Politics And The Patient Protection And Affordable Care Act


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 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 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

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 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- 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 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— whether it is depression, addiction, schizophrenia, or PTSD—is establishing

a strong and trusting relationship.


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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 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 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 (anickelmilstone@solomonmccown.com).

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


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 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 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 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- 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 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-

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NursingMatters April 2017.pdf


April 2017 • Volume 28, Number 4

Nursingmatters INSIDE:

Diagnose carefully

2 Patients

have rights

4 Be


















O . 1

72 3









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 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 jbauman@ dshealthcare.com for more 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- 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 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:

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Nursingmatters is dedicated to supporting and fostering the growth of professional nursing. Your comments are encouraged and appreciated. Email editorial submissions to klillesand@sbcglobal.net. Call 608-252-6264 for advertising rates.

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. 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 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, 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 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

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 – 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

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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 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. 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.

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 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.


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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.”

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 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 alumni@son.wisc.edu 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 harming them. A variety

of suggestions might guide practice. The fi nal

arbiter is the principle and admonition “do no harm.”


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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.

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

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-

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

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 inNursing • RN to BSN (online) • Master of Science inNursing • Bachelor of Science in Respiratory Therapy Completion (online)

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April • 2017www.nursingmattersonline.com Page 7

choices depending on how information is 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.

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 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 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

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

April • 2017 NursingmattersPage 8


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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 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 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 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: suzie.calne@woundsgroup.com

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 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 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- 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 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


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

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: mattliew.dutton@sesiahs.health.nsw.go\

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, 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

Wound care nurse positions have evolved to meet the needfor expert wound care advice within health care, althoughthe 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

(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

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.


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

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 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’, ‘OR’ and ‘NOT’ to connect terms

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 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.


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






Scope of practice








Wound care nurse









Multidiscipiinary team



Context of practice

Health facility environment

Nursing practice

Health resource allocation

Resource allocation

Scope of practice





Nursing outcomes

Wound care clinical nurse consultant

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

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 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:

the location of the practice setting (in-patient, community and chnic

Figure 1. F

cr ee


> E a

. ^

cr ee



Pr irr

c cu


“O c u



“O D


CRISMA diagram

Scopus: 1699 Cinahl: 619


Embase: 423 Medline: 343


Reference ists read for articles not identified during

the database search

Proquest: 408




Yield: 3492 Duplicates: 1112

Titles and abstracts screened for inclusion/exclusion

Yield: N=99

N=71 Articles read for inclusion/ exclusion

N=46 retained



N=5 articles retrieved


N= 46 Articles printed, read 5 Articles added

0 Eliminated


Secondary Screen N=51 17 Eliminated

Final sample: N=37 articles/theses

Hand search N=8 theses


Final sample: N=37 articles/theses


Connmunity Wound Care March 2014

Clinical focus: Role of wound care nurse


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

according to: decreases in wound-related costs and improved wound

healing rates and patient outcomes. Each of the themes will be discussed


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


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

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;

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

(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


Research and education focused on the patient

Ciinical probiem solving

Professionai practice


Reflective practice


Financial management

Direct care activities




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

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

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


• Improved wound healing rates

• Patient outcomes

Decreases in wound- related costs

With the increase in life expectancy, it can be predicted that there

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:

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 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

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


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 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 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


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 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.

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

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,

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

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

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

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).


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 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

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

not hmited to a holistic assessment of the physical or physiological needs

of the patient; it includes the integration and coordination of all patient-

centred care delivery within the multidiscipiinary team (including the

patients family and/or carers) (Zayed et al, 2008).This point is further

emphasised by the Australian Wound Management Association’s Standards

for Wound Management (Australian Wound Management Association,

2010), which require collaborative practice and inter-professional care.

The wound care nurse is ideally placed to ensure this practice via a case

management model and the advanced practice and clinical expertise

of the wound care nurse would arguably be integral to the role. Curtis

(2006) discussed the development of nursing case management around

the introduction of managed care in the US. Case management is a

system of health assessment, planning service procurement, delivery,

coordination and monitoring to meet the needs of patients and health

services efficiently (Girard, 1994).The role of the nurse case manager

includes the responsibility to coordinate all of the resources required to

provide quahty health care in a cost-effective manner (Shiell and Kenny,

1993). It is possible that the wound care nurse already includes the case

management model within the role, but there is no recognition of this in

the literature. Such a possibility warrants further exploration.


Resource-rich health systems such as the UK and US provided the

majority of the literature reviewed. The analysis of the literature

reviewed will naturally reflect a bias towards these health contexts, and so

caution should be exercised when making generalisations. There was no

literature from resource-poor nations, yet it is likely that wound care is

an important role for nurses in those countries. There needs to be further

examination into the context of practice, scope of practice and impact

of the wound care nurse internationally to provide a more well-rounded

perspective of the wound care nurse. Were there an international

consensus and definition of the role of the wound care nurse, this would

allow for a standardisation of care and benchmarking elements required

for improved care and better patient outcomes. Furthermore, this would

allow for the creation of an international wound care nurse network,

which would create opportunity for networking, the exchanging of

knowledge and protocols.


This integrative review has described the context of practice, scope of

practice and impact of the wound care nurse. Although the literature

discusses the actual day-to-day work that a wound care nurse performs,

there is httle information about the actual clinical practices of wound

care nursing or of the impact that the role provides. Further research and

detailed exploration into the role is recommended. C^vC


The first author is currently a Masters of Philosophy candidate. The second

and third authors are his supervisors. The first author contributed to the study

conception and design, collection of and review of the papers throughout the

screening process, thematic analysis and documentation of the results. The

second and third authors provided supervision, contributed to the study design,

participated in the secondary and tertiary screening processes and aided in

constructing the finished document.

The authors received no funding from any source for the preparation of this paper.

The authors declare no confiicts of interest for this article.


Arnold N, Weir D (1994) Retrospective analysis of healing in wounds cared for by ET nurses versus staff nurses in a home setúng.] Wound Ostomy Continence Nurs 21{4): 156-60

Asimus M, MacLellan L, Li P (2011) Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives. Int Wound] 8(5): 508-13

Australian Nursing Federation (2005) Scope of nursing practice, http://www.anf.

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org.au/nurses_gp/resource_15.pcdf Australian Wound Management Association (2010) Standards for Wound Management.

http://tinyurl.com/o3e3d5e (accessed 5 February 2014) Baich L, Wilson D, Cummings GG (2010) Enterostomal therapy nursing in the

Canadian home care sector: what is the value? J Wound Ostomy Continence Nurs 37(1): 53-64

Bale S (2002) The contribution of the wound care nurse in developing a diabetic foot clinic. BrJ Clin Governance 7(1): 22-6

Baxter H, Ballard K (1998) Tissue viability nurse specialist: making the role effective. Managing Clin Nurs 2(1): 77-9

Beitz JM (2000) Specialty practice, advanced practice, and WOC nursing: current professional issues and future opportunities. Adv Pract Nurs 27(1): 55-64

Benbow M (2007) Where is tissue viability in 10011 f Community Nursing 21(1): 13-16

Cooper P, Tinimons J (2001) National Association of Tissue Viability Nurse Specialists for Scotland. Job description: clinical nurse specialist in ti.ssue viability. f Tissue Viability 11(1): 48-9

Crumbley D, Ice R, Cassidy R (1999) Nurse-managed wound clinic: a case study in success. Nurs Case Manag 4(4): 168-80

Curtis K (2006) Trauma Nursing Case Management: Impact on Patient Outcomes. Faculty of Medicine School of Public Health and Community Medicine, University of New South Wales, Sydney

Dowding C (1983) Pressure sores 3—Tissue viability nurse: a new post. Nurs Times 79(24): 61-4

Edwards H, Courtney M, Finlayson K, Lewis C, Lindsay E, Dumble J (2005) Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention. Int j Nurs Pract 11(4): 169-76

Finnie A, Wilson A (2003) Development of a tissue viability nursing competency framework. BrJ Nurs 12(6): S38-44

Fitzgerald DM (1998) Vascular nurse practitioner: development of an innovative role for the 21st century.J Vase Nurs 16(4): 87-92

Flanagan M (1996) The role of the clinical nurse specialist in tissue viability. Br j Nurs 5(11): 676-81

Flanagan M (1997) A profile of the nurse specialist in tissue viability in the UK.J Wound Care 6(2): 85-7

Flanagan M (1998a) Factors influencing tissue viability nurse specialists in the UK: 2. Brf Nurs 7(12): 690-701

Flanagan M (1998b) The impact of change on the tissue viabilty nurse specialist: 1. BrJ Nurj 7(11): 648-57

Fox C (2001) Perceptions of tissue viability nnrses of their current roles. Br J Nurs 10(11): SlO-16

Gerrish K, McDonnell A, Nolan M, Guillaume L, Krishbaum M,Tod A (2011) The role of advanced practice nurses in knowledge brokering as a means of promot- ing evidence-based practice among clinical nurses. J^rfi< Nurs 67(9): 2004-14

Gibson L, McAloon M (2006) How do nurses percieve the role of the TVNS? Wounds L/iC 2(4): 36-48

Girard N (1994) The case management model of patient care delivery. AORN J 60(3): 403-15

Granick MS, McGowan E, Long CD (1998) Outcome assessment of an in-hospital cross-functional wound care team. Plast Reconstr Surg 101(5): 1243-7

Harker J (2001) Role of the nurse consultant in tissue viability. Nurs Stand 15(49): 39-42

HatfieldJ, Gulati S, Abdul Raham MNA, Coughhn PA, Chetter IC (2008) Nurse- led risk assessment/management clinics reduce predicted cardiac morbidity and mortality in claudicants.J Vase Nurs 26(4): 118-22

Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C (2006) Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manag 52(2): 48-59

Kaufman MW (2001) The WOC nurse: economic, quality of life, and legal benefits. Dermatol Nurs 13(3): 215-19

KnausVL, Davis K, Burton S, Feiten S, Fobes P (1996) Vascular nurse practitioner: a collaborative practice role in the acute care setting. J Vase Nurs 14(2): 40—4

LaSala CA, Connors PM, Pedro JT, Phipps M (2007) The role of the chnical nurse specialist in promoting evidence-based practice and effecting positive patient outcomes.J Continuing Educ Nurs 38(6): 262-70

MacLellan L, Gardner G, Gardner A (2002) Designing the future in wound care: the role of the nurse practitioner. Primary Intention 10(3): 97-112

Mulder G, Alfieri D (2007) The diabetic foot: considerations for pressure reduction and off-loading. Primary Intention 15(2): 58-65

Nunnelee JD, McSweeney M (1995) Defining vascular nursing: a survey of vascular nurses.J Vase Nurs 13(3): 79-82

Nursing and Midwifery Board of Australia (2010) Continuing professional devel- opment registration standard, http://tinyurl.com/ollmnvu (accessed 5 February 2014)

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Schultz G, Sibbald G, Falanga V, Stacey M (2003) International advisory board on


An integrative review allows for gathering and synthesising of information using a variety or research traditions. This is useful when there is a lack of robust literature or if the nature of the literature being reviewed does not lend itself to a systematic review

The wound care nurse role lends itself to that of a clinical coordinator, facilitating the holistic management of the patient whilst maintaining a clinically based advanced practitioner’s role

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Community Wound Care March 2014

Copyright of British Journal of Community Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

Why your facility needs a wound care nurse.pdf


66 l Nursing2018 l Volume 48, Number 2 www.Nursing2018.com

A CERTIFIED Wound Care Nurse (CWCN) is a nurse who’s success- fully completed an advanced training program in wound assess- ment and management. CWCNs care for patients with wounds caused by injuries, diseases, or medical treatments. They also provide wound prevention recom- mendations and interventions for at-risk patients and pre- and postsurgical care and education for patients. This article, which dis- cusses the need for more full-time CWCNs as inpatient staff, includes a literature review supporting the value CWCNs offer patients and employers in both improved quality of care and cost reduction.

Wide-ranging responsibilities CWCNs work with multidisci- plinary healthcare teams and provide services that include wound assessment, wound cleansing, nonexcisional and conservative sharp wound debridement, negative pressure wound therapy, compres- sion wraps, treatment planning, and wound-related medication recom- mendations, as well as ongoing patient assessment and treatment. This national certification, which requires advanced nursing skills, can be obtained at different nursing education levels. Two nationally recognized certification boards, the National Alliance of Wound Care and Ostomy (for RNs, LPNs, and other clinicians) and the Wound, Ostomy Continence National Certification Board (for clinicians with a bachelor’s degree or higher),

offer specialized training and standardized tests for certification. Certification is also available for advanced practice nurses (APRNs). APRN certification requires a focus on core role competencies specific to the APRN.

Patient-care guidelines The Wound, Ostomy and Conti- nence Nurses Society was founded in 1968 and currently has more than 5,000 members, many of whom help write and secure national guidelines for wound care practice.1 Research shows that when compared with traditional practices (“how things have always been done”), evidence-based practice yields higher-quality healthcare, better patient outcomes, and lower costs.2 National clinical guidelines

for wound care set forth by Health Service Executive, Inc., an Ireland- based health organization man- aged by the Ireland Department of Health, describe corporate responsi- bilities for current best practice that are widely recognized as national guidelines:3

• A collaborative and interdisci- plinary approach to wound manage- ment is recognized as the optimal

approach to preventing and manag- ing wounds. • Clinical practice in wound management should comply with and respect legislation, scope of practice, clinical practice guidelines, and organizational policies and procedures. • Compliance with the above ensures patient safety and facilitates wound healing.

For a facility to provide evidence- based best practice, consistency in the quality of care must be provided to patients in all areas. Evidence- based best practices to prevent hospital-acquired pressure injuries include assessment, use of pressure- redistribution surfaces, reposition- ing, nutritional support, and moisture management. All of these specialized interventions are included in the CWCN’s advanced training.4 The CWCN contributes to the quality of patient care by providing direct care, education, and consultation for patients, and consultation and direction for non-CWCN nurses. They also develop procedures, guidelines, and protocols for patient care.4

Literature review Wound care requires a multidisci- plinary approach to provide holistic, comprehensive care for patients who may have several comorbidities.5 One study of effective wound care centers identified that multidisci- plinary teams including a CWCN had a greater than 50% improve- ment in reducing amputation rates and wound-related complications

Why your facility needs a full-time certified wound care nurse By Stacy Newbern, BSN, RN-BC, CWCN, OMS, FNP

Employing a full-time CWCN streamlines treatment to make

the most effi cient use of hospital and clinic resources while reducing workload for

unit nurses.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

www.Nursing2018.com February l Nursing2018 l 67

compared with teams without a CWCN.4,5 Data obtained from the National Database of Nursing Quality Indicators have linked nursing specialties, and the CWCN in particular, to lower hospital- acquired pressure injury rates and better pressure injury risk assess- ment and prevention practices.4 In an independent study performed and trialed within the Veterans Affairs Healthcare System, universal pressure injury prevention bundles with CWCN support lowered the incidence of unit-acquired pressure injuries from 15.5% (without CWCN support) to 2.1% (with CWCN support) on average.1

A study by Aydin and colleagues compared unit/patient characteris- tics, nurse workload, nurse exper- tise, and hospital-acquired pressure injury preventive clinical processes of care for prevalence of hospital- acquired pressure injuries in 789 medical-surgical units at 215 hospitals.3 The study found that RN workload, expertise, and clinical process of care (risk assessment) can be adjusted to reduce the incidence of hospital-acquired pressure injuries through support strategies for the unit nurse. These include full-time nurses experienced in wound care and stress the impor- tance of early skin and pressure injury risk assessment.3 These studies support the concept that more CWCN involvement with inpatient assessment and care results in better patient and facility outcomes.

These studies are also significant because insurance companies are increasingly basing their reim- bursement rates on patient out- comes and quality of service. The estimated cost of hospital-acquired pressure injury care is $9.1 billion to $11.6 billion each year and is

linked to an increase in patient pain, lower quality of life, and increased mortality risk during a hospital stay.6

A study of all-payer statewide administrative data for California from 2007 to 2009 compared pressure injury rates and hospital charges for adults discharged from acute care hospitals after the Hospital-Acquired Conditions Initiative pressure injury payment changes. Initiated by Medicare and other payers, these changes included refusal to pay for Stage III and Stage IV hospital-acquired pressure injuries, which decreased payments in the state overall by $310,444 for all payors and $199,238 for Medi- care. Other initiatives reduced payments related to skin injuries, decreasing the amount to $62,538,586 for all payors and $47,237,984 for Medicare.6

According to Bureau of Labor statistics, in 2014 the average hourly rate of pay for general hospital nurses in the United States was $35.71.7 Utilizing the average amount provided by this statistic, hiring one full-time CWCN to provide wound assessments and treatments for 5 days each week, or a 40-hour workweek, would cost the average hospital approximately $74,267 per year—potentially less than what a hospital-acquired injury or skin infection may cost the hospital.

Current practices in most hospital facilities allow clinical nurses and providers to place wound care consultations via the patient electronic health record when a wound care nurse is employed by the facility. This practice relieves the workload of the unit nurse, who spends an average of 1 hour on each inpatient consult, including assess- ment, development of treatment plan and relaying the plan to the

healthcare provider; cleansing, debriding, and dressing the wound; and documenting. For patients with multiple wounds or affected body surfaces, the consult may take up to 2 hours.

If we know that having a CWCN in the hospital setting is supported by national advisories, and evidence- based best practice indicates positive outcomes when the CWCN works as part of the multidisciplinary team, why aren’t hospitals adding them to the team?

Assessing skin integrity Evidence-based best practice indicates each patient should have a skin integrity risk assessment on admission to the unit and every 24 hours using a tool to identify existing wounds or increased risks for wounds so interventions can be initiated immediately to prevent further injury.8 The National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Ulcer Injury Alliance 2014 guideline identifies that adults with medical devices are at risk for pressure inju- ries (B strength of evidence) and recommend evaluating skin under and around medical devices at least twice daily for signs of pressure- related injury.9 A pressure injury risk assessment tool is considered necessary for a comprehensive pressure injury prevention program.8

The Braden scale risk assessment tool was introduced in the late 1980s and has since become the most used and validated pressure injury tool.10 The score is based on six variables: activity, mobility, nutritional status, sensory percep- tion, moisture, and friction and shear, with a maximum score of 23. A score equal to or lower than 18 indicates an increased risk for

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


68 l Nursing2018 l Volume 48, Number 2 www.Nursing2018.com

pressure injury and the need for evidence-based interventions designed to maintain or restore skin integrity.10 In a study to determine the efficacy of multidisciplinary interventions on reducing the incidence of hospital-acquired pressure injuries, the Braden scale was found to have a sensitivity of 92.30% for predicting the develop- ment of pressure injury.10 No risk assessment tool, however, is meant to replace clinical assessments and professional judgment; it’s designed for use in conjunction with clinical assessments.

The National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Ulcer Injury Alliance 2014 clinical guideline recommends use of a systematic process for determining pressure injury risk including clinical judgment, skin assessment, and review of risk factors that are not part of the pressure injury risk assessment tool, because not all risks are quantified on the Braden Scale or other tools used for pressure injury risk assessment.9 Because CWCNs have advanced skills, they can recognize risk factors not included in the Braden scale by performing a comprehen- sive clinical assessment of the skin; evaluating comorbidities, health, and functional status; identifying risks related to medical devices; and immediately implementing preven- tive and intervention care plans. These measures improve patient outcomes and quality of service in the inpatient setting, and reduce workloads for the unit nurse and provider.

Quality improvement proposal Evidence-based best practice guidelines recommend having

nurses who are specially trained in wound care provide care for patients with wounds or who are at risk for pressure injuries in both inpatient and outpatient settings. Employing a full-time CWCN to care for these patients streamlines treatment and makes the most efficient use of hospital and clinic resources while reducing workload for unit nurses.

Using evidence-based guidelines for wound care treatments as outlined by the Wound Ostomy and Continence National Clinical Practice Guidelines for Prevention and Management of Pressure Ulcers (Injuries) can help standard- ize care and ensure that the CWCN provides the required assessments, care planning, and implementation of treatment for patients at high risk for healthcare-acquired infections secondary to loss of skin integrity and development of pressure injuries.3 Employing a full-time CWCN on the inpatient unit facilitates timely responses to wound care-related needs, improv- ing patient outcomes and decreas- ing costs to the patients and facilities. For more information, see Wound care resources. ■


1. Wound Ostomy and Continence Nursing Board. History. www.woc_ncb.org/about-us/history.

2. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals. What are

the best practices in pressure ulcer prevention that we want to use? 2014. www.ahrq.gov/ professionals/systems/hospital/pressureulcertoolkit/ putool3.html.

3. Wound Management Association of Ireland. National Guidelines for Best Practice and Evidence-Based Guidelines for Wound Manage- ment. 2016. www.wmai.ie/wpcontent/up- loads/2011/09/wound_guidelines_2009.pdf.

4. Boyle DK, Bergquist-Beringer S, Cramer E. Relationship of wound, ostomy, and continence certifi ed nurses and healthcare-acquired conditions in acute care hospitals. J Wound Ostomy Continence Nurs. 2017;44(3):283-292.

5. Kim PJ, Evans KK, Steinberg JS, Pollard ME, Attinger CE. Critical elements to building an effective wound care center. J Vasc Surg. 2013;57(6):1703-1709.

6. Meddings J, Reichert H, Rogers MA, Hofer TP, McMahon LF Jr, Grazier KL. Under pressure: fi nancial effect of the hospital-acquired conditions initiative. A statewide analysis of pressure ulcer development and payment. J Am Geriatr Soc. 2015;63(7):1407-1412.

7. U.S. Bureau of Labor Statistics. Occupational Employment Statistics. 2017. www.bls.gov/oes/ tables.htm.

8. Gadd MM, Morris SM. Use of the Braden Scale for pressure ulcer risk assessment in a community hospital setting: the role of total score and individual subscale scores in triggering preventive interventions. J Wound Ostomy Continence Nurs. 2014;41(6):535-538.

9. National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel/Pan Pacifi c Pressure Ulcer Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Perth, Australia: Cambridge Media; 2014.

10. Mallah Z, Nassar N, Kurdahi Badr L. The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: controlled before and after study. Appl Nurs Res. 2015;28(2):106-113.

Stacy Newbern is a wound care clinic supervisor at Central Peninsula Hospital in Soldotna, Alaska.

The author has disclosed no fi nancial relationships related to this article.


Wound care resources

National Pressure Ulcer Advisory Panel www.npuap.org

European Pressure Ulcer Advisory Panel www.epuap.org

Pan Pacific Pressure Ulcer Injury Alliance www.woundsaustralia.com. au/publications/2012_AWMA_ Pan_Pacific_Guidelines.pdf

Wound Ostomy and Continence National Clinical Practice Guidelines


Wound Management Association of Ireland www.wmai.ie

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Wound Care Nursing A Patient-Centered Approach_.pdf



Media Reviewers: Diane Maggio, BSN, RN, CRRN, CWON, and Louise Hummel, MSN, RN, CNS, CEN, Atlantic City, NJ, and La Jolla and San Marcos, Calif

Wound Care Nursing: A Patient-Centered Approach. 2nd ed.

Bale S, Jones V. Philadelphia: Mosby Elsevier; 2006, 235 pp, ISBN 0-7234-3344-5

The second edition ofWound Care: A Patient-CenteredApproach is a great resource for professional nurseswho are seeking to incorporate nursing theory as it relates to wound care. The style of writing may take a little getting used to, because the book includes some British terms that may be unfamiliar to American nurses, but this element adds character to the writing. The book’s orga- nized layout includes sections on normal to abnormal skin and the healing processes affecting both types. Material on care planning for individuals addresses assessment, diagnostic approach, evaluation, and wound management as they are affected by age, environmental needs, and social needs of the individuals. Information on care plan- ning draws on the work of numerous theorists including Peplau, Joyce, and Rielh-Sisca, to name a few.

The European Pressure Ulcer Advisory Panels defi- nitions were used in the description of Pressure Ulcers. The National Pressure Ulcer Advisory Panels (NPUAP) definitions used in the United States have recently been updated to expand the definition of Stage I pressure ulcers to include dark complected patients and added the new Suspected Deep Tissue Injury description. Medicare has adopted the NPUAP’s definitions and has adjusted the payment scale to reflex the change.

Wound Care: A Patient-Centered Approach will help guide the reader through the assessment of a patient and

how to plan an individual’s care; it is not just a cookie- cutter guide to treating a wound type. Individual case stud- ies are used to help explain the rationale for treatments, the nursing theory that was used to define the care plan, and practice points for each situation. I found many tables and charts that I will use as reference guides in my practice.— Diane Maggio, BSN, RN, CRRN, CWON

doi: 10.1016/j.jen.2008.09.007

Mechanical Ventilation Made Easy

Fischer MJ. Nashville (TN): American Respiratory Consulting Services; 2007, 48 pp, $14.99

Mechanical Ventilation Made Easy is an invaluablepocket-size reference for anyone who has sud-denly found himself or herself caring for a patient undergoing mechanical ventilation. This publica- tion is a very useful tool in understanding the various modes of mechanical ventilation. The pocket-size reference is di- vided into 4 sections: “Definitions,” “Modes of Mechanical Ventilation,” “Arterial Blood Gases,” and “Basic Ventilator Changes That Affect Blood Gases.”

Written in simple terms, each section provides easy-to- understand explanations, as though the author is speaking directly with you. The “Modes of Mechanical Ventilation” section provides explanations of the most basic modes of mechanical ventilation (controlled mechanical ventilation, volume control, pressure control, pressure-regulated volume control, synchronized intermittent mandatory ventilation, pressure support and volume support, continuous positive airway pressure, biphasic positive airway pressure [BiPAP], and airway pressure release ventilation) in straightforward, easy-to-understand terms. Each explanation includes a patient situation that illustrates indications for the mode of ventilation.

The section on arterial blood gases offers explanations of arterial blood gas components and a step-by-step approach to interpretation. Examples are given for the numerous types of interpretation: respiratory acidosis or alkalosis ver- sus metabolic acidosis or alkalosis and compensated ver- sus uncompensated.

Diane Maggio is Wound, Ostomy, and Continence Nurse, AtlantiCare Re- gional Medical Center, Atlantic City, NJ.

Louise Hummel, San Diego Chapter, is Faculty, California State University San Marcos, School of Nursing, San Marcos, Calif, and Staff Nurse, Emer- gency Department Scripps Memorial Hospital, La Jolla, Calif.

J Emerg Nurs 2008;34:576-7.


Copyright © 2008 by the Emergency Nurses Association.


576 JOURNAL OF EMERGENCY NURSING 34:6 December 2008http://dx.doi.org/10.1016/j.jen.2008.09.007

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