate with wound clinics, wound care clinicians, home care clinicians, visiting nurse as-
- 14. sociations, and/or hospitals. We work very hard to develop and employ a true team-based ap- proach that includes the patient as part of that team. Through close collaboration to ensure we are all on the same page in terms of treatment, we are able to achieve much greater suc- cess in healing our patients. Collaboration and a strong nurse-patient bond were critical when I worked with a 58-year-old male patient who suffered from diabetes and had multiple vas- cular leg wounds. The man had a clinical diagnosis of paranoid schizophrenic disorder and was
- 15. suspicious and mistrustful of the healthcare system. As a result of his diabetes, he was in renal failure and refused dialysis. Sim- ilarly, when it came to treating his wounds, he refused the type of dressing that best fit his situa- M e d ia f o r M e d ic a l S A R
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- 21. /PDFXTrapped /False /CreateJDFFile false /SyntheticBoldness 1.000000 /Description << /DEU <FEFF00560065007200770065006e00640065006e00200053006 90065002000640069006500730065002000450069006e00730074 0065006c006c0075006e00670065006e002c00200075006d00200 0650069006e0065006e0020004200650072006900630068007400 2000fc00620065007200200064006900650020005000440046002 f0058002d00310061002d004b006f006d00700061007400690062 0069006c0069007400e4007400200065007200680061006c00740 065006e00200075006e00640020005000440046002d0044006f00 6b0075006d0065006e007400650020006e0075007200200064006 1006e006e0020007a0075002000650072007300740065006c006c 0065006e002c002000770065006e006e002000730069006500200 0fc0062006500720020006400690065007300650020004b006f00 6d007000610074006900620069006c0069007400e400740020007 600650072006600fc00670065006e002e0020005000440046002f 00580020006900730074002000650069006e00650020004900530 04f002d004e006f0072006d0020007a0075006d00200041007500 7300740061007500730063006800200076006f006e00200064006 90067006900740061006c0065006e00200044007200750063006b 0076006f0072006c006100670065006e002e00200057006500690 07400650072006500200049006e0066006f0072006d0061007400 69006f006e0065006e0020007a0075006d0020004500720073007 40065006c006c0065006e00200076006f006e0020005000440046 002f0058002d00310061002d006b006f006d00700061007400690 062006c0065006e0020005000440046002d0044006f006b007500 6d0065006e00740065006e002000660069006e00640065006e002 000530069006500200069006d0020004100630072006f00620061 0074002d00480061006e00640062007500630068002e002000440 06900650020005000440046002d0044006f006b0075006d006500 6e007400650020006b00f6006e006e0065006e0020006d0069007 40020004100630072006f0062006100740020006f006400650072
- 30. 2000f600700070006e006100730020006d0065006400200041006 30072006f0062006100740020006f006300680020005200650061 00640065007200200034002e003000200065006c006c006500720 02000730065006e006100720065002e> /ENU (Use these settings to create PDF's if you are not downloading low Res ads from AdSpring.) >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice NursingMatters April 2017.pdf www.nursingmattersonline.com April 2017 • Volume 28, Number 4 Nursingmatters INSIDE: Diagnose carefully 2 Patients have rights 4 Be
- 33. E R EQ U ES TE D A special license plate will be available soon through the Wisconsin Department of Transportation — a plate for nurses, nursing staff, students, friends and family members. The specialty plate passed through legislation in 2016. It is intended to recog- nize the work and dedication of Wisconsin nurses as they change people’s lives. It offers a visual reminder to consider nursing as a career path because nurses make a differ- ence every day in the lives of those they serve. Help spread the word. A person does not need to be a nurse to purchase the specialty license plate. The future of nursing will benefit because the plate
- 34. creates a funding source for professional development, education and scholarships for Wisconsin nurses. The distribution of funds will be determined by an Advisory Council of the Nurses’ Educa- tion Fund comprised of sev- eral nursing organizations. The program is made possible by the Wisconsin Organization of Nurse Exec- utives. The organization col- laborated with many nurses and nursing organizations during various phases of the legislative process. Without the group’s support the leg- islation would not have been approved. Nurses thank it for its support. The anticipated cost of the plate is $40; there will be a $15 issuance fee and $25 annual donation to the Wisconsin Nurses’ Education Fund. Promotional displays and materials are available now for nursing conferences or placement within an orga- nization. Email [email protected] dshealthcare.com for more
- 35. information. Celebrate nursing April • 2017 NursingmattersPage 2 Mary Ellen Wurzbach, RN, BSN, MSN, FNP, PhD John McNaughton Rosebush Professor Emerita University of Wisconsin-Oshkosh In 1986 I wrote an article entitled “Ethical Evaluation of a Nursing Diagno- sis.” This is a similar article based on the thought and experiences of the past 30 years. At the first writing I advocated promoting autonomy and doing no harm. Through the years I would still advocate for those two principles but with more evidence of the essential nature of these two ideas. At the time of the first writing, nurse practitioners were beginning to jointly practice with physicians in Wisconsin. They were learning medical diagnosis. In nursing there was a movement toward nursing diagnosis based on the American Nurses Association Social Policy State-
- 36. ment definition of nursing as the diagno- sis and treatment of human responses to health and illness. I was a newly-minted family nurse practitioner. There were many discussions at the meetings of preceptors, faculty and students about whether nurses could diagnose and treat, and whether they should have the right to prescribe. This article is based on observations of the practice of diagnosis. When I was a child, diagnosis was the epit- ome of medical practice. The “good diagnostician” was revered. Diagnosis was the essence of medicine. With the nurse-practitioner movement, diagnosis too became important to nurses. Given the reverence shown diagnosticians it came as a surprise to me that there was such an emphasis on prescription – and that there was a downside to both diagnosis and prescriptive authority. I was surprised that diagnoses are not as Question: To diagnose or not to diagnose It might be time to consider what to do about the uncertainty of a diagnosis or the moral implications of it from both a patient and practitioner perspective. Mary Ellen
- 37. Wurzbach continued on page 3 Nursingmatters is published monthly by Capital Newspapers. Editorial and business offices are located at 1901 Fish Hatchery Road, Madison, WI 53713 FAX 608-250-4155 Send change of address information to: Nursingmatters 1901 Fish Hatchery Rd. Madison, WI 53713 Editor .......................................... Kaye Lillesand, MSN 608-222-4774 • [email protected] Managing Editor .................................. Julie Belschner 608-250-4320 • [email protected] Advertising Representative.................... Teague Racine 608-252-6038 • [email protected] Recruitment Sales Manager ...................... Sheryl Barry 608-252-6379 • [email protected] Art Director ..........................................Wendy McClure 608-252-6267 • [email protected] Publications Division Manager ................. Matt Meyers 608-252-6235 • [email protected] Nursingmatters is dedicated to supporting and fostering the growth of professional nursing. Your comments are encouraged and appreciated. Email editorial submissions to [email protected] Call 608-252-6264 for advertising rates.
- 38. Every precaution is taken to ensure accuracy, but the publisher cannot accept responsibility for the correctness or accuracy of information herein or for any opinion expressed. The publisher will return mate- rial submitted when requested; however, we cannot guarantee the safety of artwork, photographs or manu- scripts while in transit or while in our possession. EDITORIAL BOARD Vivien DeBack, RN, Ph.D., Emeritus Nurse Consultant Empowering Change, Greenfield, WI Bonnie Allbaugh, RN, MSN Madison, WI Cathy Andrews, Ph.D., RN Associate Professor (Retired) Edgewood College, Madison, WI Kristin Baird, RN, BSN, MSH President Baird Consulting, Inc., Fort Atkinson, WI Joyce Berning, BSN Mineral Point, WI Mary Greeneway, BSN, RN-BC Clinical Education Coordinator Aurora Medical Center, Manitowoc County Mary LaBelle, RN Staff Nurse Froedtert Memorial Lutheran Hospital Milwaukee, WI Cynthia Wheeler Retired NURSINGmatters Advertising Executive, Madison, WI Deanna Blanchard, MSN Nursing Education Specialist at UW Health Oregon, WI Claire Meisenheimer, RN, Ph.D.
- 39. Professor, UW-Oshkosh College of Nursing Oshkosh, WI Steve Ohly, ANP Community Health Program Manager St. Lukes Madison Street Outreach Clinic Milwaukee, WI Joyce Smith, RN, CFNP Family Nurse Practitioner Marshfield Clinic, Riverview Center Eau Claire, WI Karen Witt, RN, MSN Associate Professor UW-Eau Claire School of Nursing, Eau Claire, WI © 2017 Capital Newspapers April • 2017www.nursingmattersonline.com Page 3 analytical or value-free as one always supposed. It was a surprise that there are real consequences for practitioners and patients when a diagnosis is assigned to someone. Through the years I have seen that manifested in various ways and come to several conclusions. First is the observa- tion that diagnoses need to be accurate. Secondly, once assigned they ought to be followed by palliation of symptoms – improvement in a patient’s circum- stances such as health and possibly life. It came as a revelation to me to find that some diagnoses have no treatment. They
- 40. might identify a problem for which there is no solution or treatment – and how anxiety-producing and unhelpful that can be. Unfortunately our health-care system is structured around the neces- sity for a diagnosis of every condition known, despite the possibility that some patients might be more benefited by not being diagnosed. In some situations diagnoses change through time, as is the case with many taxonomies. One belief system or treat- ment regimen might accompany or follow from a diagnosis years ago, but have a different treatment or resolution today. Conversely, diagnoses may not change and, despite the fact that society has changed, become entrenched, anachro- nistic and at odds with current practice. As the population ages we will be con- fronted with more and more diagnoses. More than anything it may be time to consider whether the health-care system should be medical-diagnosis driven. It might be time to consider what to do about the uncertainty of a diagnosis or the moral implications of it from both a patient and practitioner perspective. As I grow older I find that many of the traditions with which I grew both per- sonally and professionally require further consideration. On further inspection,
- 41. often the ideas we take for granted and assume to be “true” may have flaws. Diagnosis is one aspect of health care that may require revision, but it’s merely an exemplar of a variety of changes that nurses could initiate. Diagnosis, pre- scription practices, parity in palliative care, and improvements to end-of-life care, particularly in the last five days of life. These are some of many areas for improvement in a summative evaluation of health care. Patients and practitioners alike do not always question traditional practices. Nurses are involved in many health-care situations with which they disagree. They are experiencing many aspects of the health-care system that could be changed, although change comes slowly. Even the most entrenched practices can be critiqued, and improved or changed over time. Where to go from here is not certain, but this article is a success by my own standards if even one practitioner thinks twice about a diagnosis and its implica- tions and consequences before assigning it. I have taught ethics for more than 30 years and would still, after all of this time since my first article on this subject, advocate for promoting autonomy in our patients and doing them no harm. Harm is seldom intentional, but doing no harm
- 42. requires considering and anticipating the possible consequences of any diagnosis. It’s the ethically required right that every patient has – to be unharmed by diag- nosis or treatment. Promotion of one’s autonomy and “the good,” although not an ethical requirement, is the positive right for which patients hope. Diagnosis continued from page 2 “Diversity in Healing Practices” will be offered this month at Viterbo Univer- sity in La Crosse, Wisconsin; Nursing Research on the Green will present. The keynote speaker for the event will be Teddie Potter, PhD, RN, FAAN. Potter of the University of Minnesota is currently the coordinator of the Doctor of Nursing Practice in Health Innovation and Leadership, as well as the Director of Inclusivity and Diversity in the School of Nursing. She has been a nurse educa- tor for more than 16 years and has been an innovator in homecare; she helped to start one of the first palliative-care programs in the nation. She is also the executive editor for the Interdisciplinary
- 43. Journal of Partnership Studies. The pub- lication is a peer-reviewed open-access online journal promoting interdisciplin- ary collaboration as a solution to solving society’s grand challenges. A community event to celebrate and recognize “Excellence in Nursing,” it will be held from 9 a.m. to 3 p.m. April 27. It includes the presentation of research posters along with a lunch reception. Four break-out sessions are offered in the morning. • “Home Based Primary Care – an Innovative Approach to Improve Health Care for our Veterans” by Jenna Burns- tad, RN and Ann Anderson RN • “Innovation in Public Health Nurs- ing Practice” by Jen Rombalski, MPH, RN • “Environmental Health – Should Nurses Care?” by Kathryn Lammers, PhD, RN, PHN • “Meeting Patients Where They Are: The Miracle of Animals” by Barb Haverty, RN, and Robbie Mack, MS, LPC, ICS. The first three sessions will repeat in the afternoon, along with a featured breakout with Potter, “Practicing BASE –
- 44. A Design Thinking Exercise.” The event is possible by collaboration between Gundersen Health System, Gun- dersen Lutheran Medical Center Inc., Gundersen Medical Foundation, Logis- tics Health Incorporated, Mayo Clinic Health System-Franciscan Healthcare, Mayo Clinic Health System-Franciscan Healthcare Foundation, Pi Phi Chapter of Sigma Theta Tau International, Viterbo School of Nursing, Western Technical College and Winona State University. There is no fee for the event but pre-registration is recommended due to limited seating for breakout sessions and to assist with catering. Visit www. viterbo.edu/piphi and select “Nursing Research on the Green” from the “In This Section” menu in the left column. Click on “Register Here!” Consider diversity in healing Teddie Potter 45 S. National Ave. l Fond du Lac, WI 54935 l 1-800-2- MARIAN ext. 7650 Earn your RN-BSN degree NOW ACCEPTING APPLICATIONS FOR FALL 2017! 100% online • Classes begin in August APPLY
- 45. TODAY ! marianun iversity.e du Marian also offers master’s degrees in: Family Nurse Practitioner • Nurse Educator Organizational Leadership April • 2017 NursingmattersPage 4 Col. Janis K Bauman was awarded the Legion of Merit accommodation by Maj. Gen. Donald Dunbar on her retirement from the Wisconsin Army National Guard. Bauman was recognized for exceptionally meritorious service to the Wisconsin Army National Guard. Bauman’s leadership, dedication, and commitment to the military medical community are the hallmarks of an out- standing career, according to the service. She provided a steadfast vision and guidance that led to the improvement of administrative procedures for ensuring medical readiness within the Wisconsin Army National Guard at all levels. Above all, Bauman exhibited an exceptional work ethic that will serve as the standard
- 46. for all other medical leaders to emulate. Her numerous accomplishments, con- tributions and professionalism are in keeping with the highest traditions. They reflect great credit upon herself, the Wisconsin Army National Guard and the U.S. Army. The Legion of Merit follows strict eligibility criteria, which require evi- dence of significant achievement of an extremely difficult duty performance in an unprecedented and clearly exceptional manner. Bauman received the recogni- tion upon her retirement after 29-plus years with the Wisconsin Army National Guard. She joined the Army Nurse Corp in 1987 with the 13th Evacuation Hospital in Madison, Wisconsin, and spent the next 29 years working in various posi- tions throughout the Wisconsin Army National Guard. Her career assignments included a deployment overseas work- ing with the 13th Evacuation Hospital, missions to Nicaragua caring for locals in various regions of the country, and volunteering to help other states on their retention boards. Prior to retirement she was commander of the Wisconsin Medi- cal Command for three-plus years, which is directly responsible for planning, resourcing and executing routine medical evaluations for more than 7,400 soldiers.
- 47. Her final assignment as medical officer for the 64th Troop Command Brigade, which is focused on domestic operations related to emergency preparedness. Bau- man’s civilian job is chief nursing officer and vice-president of Patient Care Services for Divine Savior Healthcare in Portage, Wisconsin. Army nurse recognized for merit Mary Ellen Wurzbach, RN, BSN, MSN, FNP, PhD John McNaughton Rosebush Professor Emerita University of Wisconsin-Oshkosh One of the aspects of nursing practice that is seldom discussed is that of pre- scriptive authority. Since the beginning of the nurse practitioner movement, who prescribes and under what circumstances has been a cause of much controversy and concern. Today most nurse practitioners, nurse midwives and nurse anes- thetists have prescriptive authority with or without a relationship with a physician. Many have learned their pre- scriptive practices from their preceptors in school, in a partnership in practice, or from peers.
- 48. But there are many aspects of pre- scriptive authority that have become tra- ditional practice that may be detrimental to the health of our patients. Some suggestions for improving the process of prescription are offered in this article. A variety of suggestions can be made that might improve prescriptive practices. Usually when the ethics of any practice are discussed, several principles apply. In cases of prescriptive practices the prin- ciples in conflict are beneficence – to do good – and nonmaleficence – to do no harm. Most bioethicists would say that the overriding principle is non-malefi- cence. Furthermore, many would say that beneficence is optional and a matter of agreement between patient and practi- tioner. Patients have positive and negative rights. They have the negative right to be kept safe from harm and the positive right Patients have rights – positive and negative Mary Ellen Wurzbach continued on page 5 Bauman exhibited an exceptional work ethic that
- 49. will serve as the standard for all other medical leaders to emulate. Her numerous accomplishments, contributions and professionalism are in keeping with the highest traditions. ONLINE RN to BSN www.GetMyBSN.com [email protected] Viterbo’s degree completion program offers: • affordable $450 per credit tuition. • the opportunity to earn your Viterbo BSN in two years or less. • convenient eight-week classes. • the ability to transfer up to 90 credit hours • three start times per year: January, May, and August.
- 50. Doctor of Nursing Practice (DNP) • BSN to DNP – option of Family NP or Adult-Gero NP • MSN to DNP – for practicing NPs • Hybrid course delivery Col. Janis K Bauman is awarded the Legion of Merit accommodation by Maj. Gen. Donald Dunbar on her retirement from the Wisconsin Army National Guard. Bauman was recognized for exceptionally meritorious service to the Wisconsin Army National Guard. Legion of Merit April • 2017www.nursingmattersonline.com Page 5 to benefit from treatment. Most ethicists would say that the negative right to be safe from harm supersedes the positive right of benefit. In other words, the burdens should not outweigh the benefits. The burden or harm ought to be avoided, and considered more important to avoid than the perceived benefits of any medication. There are many ways of prescribing and benefiting patients without harming them. A variety of suggestions might guide practice. The final arbiter is the principle and admonition “do no harm.”
- 51. When prescribing choose the least dangerous medication based on one’s own experience, and on the medication side-effect lists distributed by the man- ufacturer or pharmacy. Become familiar with the insert from the pharmacy or a small contingent of drugs that conform to the patient population one sees. Avoid medications with black-box warnings from the U.S. Food and Drug Administra- tion. Individualize prescriptions based on a patient’s personal needs. Keep a Physi- cians Desk Reference or other reference material available at all times. Above all, it’s not safe to prescribe for someone who one has only just met. Consider the patient’s current medica- tions. Perhaps a particular drug, although not new, has met the patient’s needs for years. It would not be prudent to sud- denly switch or prescribe new medication for someone unknown to the prescriber. Phone prescriptions are particularly problematic. If for some reason a medication is prescribed for a new patient or changed for an existing one, schedule another appointment to assess the result. Provide patient education about what to do if a problem should arise. Patient education entails a description of the side effects, what to do if side effects occur, whether to discontinue the medication if it
- 52. becomes problematic and an anticipation of what to do should harm present. If a dosage reduction is required, anticipate consequences. Prior to providing a pre- scription, examine the health history and assessment in detail – or perform the necessary actions to assess the safety of a particular medication. New website launches The University of Wisconsin-Madison School of Nursing has launched a new website with new resources for alumni. Interested in volunteering? Looking for ways to connect with old classmates? Visit nursing.wisc.edu for more information. Developers want to hear feedback. Email [email protected] with comments. Patient rights continued from page 4 Today most nurse practitioners, nurse midwives and nurse anesthetists have prescriptive authority with or without a relationship with a physician. continued on page 6 There are many ways of prescribing and benefi ting patients without
- 53. harming them. A variety of suggestions might guide practice. The fi nal arbiter is the principle and admonition “do no harm.” GRADUATE NURSING DocToR of NURSING PRAcTIcE (DNP) in Leadership Fully Online and Blended Options Prepares for formal managerial, director and executive level roles. MASTER of ScIENcE in NursingAdministration and Education P R o G R A M S www.edgewood.edu Apply Today! Use the code 275 to apply for free! contact Jenna Alsteen - 608.663.4255, [email protected] GRADUATE cERTIfIcATES in NursingAdministration and Education April • 2017 NursingmattersPage 6
- 54. A good relationship with a pharmacy is essential. It has software programs – the practitioner should too – that list and describe interaction effects. Many web- sites provide similar information. Com- municate with the pharmacist. Remember that every brand name and every generic from a new manufacturer may have new effects, side effects and interactions. There is safety in consistency. Ask the pharmacy not to change the manufacturer of a generic medication or from brand to generic, without discussing it with the patient. It is an unsafe practice of some pharmacies, over time, to provide the patient with multiple capsule and pill forms of the same generic drug made by different manufacturers. This negates one primary safety measure – the patient’s observation of what their medication looks like. It makes it difficult to know, when ingesting or pouring medications at home, whether the pharmacy made a mistake, whether a medication has been changed, or whether it is the same med- ication but a different generic made by a different manufacturer. At home a patient might assume a mistake has been made and a different drug given to them by the pharmacy. There may also be production variations between manufacturers that could affect the way the patient responds to a given dose of a medication.
- 55. Another consideration when pre- scribing or providing patient education is “framing.” Framing is the perspective from, or context within which, one offers information. Patients will make different Patient rights continued from page 5 INDIANAPOLIS – Employee engage- ment and retention can be an elusive con- cept to many organizational leaders, yet it is key in running a successful organization. According to Joe Tye and Bob Dent, under- standing the importance of accountability for employees – and encouraging them to take ownership of their disciplines – is imperative in running a successful organi- zation of any kind. Tye and Dent’s new book, “Building a Culture of Own- ership in Health- care: The Invisible Architecture of Core Values, Attitude, and Self-Empowerment,” was published by the Honor Society of Nursing, Sigma Theta Tau Interna- tional. The book takes readers on a journey from accountability to ownership, provid- ing a proven model along with strategies
- 56. and practical solutions to help improve organizational culture in the health-care setting, according to the publishers. Using construction as a metaphor, the authors make a case that an organization’s invisible architecture – a foundation of core values, a superstructure of organizational culture and the interior finish of workplace attitude – is no less important than its vis- ible architecture. They assert that culture will not change unless people change – and people will not change unless they are inspired to do so and given the right tools. Although initially written for a health- care audience, Tye and Dent offer unique insight through their invisible architec- ture theory, making the book an import- ant read for leaders in all industries, they say. Nurse leaders and business managers alike may benefit in learning how invest- ing in both organization and people can enable a significant successful change in productivity; employee engagement, satisfaction, recruitment and retention; quality of work; client satisfaction; and financial outcomes. Visit www.nursingknowledge.org/stti- books for more information. About the authors Joe Tye, Master of Health Administra-
- 57. tion and Master of Business Information, is the chief executive officer and head coach of Values Coach Inc., a company he founded in 1994 following a career in health-care admin- istration. His background includes stints as chief operating officer of two large community teaching hospitals. He has written 12 books on values-based life, leadership skills, and strategies to create competitive advantage by fostering a culture of ownership. Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE, is the senior vice-president, chief operat- ing officer, and chief nursing officer at Midland Memorial Hospital. He maintains academic appointments with Texas Tech University Health Sciences Center School of Nursing and the University of Texas of the Permian Basin. He is presi- dent-elect of the American Organization of Nurse Executives. Book helps create healthy work Bob Dent and Joe Tye say understanding the importance of accountability for employees is critical to any organization. Bob Dent
- 58. Joe Tye and practical solutions to help improve organizational culture in the health-care setting, according to the publishers. Bob Dent and Joe Tye say understanding the importance of accountability for employees is critical to any organization. continued on page 7 Since 1980, we have educated nurses and healthcare workers who change lives. Today, Cardinal Stritch University continues to be a leading provider of graduate and undergraduate programs that blend theory and practice to meet the health needs of the community. • Bachelor of Science in Nursing • RN to BSN (online) • Master of Science in Nursing • Bachelor of Science in Respiratory Therapy Completion (online) Get started! Call (414) 410-4000 or learn more: go.stritch.edu/Nursing April • 2017www.nursingmattersonline.com Page 7 choices depending on how information is
- 59. presented to them. Two aspects of educa- tion are essential. • First, tell patients the benefits versus the burdens, because one may have a “duty to warn” of side effects or conse- quences unknown to the patient. • Secondly, conveying one’s treatment rationale allows the patient to decide if they agree or disagree with the treatment plan. An attempt to be impartial but to convey known concerns may help or hinder. There are times to be impartial but also times to try to convince patients of the “rightness” of a course of action if there is an immediate need or long- term consequence. That depends on how severe the consequence is and how likely it is. Fear-engendering communication, however, is neither beneficial nor effec- tive. The patient’s perspective and choice should take precedence. Safety is a primary consideration of prescriptive authority. Accepting or imitating unsafe practices of other prac- titioners or of the health-care system as a whole is not protective of one’s patients or one’s professional standing. In a more essential sense acceptance or imitation may intrinsically be unethical and/ or immoral.
- 60. The manner in which we practice health care can be transformative. Every example we undertake of safe, effective and cautious practice may make profound changes in health care if others follow our lead. Benedictine University The nurses of the future will be involved with policy and new roles in advanced practice nursing. Allocation of nursing staff and how nursing will integrate with the full spectrum of health-care practice is likely to change during the next 10 to 20 years. Leadership roles can be a vibrant part of a nursing career so that nurses are able to add their expertise to policy decisions and better integration of services. Currently 60 percent of nurses practice in hospitals. That can change as nursing services are allocated to more locations – from homes to clinics, and public-health-policy positions to neighborhood centers. A newer position in nursing is the advanced practice nurse, who could be in a specialty such as midwifery or anesthesia. With the advanced training nurses receive, options for more specialties are possible. At Benedictine University, the online Master of Science in Nursing offers a pro- gram accredited by the Commission on Collegiate Nursing Education. The program
- 61. provides the opportunity to learn tools for leadership, along with advanced nursing practices and what is required for advance- ment in the career. “With the multitude of specialties in nursing, I’ve been fortunate to work with diverse groups in programs for geriatric psychiatry, children’s social development, as well as project director for a National Institute of Health-funded research grant,” said Alison Ridge, assistant professor and program director. “Nursing provides great career versatility and exciting challenges.” The program begins with 18 credit hours of foundational courses that focus on collaboration among health-care pro- fessionals, ethics, research and process improvement, information processing and technologies, policy and advocacy, quality improvement and safety. Once the foun- dation courses are completed, students are given a choice of two concentrations – either nurse educator at 21 credit hours or nurse executive leadership at 18 credit hours. Each of the concentration curricula includes a capstone course, where course- work is used in practical applications. Career opportunities for nursing posi- tions are numerous with a current shortage of nursing care. With the population of Baby Boomers reaching retirement, care needs will increase. The U.S. Bureau of
- 62. Labor Statistics estimates an increase in the need for nurse educators of 35 percent by 2022, and a median wage for registered nurses of $67,490. Prospects are bright for the leadership positions. Graduates of Benedictine’s program were polled; 95 percent reported that Bene- dictine prepared them for their current career and, as a result of the program, they either had received or anticipated raises. Graduates reported working in positions at UNC Health Care, the U.S. Army, Yale New Haven Hospital, Vanderbilt University Medical Center and Rush University Medi- cal Center. “This is a great time to be in nursing,” said Julie Sochalski, director of the U.S. Department of Health and Human Services Division of Nursing from August 2010 to September 2013. “It has a glorious past. It has a tremendous future, and I think anybody who is choosing this has cho- sen wisely.” Benedictine University is dedicated to the education of undergraduate and graduate students from diverse ethnic, racial and reli- gious backgrounds. Visit www.ben.edu for more information. Nursing roles expand in future
- 63. BENEDICTINE UNIVERSITY As an integral component of Benedictine University, the Department of Nursing embraces Benedictine values, exemplified by our commitment to the value of hospitality—upholding the value of each person and open to the all people in the human family. The mission of the department is to educate men and women to deliver responsible, competent nursing care to all. BENEDICTINE UNIVERSITY At Benedictine University, the online Master of Science in Nursing offers a program accredited by the Commission on Collegiate Nursing Education. Patient rights continued from page 6 “With the multitude of specialties in nursing, I’ve been fortunate to work with diverse groups in programs for geriatric psychiatry, children’s social development, as well as project director for a National Institute of Health- funded research grant.” Alison Ridge, assistant professor and program director
- 64. April • 2017 NursingmattersPage 8 MSOE Why School of Nursing*? M.S. in Nursing Meeting the needs of mid-management and executive level nurses, and nurse entrepreneurs who must be able to lead teams, manage financial resources, analyze large data sets, understand complex organizational systems, and ensure quality and safety, all through the lens of nursing practice. • Direct entry in B.S. in Nursing • Guaranteed placement in clinical sequence • 100% graduate placement rate • Direct patient care starts as sophomore • Accelerated B.S. in Nursing for those with a BS or BA looking for a new career GR AD UA TE UN
- 65. DE RG RA DU AT E msoe.edu • (800) 332-6763 *All programs are CCNE accredited. Dr. Bardia Anvar Medical Director of Skilled Wound Care An aging Baby Boomer population has spurred a growing demand for nurses trained in treating and preventing pres- sure injuries. According to the U.S. Department of Health and Human Ser- vices, the injuries claim the lives of 60,000 Ameri- cans each year. That number is expected to increase substantially. Take into account that, in the past decade alone, there has been a 63 percent increase in such injuries – previously known as pressure ulcer wounds or “bedsores.” Today an estimated 3 million Ameri- cans suffer from them, yet there are not enough nurses certified to treat that
- 66. growing population. • By 2025, about 18 percent of Amer- icans will be 65-plus and those 85-plus are expected to grow from the current 6 million to nearly 9 million in 2030. • The number of Americans living with chronic medical conditions like diabetes – a group particularly vulnera- ble to debilitating wounds – is expected to grow to 48.3 million by 2050. Though wound prevention and treatment is an interdisciplinary effort, the responsibility for those requiring day-to-day care falls squarely on the shoulders of nurses. With a mounting focus on patient safety and outcome performance, the demand for certified wound nurses is especially high, with job opportunities in hospitals, home care, outpatient wound centers, and especially in long-term-care and skilled-nursing facilities. Among their duties are creat- ing treatment plans, monitoring wounds to ensure infections do not develop, recommending appropriate treatments when infections do occur, cleaning wounds so they heal as quickly as pos- sible, and teaching their patients how to care for their healing wounds. According to nursingcrossing.com the average salary for wound-care nurses
- 67. ranges from $56,000 to more than $85,000 per year. Those specializing in wound care are typically more highly paid than registered nurses in other spe- cialties. Many nurses are embracing the growing field – not only because the rate of pay is excellent and in many cases they can set their own schedules – but the very reason why they entered the field is being satisfied. They are caring for an especially vulnerable population whose very lives might be in their hands. By successfully treating them or being instrumental in preventing such wounds from occurring, these special caregivers are clearly making a difference. Board-certified general surgeon Bar- dia Anvar is medical director of Skilled Wound Care, which services nursing facilities and health plans throughout the United States in treating patients with pressure wounds. He is the author of “Mastery of Skin Wound and Ostomy Care,” and a frequent speaker. In addi- tion he is the founder of the College for Long Term Care, a certification program for those in the skilled nursing field and others who work with the elderly. Its mission is to increase public education and research of pressure ulcer injuries and promote proper treatment protocols. Visit SkilledWoundCare.com or call
- 68. 866-WOUND-80 or 310-445-5999 for more information. Demand exploding for wound-care nurses Bardia Anvar According to nursingcrossing.com the average salary for wound-care nurses ranges from $56,000 to more than $85,000 per year. Those specializing in wound care are typically more highly paid than registered nurses in other specialties. Special Attributes required for wound care nurses.pdf Editorial & opinion Special attributes required for wound care nurses Suzie Calne Editor, Wounds International If you would like to contribute to a future issue of the journal, please contact Suzie Calne, Editor, Wounds International, at: [email protected] A s a student nurse, there were inevitable occasions when I would be asked to write an essay exploring the skills required to become a ‘good nurse’, enabling and encouraging me to focus on improving my proficiency in those I thought
- 69. were most important. Many years have passed since that time, and the expectation and role expansion have changed things considerably. When, at 5am on Saturday morning, my son called me to help a friend who had fallen off his bike, I found myself once again considering the qualities one requires to become a nurse. I focused on monitoring for signs of head injury while my son started cleaning away dried blood, fetching ice, assertively offering mouthwash for a split lip and hunting in a box of wound dressings for one that would protect the most serious cuts and abrasions. I was immediately impressed with my son’s competence; his ability to deal with blood and his practical approach to what was for him an entirely new experience. I reflected on the fact that he was not squeamish and that he remained calm, kind and compassionate, and wondered if this offered possibilities for him in the future if he chose to consider a career in some aspect of nursing. The speciality of wound care, of course, demands its own additional and ever- increasing range of competencies. For wound care nurses, a deep and critical understanding of the complex science and pathophysiology of wound healing and dressing technology is necessary to allow good decision making. In addition to an extensive knowledge base, practical skills are critical and a high level of dexterity is needed in order to, for instance, debride wounds, apply bandages and cut
- 70. dressings. I know of a tissue viability nurse who in a previous life had worked as a skilled seamstress and another who had worked as a hairdresser, both of which make perfect sense, and now additional expertise are required, such as an understanding of health economics, politics and an increasing aptitude for digitalised technology. It seems surprising, given the complexity and importance of wound care and the demanding range of skills (I have only touched the tip of the iceberg) required to be a good wound care clinician, that the speciality so rarely gets the funding and recognition it deserves. The glittering prizes are often afforded to those representing other areas of health care. It is, therefore, significant when one of the key opinion leaders from the relatively small world of wounds is acknowledged in the public arena and such acknowledgement must be celebrated. Ellie Lindsay was awarded an Order of the British Empire (OBE) in the 2015 Queen’s birthday honours for services to nursing. The honour recognises the years of hard work and commitment to the Leg Club model, which is recognised as a viable, replicable and cost- effective way to treat people with lower-limb problems (http://www.legclub.org/trustees/ellie- lindsay). Leg Clubs are held in centres where ‘members’ can seek advice and expert treatment, as well as socialising with other members in a non-
- 71. threatening environment. This allows members to have a personal ‘voice’ and clinicians are more able to tailor care to meet the needs of the individual. The success of the Lindsay Leg club model is widely celebrated and the fact that this model of care has been replicated in many different countries illustrates the huge value of this patient-centred approach to managing leg ulcers[1]. We are lucky that global wound management has benefited from Ellie’s amazing contribution. Her dynamism, humour, charisma, compassion, determination, drive and extraordinary interpersonal skills epitomise the attributes that will be of benefit to all those considering a career in wound care nursing. WINT 1. Young L. The leg club reaches Tasmania. Wounds International 2012. Available at: http://bit.ly/1LWZWs3 (accessed 09.09.2015) Suzie Calne Editor, Wounds International 4 Wounds International 2015 | Vol 6 Issue 3 | ©Wounds International 2015 | www.woundsinternational.com Copyright of Wounds International is the property of SB Communications Group, A Schofield Media Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
- 72. written permission. However, users may print, download, or email articles for individual use. The role of the wound care nurse.pdf Clinical focus The role of the wourKTcare nurse: an integrative review Abstract The role of the wound care nurse has developed to meet the need for expert wound care advice. Internationally, the role has developed with a variety of different titles. Although all positions have some common tasks and obligations, there remain gaps in knowledge around the role of the wound care nurse. This article aims to determine the state of knowledge in relation to the context of practice, scope of practice and impact of the wound care nurse. An integrative review design was used to allow a broad search strategy and to gather papers from a variety of sources. A multi-method search
- 73. strategy of the literature published between 1980-2011 was undertaken. This included 5 electronic databases, a thesis search and manual search. It was found that the characteristics of the patients wound care nurses care for reflect an ageing population and disease processes, including diabetes and obesity. Internationally, there is little consensus on the level of competence, educational requirements and qualifications required to practise as a wound care nurse. There was some evidence that the wound care nurse improved healing times and decreased pressure injury prevalence. Key words: • Integrative review == Wound care • Patient outcomes • Health service delivery Matthew Dutton email: [email protected] Sydney Nursing School, University of Sydney, Austral St George Hospital, NSW Australia Mary Chiarella Sydney Nursing School, University of Sydney, Australia Kate Curtis Sydney Nursing School, University of Sydney, Australia,
- 74. St George Hospital, NSW Australia, The George Institute for Global Health, St George Clinical School, Faculty of Medicine, University of NSW, Australia Accepted for publication 29 JANUARY 2014 W ound care nurse positions have evolved to meet the need for expert wound care advice within health care, although the nomenclature may differ. The position is variously described as tissue viability nurse (Flanagan, 1998a), wound ostomy nurse (Kaufman, 2001) and wound certified nurse (Crumbley et al, 1999).The wound care nurse role was first described in the literature in the early 1980s in England as a 'tissue viability nurse' (Dowding, 1983). Since then. as with many specialist roles, the wound care nurse's role has developed in a haphazard way. Wound management is an area of nursing practice that has a presence in all of the specialties within the health- care setting and contexts: acute, mental health, community, and long-term care
- 75. (Finnie and Wilson, 2003). For the purposes of this research, the role under investigation will be referred to as the wound care nurse. There is little external understanding of what the wound care nurse role actually entails (Finnie and Wilson, 2003). To maximise education and trainmg in the role, it would be beneficial to identify exactly what the field of wound care nursing encompasses and the expectations of the position. Although many wound care nurses have some common tasks and obligations, the variations among the positions between various institutions have led to individual roles following diverse pathways with differences in responsibility. The literature describes the role and benefits of nurse-led wound resource teams and clinics (Granick et al, 1998; Crumbley et al, 1999), such as the potential to
- 76. prevent wound deterioration and subsequent hospitalisation through timely care. However, there has been little exploration of the impact of a dedicated wound care nurse position in a health service or hospital. This literature review aims to determine the current state of knowledge regarding the context of practice, scope of practice and impact of the wound care nurse. Method An integrative review was used to allow a broad search strategy to gather as many quality papers as possible. An integrative review Community Wound Care March 2014 Clinical focus: Role of wound care nurse gathers and synthesises fmdings from studies using a variety of research traditions; additionally it may integrate theoretical work around the
- 77. research subject (Spenceley et al, 2008). Prior to undertaking the formal literature review, a scoping review was undertaken around the research question in order to determine what review strategy was best suited to address the research question. There was a lack of robust research papers, and the nature of the articles did not lend themselves to a systematic literature review but were rather more suited to an integrative approach. It was decided that the integrative review method would facilitate a more comprehensive understanding of the topic. Search method A multi-method search strategy was used including an electronic database search, thesis search and manual search. A search of the databases Medline, Cinahl, Embase, Proquest, and Scopus was performed. Search terms were formulated for context of practice, scope of practice
- 78. and impact. As there were a large variety of titles/names used to identify the wound care nurse, a broader list of search terms was developed to capture as many papers as possible {Table J). A thesis search was performed in the following databases: Trove, Proquest, British Library EThOS, DART and Thesis Canada. Due to a difficulty in finding relevant theses in the thesis databases, a broader search strategy was used. Search terms were formulated for context of practice, scope of practice and impact. The search also encompassed the different nomenclature (described at the beginning of this paper) for the wound care nurse in an attempt to gather all related papers and theses through a broad search strategy. These terms were combined utilising Boolean connectors such as 'AND', ' O R ' and ' N O T ' to connect terms
- 79. and determine the relationship between them. Reference lists from the selected papers were hand searched for papers not identified through the literature and thesis search. The literature search was undertaken between October 2011 and March 2012. Inclusion and exclusion criteria The abstracts identified by the search were screened to find a selection of articles that focused on the context of practice, scope of practice and impact of the wound care nurse. Due to the scarcity of primary research papers, editorial, opinion, descriptive, qualitative and quantitative studies w êre included in this review. The papers included for selection were chosen to enable a broad review of the wound care nurse positions. Articles were excluded if they were not written in English; did not focus on wound care nursing; if the outcome of an intervention
- 80. was not related to the wound care nurse; if opinion pieces were not well reasoned or clear; or if the studies primarily focused on the comparison of or effectiveness of wound care dressing products, rather than the context, scope or impact of the wound nurse. The parameters for year of publication were set at between 1980 and 2011 as a number of seminal articles relating to the research question were published in the 1980s. Screening The primary search yielded 3492 articles "with 1112 duplicates. Manuscript titles and abstracts were screened against the inclusion criteria. The full text of articles were reviewed if they were unable to be Table 1. Search terms ¡ Context of practice #1 # 2
- 81. #3 # 4 #5 Scope of practice # 6 #7 Impact #8 # 9 #10 #11 Wound care nurse #12 #13 #14 #15 #16 #17
- 82. #18 #19 Multidiscipiinary team # 2 0 #21 Context of practice Health facility environment Nursing practice Health resource allocation Resource allocation Scope of practice Role Impact Influence Outcomes Nursing outcomes Wound care clinical nurse consultant
- 83. Wound care nurs" Wound ostomy continence nurs* Stomal therapist* Stomal therapy Vascular nurs* Plastic surgery nurs* Tissue viability nurs* Multidiscipiinary team Multidiscipiinary care team included or excluded based on the abstract. Potentially eligible full-text articles were reviewed using a quality appraisal tool adapted from Polit and Beck (2006). The tool sought to identify context of practice, scope of practice or impact of the wound care nurse within the body of the paper. The tool additionally required the paper to have the following characteristics: a recognisable introduction, the title of the text being
- 84. congruent within the text, the paper having a solid basis in the literature, and despite any limitations of the study that the fmdings appeared to be valid. The screening process is summarised m a PRISMA diagram {Figure i).The studies were peer reviewed by two doctorally prepared nurse researchers to ensure that they met the inclusion criteria. Community Wound Care March 2014 Clinical focus: Role of wound care nurse Results Themes A total of 37 articles were ultimately included in the review. These included 30 peer-reviewed research papers, 3 editorials, 2 theses (1 randomised control trial and 1 descriptive study), 1 job description/ competency standard and 1 transcribed panel debate. All of the papers were written by authors from resource-rich countries. A range
- 85. of methods was used in the papers, such as retrospective analysis and systematic review. Of the papers reviewed, 58% were published in the years 2000-2009, 28% in the years 1990-1999, 11% from 2010 to 2012 and 3% in the years 1980-1989. The 37 papers included in the review were analysed and categorised into three groups according to the areas of inquiry—context of practice, scope of practice and impact {Figure 2). From within these groups, the papers were coded by themes in a comprehensive and systematic manner. The entire sample was then critically analysed to gain an understanding of the overall state of knowledge of the three areas of inquiry in relation to wound care nursing. The following themes were identified in relation to the context of practice of the wound care nurse:
- 86. the location of the practice setting (in-patient, community and chnic Figure 1. F cr e e n > E a . ^ cr e e n m P rir r c cu u
- 87. "O c u if) T3 "O D u CRISMA diagram Scopus: 1699 Cinahl: 619 I Embase: 423 Medline: 343 1 Reference ists read for articles not identified during the database search Proquest: 408 L J J r
- 88. Yield: 3492 Duplicates: 1112 Titles and abstracts screened for inclusion/exclusion Yield: N=99 N=71 Articles read for inclusion/ exclusion N=46 retained 1 r N=5 articles retrieved f N= 46 Articles printed, read 5 Articles added 0 Eliminated r Secondary Screen N=51 17 Eliminated Final sample: N=37 articles/theses Hand search N=8 theses
- 89. Duplieates=l Final sample: N=37 articles/theses I Connmunity Wound Care March 2014 Clinical focus: Role of wound care nurse I based); the characteristics of the patients; the focus of nursing activities (advanced practitioner, researcher, leader, change agent and consultant) and resource availability. The themes identified in the scope of practice of the wound care nurse category were client health needs, both wound specific and hohstic in nature, and the requirements of the wound care nurse themselves, i.e. level of competence, educational requirements and qualifications. The impact of the wound care nurse was categorised
- 90. according to: decreases in wound-related costs and improved wound healing rates and patient outcomes. Each of the themes will be discussed below. Context of practice A total of 25 papers were found that addressed context of practice. Context of practice is defined for the purpose of this study as the conditions that define the individual wound care nurse's practice, including, according to the Nursing and Midwifery Board of Australia (2010): the practice setting; the location of the practice setting; the characteristics of patients or clients; the focus of nursing activities, the degree to which the practice is autonomous; and the resources that are available including access to other healthcare professionals. Current philosophies of chronic wound management seem to suggest a major shift of responsibility for the management from medical to
- 91. nursing staff (Flanagan, 1998b; Harker, 2001). By that it is meant that, although the patient is not admitted under the wound care nurse, the wound care nurse has significant responsibility for that patient's wound management. It has been observed that wound management is almost exclusively being taken up by the nursing profession who are developing a distinct body of knowledge about it (Templeton andTelford, 2010). The wound care nurse role has been delineated as a model used to describe the domains of the clinical nurse specialist role: researcher, practitioner, change agent, educator and consultant (Finnie and Wilson, 2003). Multiple domains of practice were identified in this review, ranging firom direct comprehensive care to researcher and change agent (Box Í) (Baxter and BaUard, 1998; Fitzgerald, 1998; Flanagan, 1998b;
- 92. Harker, 2001; Kaufhian, 2001; Bale, 2002; Finnie and Wilson, 2003). The role of the wound care nurse as perceived by nursing staff was that they provided clinical expertise and direct patient care (Gibson and McAloon, 2006). However, the same nursing staff showed a lack of insight into any other aspects of the wound care nurse's role. A broad range of terms are used to describe the different in- patient and out-patient settings in which the wound care nurse practises (LaSala et al, 2007). The majority of wound care has been identified as being undertaken outside of the hospital, although hospital specialist clinics can provide a valuable service in supporting the community (Bale, 2002). Employment settings may include: academic, hospital, office, private practice, vascular laboratory, nursing-led clinics and community nursing
- 93. (Dowding, 1983; Nunelee and McSweeney, 1995; Hatfield et al, 2008). Unlike many other speciahst nursing roles, wotind care nurses are generally not linked to a medical specialty within these settings and often function independently (Finnie and Wilson, 2003). The wound care nurse is an integral part of the interdisciplinary team and provides a Box 1. Domains of practice of the wound care nurse Direct comprehensive care Professionai ieadership Support systems Publication Research and education focused on the patient Ciinical probiem solving Professionai practice Teamwork Reflective practice Empowerment
- 94. Financial management Direct care activities Education Consuitant Researcher Change agent direct link between the nursing, medical and allied health professionals that often come from diverse teams (Fitzgerald, 1998). The characteristics of the patients cared for by the wound care nurse reflect the demographic changes occurring in older people in resource rich countries such as obesity, longer life expectancy, long-term exposure to environmental toxins and the availability of treatments that save lives but do not cure the underlying illness (Kaufhian, 2001;Baich et al, 2010).Thus, the wound care nurse is responsible for the management of
- 95. more complex wounds in an older, sicker population (Kaufman, 2001; Benbow, 2007). Contributing factors to a predicted increase in the prevalence of wounds and delayed wound healing include obesity and diabetes (Schultz et al, 2003). Obesity is a major issue that can lead to an increase in the incidence of type 2 diabetes. The development of foot and lower- limb ulcérations in diabetes has been well documented and has been linked to numerous intrinsic and extrinsic risk factors leading to tissue compromise and deterioration (Mulder and Alfieri, 2007). Community Wound Care March 2014 Clinical focus: Role of wound care nurse Figure 2. Thennes encompassed by the role of the v^ound care nurse Context of practice • Location of practice setting
- 96. Characteristics of the patients The focus of nursing activities • Resource availability Scope of practice • Client health needs • What is required of the wound care curse? > Competence > Education > Qualifications und car nurse impact • Improved wound healing rates • Patient outcomes Decreases in wound- related costs With the increase in life expectancy, it can be predicted that there
- 97. will be an increase in wounds among the elderly, requiring more wound care resources. People with chronic wounds therefore represent a significant and costly clinical problem in the modern health- care environment (Templeton et al, 2009). In all resource-rich countries, these demographic changes combined with improvements in technology are leading to an increase in health-care spending (Sibbald et al, 2012). With increases in health-care spending there is a need for monitoring and justification in spending. Therefore, much of the wound care nurse's time is spent overseeing wound management resources. This can inhibit clinical practice as many wound care nurses spend time negotiating with budget-holders in an advisory role (Flanagan, 1998b). Flanagan (1998a) expands on this issue in a qualitative analysis of wound care nurses by identifying two core concepts:
- 98. H Organisational constraints: respondents felt that administrative tasks had increased, especially related to auditing and budgeting. The respondents also mentioned that time constraints and lack of organisational support were significant obstacles to managing a budget M Optimising resources: respondents described difficulties in negotiating for resources to support wound care services. While recognising the need for cost containment, respondents mentioned that, while budgets are small, demands for costly wound care provision are often high (Flanagan, 1998a, p.697). Scope of practice For the purpose of this paper,'scope of practice' refers to the way in which nurses are educated, competent and authorised to perform their role (Australian Nursing Federation, 2005).The role is influenced by the following factors: the context in which they practise; client's
- 99. health needs; level of competence; domains of practice (see Table Í); education and qualifications of the individual nurse; and the service providers' pohcies (Australian Nursing Federation, 2005).The literature reveals no consensus or consistency in relation to title used to portray expert practice for wound care nurses. This means that titles such as clinical nurse specialist or nurse practitioner are often taken for granted, have no precise meaning and have been developed in response to local needs (Flanagan, 1998b). However, as previously stated, the role of the wound care nurse is often described in the following terms; researcher, practitioner, change agent, educator and consultant (Finnie and Wilson, 2003). A total of 41% of wound care nurses claimed that the increasing elderly population was a major reason for the types of wounds they
- 100. see (Fox, 2001).The health needs of this client population are well Community V/ound Care March 2014 Clinical focus: Role of wound care nurse I documented. These include (but are not limited to) pressure injury, vascular leg ulcers, diabetic foot ulcers, dehisced surgical wounds, traumatic wounds, cellulitis and many dermatologie conditions (Dowding, 1983;Arnold and Weir, 1994; Schultz et al, 2003; Baich et al, 2010). Due to the complexity of wound healing itself and the impact that any number of comorbid factors can have on wound healing, it would seem important that a wound care nurse would be required to have relevant educational qualifications. Qualification levéis There is a range of qualification levels for practising wound
- 101. care nurses. In a quantitative questionnaire of wound care nurses in the UK, Flanagan (1997) found that 28% were graduates, 19% were undertaking first- degree courses and 6% had obtained a master's degree or higher. In the US, Nunnelee (1995) found that 68.6% of vascular nurses had at least an associate degree in nursing or some form of bachelor degree and 22.5% had a master's degree or higher. However, when examining wound care nurses' perceptions of the required qualifications for their role, experience was considered the key credential rather than undergraduate or postgraduate study. In addition, when asked about how nurses gained further knowledge of wound care and tissue viability, 57% (n=50) stated that networking with other wound care nurses was an important method of keeping up to date. None of those surveyed identified
- 102. a local or national criterion to be a wound care nurse. One such set of estabhsh criteria is the National Association of Tissue Viability Nurses Society (Scotland) Competency Standards (Cooper andTinnnons, 2001). These criteria include having a first degree or commitment to follow a degree pathway and a portfoho of evidence of related experience and achievements. International consistency There is no consistency internationally in the educational requirements recommended to undertake the role of the wound care nurse. There are no educational requirements specified in the UK, which is said to have contributed to the haphazard development of wound care nurses currently practising without relevant qualifications (Flanagan, 1996). Since 1983, wound care nursing in the US has required
- 103. baccalaureate- level preparation before formal wound ostomy continence (WOC) education can commence (Beitz, 2000). Specialty certification remains voluntary in the US, yet highly desirable and 'expected' by many employers (Beitz, 2000). Yet within the US, the scope of practice for advanced practice nurses (APNs) has been delineated by specialty practice organisation, educational associations, faculty groups, task forces and certifying bodies (Beitz, 2000). The variety of organisational bodies associated with wound care nursing demonstrates the disparity in the organisation; structure and support senior clinical nursing roles receive. The wound care nurse under the APN model would have a much more defined and clearer certification path than that of the wound care nurse under the WOC model.
- 104. Certification is a formal process by which a person validates, in accordance with established standards, that they have achieved a specific level of knowledge or performance. Within the specialty of wound care nursing, only the US has certification specifically for nurses (Sibbald et al, 2012).This can be undertaken through the Wound Ostomy Continence Nurses (WOCN) certification board, the National Alliance ofWound Care, or the American Academy of Wound Management. The completion of a specialised course in a university in other countries provides status and credentials that are recognised, but is not a formalised certification process (Sibbald et al, 2012). Impact It has been claimed that the nurse-led specialty of wound care contributes to improving patient care (Finnie and Wilson, 2003). While it was difficult to obtain unequivocal information about the impact wound
- 105. care nurses might have, there were some studies that demonstrated impact. However, these were heavily focused around the reduction of pressure ulcer prevalence (PUP) and cost savings, both financial and in regards to in-patient length of stay (LOS). Other outcomes identified in the review included wound healing rates and patient satisfaction rates with the wound care nurse's service. Outcomes regarding limb salvage rates are identified, but the wound care nurse's contribution and impact is discussed as part of the multidisciplinary team. The exact role of the wound care nurse within the multidisciplinary team is not delineated. Papers discussing healing rates as an outcome measure were poorly represented. Of those that discussed that specific outcome, Baich et al (2010) found that wound care nurses achieved a 78.5% healing rate,
- 106. with an average 31.6 visits per patient compared with non- wound care nurses healing rates of 36.6% with an average of 17 visits per person. In a randomized control trial pilot study, Edwards et al (2005) documented decreases in venous ulcer size and Pressure Ulcer Scale for Healing (PUSH) scale at 12 weeks. Four authors identified a decrease in pressure injury prevalence (PIP) as a key outcome of the involvement of a wound care nurse (Granick et al, 1998; Kaufman, 2001; Hiser et al, 2006; Baich et al, 2010;Asimus et al, 2011).The decreases in three hospital PIP rates are documented as follows: 20.1% to 4.3% (Granick et al, 1998); 23% to 5% (Kaufman, 2001); 9.2% to 6.6% (Hiser et al, 2006); and within one area health service as 29.4% to 13% (Asimus et al, 2011). The increase in pressure ulcer prevention has been reported to occur
- 107. with the introduction of a wound care nurse and has also been associated with cost savings. One study reported a 500000 Australian dollars (AUD) cost saving due to significant reductions in hiring of powered mattress systems (Asimus et al, 2011). With the decrease in PIP and the introduction of PUP protocols (which included nursing interventions) within a medical intensive care unit it was calculated that even with a 1-day reduction in LOS, the minimum annual cost reduction (based on the daily cost of care in that unit) would be 317 000 US dollars (USD) (Hiser et al, 2006). Other sources of cost saving include the reduction of hospitalisation for wound-related complications translating into monthly savings of 32 347 USD (Kaufman, 2001). Wound healing rates when those patients were seen by a wound care nurse equated to an average
- 108. saving of 1697 USD per patient (Baich et al, 2010). A further outcome identified was improvements in morbidity and mortality of a group of patients known as claudicants, which means they had reproducible calf pain associated with exercise alleviated by rest. Enrolment in a nurse-led clinic resulted in 100% antiplatelet and statin compliance rate, a smoking cessation rate of 17%i and significant improvements in total cholesterol (5.2—4.5 inmol/1), low- density lipoprotein (LDL) (3.1-2.5 mmol/1) and triglycéride (1.7-1.4 mmol/1) (Hatfield et al, 2008). The implementation of a wound care nurse was associated with improved satisfaction among patients and clinicians (Knaus et al, 1996; MacLellan et al, 2002). Both studies demonstrated positive responses about the wound care nurse role, stating the service was safe, efficacious
- 109. Community Wound Care March 2014 Clinical focus: Role of wound care nurse and valued. However, it should be recognised that there have been concerns expressed about patient satisfaction measurement, including: validity and reliability; methodology; survey design; survey administration techniques; and timing (Urden, 2002). Discussion The reviewed literature highlighted several themes pertinent to the wound care nurse role and its context of practice, scope of practice and impact. A major finding was that much of the literature discussed 'nurses' as opposed to 'nursing'. For example, there was much discussion about the desired qualities and qualifications of a wound care nurse, but far less explanation about what a wound care nurse actually
- 110. did in the clinical setting. The impact and outcomes of the wound care nurse were poorly represented within the literature, providing httle evidence to demonstrate that a wound care nurse actually does makes a difference and, if they do, what it is that they actually do that makes a difference. Due to the variety of the employment settings identified within the literature and the diversity of the role of the wound care nurse, a more detailed examination of the nursing care provided by the wound care nurse would provide greater insight into the role. It has been argued that advanced practice nurses, including wound care nurses, act as knowledge brokers in promoting evidence-based practice among clinical nurses (Gerrish et al, 2011). If this is the case, then it is incumbent on the profession to provide evidence in the form of
- 111. outcomes to demonstrate that the interventions they are providing are actually benefiting the patient and/or the institution. Furthermore, given the information gathered around the scope and context of practice of the wound care nurse, it could be argued that the position lends itself to that of a clinical case manager or coordinator, facilitating the holistic management of the patient while concomitantly maintaining a clinically based advanced practitioner's role. Finally, the fmdings are limited due to the quantity and quality of available research arotmd the role of the wound care nurse. Models of care delivery Holistic management as a feature of wound management is a consistent theme within the literature (Baxter and Ballard, 1998; Schultz et al, 2003; Tudor, 2003; Australian Wound Management Association, 2010). This is