WOCN Looks to the Future
The year 2000 was a milestone year and an opportunity for the Wound, Ostomy and Continence Nurses (WOCN) Society to take note of how far they had come, to anticipate the needs of the future, and to anticipate what role they foresee for themselves in the future. JWOCN's January 2000 issue was no exception. In its 40 years of existence, WOC nursing has evolved from a specialty founded by several key surgeons and persons living with an ostomy seeking better care for all ostomates, to a specialty nursing practice exploring the idea of moving toward advanced practice nursing.
Specialty Versus Advanced Nursing Practice
Specialty practice nursing requires concentration in a selected clinical area within the broader field of nursing. Early specialization involved primarily on-the-job training or hospital-based training courses, and many nurses continue to develop specialty skills through practice experiences and continuing education. Specialty nursing practice emerged in response to changes in health care and the increased need for knowledge within an area of patient care.1 According to Beitz2 the optimal educational preparation for specialty practice nursing varies. All forms of specialty nursing require at least an RN, but the initial educational training may vary from diploma to baccalaureate degree, and the standards of specialty practice are usually defined by the professional association for that specialty area.
The advanced practice registered nurse (APRN) holds a master's or doctoral degree, concentrating in a specific area of advanced nursing practice.3 The American Nurses Association's (ANA's) Scope and Standards of Advanced Practice Registered Nursing states that APRNs manifest a high level of expertise in the assessment, diagnosis, and treatment of the complex responses of individuals, families, or communities to actual or potential health problems, prevention of illness and injury, maintenance of wellness, and provision of comfort. Since the Budget Reconciliation Act of 1997, APRNs can obtain a provider number and direct reimbursement from Medicare. In addition, APRNs enjoy a more autonomous and visible practice compared with their specialty practice colleagues. This autonomy includes regulatory recognition for expanded activities such as prescriptive authority and reimbursement.1 This autonomy also provides a variety of opportunities for advanced practice WOC nurses today, and in the future.
WOCN's Progress Toward Advanced Practice
Salyer and Hamrick4 describe 3 stages in the evolution from specialty practice nursing to advanced practice nursing. Stage I is characterized by development of the specialty practice itself. In the 1960s, the first enterostomal therapists (ET) responded to increasing complexity in the needs of patients following fecal or urinary diversion surgery and new technology available. Most received on-the-job training, and initially, they were not exclusively nurses. Stage II of this evolution occurs as the specialty organizes and specific training develops, progressing to certificate training. Specialty organizations form, certification examinations develop, and writings appear about the role of the nurse within the specialty. In 1979, board certification for ET nursing became available, and by 1983 bachelor's preparation was required for certification as an ET nurse. Simultaneously, the focus expanded from care of the patient with an ostomy to include care of patients with chronic wounds and urinary or fecal incontinence.
The initial phase of stage III is characterized by the evolution to advanced practice. The specialty's knowledge base grows, and its scope of practice expands. Typically, leaders within the specialty practice advocate transition to graduate education and standardized practice within the specialty. Advanced Practice Nurses (APNs) migrate to the specialty, and articles appear differentiating APN roles in the specialty. This best describes where WOC nursing is as we move into the 21st century. Because WOC nursing practice already encompasses many core competencies of advanced practice nursing, such as direct clinical practice, expert guidance and coaching, consultation, and collaboration, the movement toward advanced practice can be viewed as a natural progression of our specialty. In addition, increased expectations for research necessitate that WOC nurses obtain research skills learned in graduate-level coursework. As a result of these factors and the expanding opportunities for advanced practice for every nurse, WOC educational preparation has progressed to graduate-level coursework and multiple programs have mechanisms allowing nurses to obtain WOC certification and advanced practice credentials concurrently.4
AACN's Look to the Future
The American Association of Colleges of Nursing (AACN) also had a watershed moment looking at the uniqueness of advanced practice nursing today and where it is going in the future. In October 24, 2004, AACN adopted a position that accepted the doctor of nursing practice as the highest level of preparation for clinical practice. At that time, AACN member institutions voted to move the educational level of preparation for advanced practice nursing from a master's to doctoral degree by the year 2015.5 The AACN articulated multiple benefits associated with such a move, which are outlined at the end of this article.
The Changing Demands of the Nation's Complex Health Care Environment
Americans are growing older, and adults aged 65 years and older are the fastest-growing segment of the US population.6 Their numbers will increase from 35 million in 1999 to 40 million in 2010. The average life expectancy has increased by 30 years in the last century; it is expected to be 81 years for women and 76 years for men who reach age 65 by the year 2010.
According to the Institute for the Future, a research firm that has been forecasting the future of health and health care since 1985, baby boomers (Americans born between 1946 and 1964) will inevitably transform the health care system as it adapts to their expectations and preferences.6 The institute predicts that boomers' involvement in their own care will be distinctly different from past generations of older Americans. They will accelerate the movement and awareness of self-care and wellness and will irreversibly alter the traditional doctor-patient relationship.
The Institute for the Future6 also predicts that the number of people receiving health insurance from employers will diminish. The number of uninsured is expected to rise from 43 million in 2002 to 48 million in 2010. Medicaid is expected to grow from 28 million members in 2002 to 34 million by 2010, and the Medicare population is expected to grow from 38 million to 49 million by 2010.
Hospitals have experienced and are likely to continue to experience a decrease in the number of in-patient beds, and in-patient stays continue to decrease in length. Home health, long-term care facilities, and ambulatory care will continue to increase, and care will grow more complicated at these levels. Telehealth technologies, monitoring patients at home using sensor devices, is anticipated to have a larger impact in the future.
Disease management, managing and establishing routines for the care of the chronically ill with the expectation that this will save money, is expected to substitute preventative maintenance for adverse acute needs. Pay for performance and other outcome-based systems are expected to be implemented soon in home health settings, and, in the future, reward health care providers for keeping people healthy and preventing acute episodes. One goal of the US Department of Health and Human Services is to increase the proportion of health professional training schools whose basic curriculum includes competencies for health promotion and disease prevention.7
How Will APNs Fit Into the Reforming Health Care System?
APRNs must be prepared for both the considerable opportunities and significant threats created by these sweeping changes in health care delivery. We are challenged by a health care system that increasingly demands both effective prevention and ongoing management of chronic diseases. Pressures on the US health care system and greater focus on health promotion and prevention have opened up and will continue to create opportunities for APRNs.8
According to AACN, the growing complexity of health care, burgeoning growth in scientific knowledge, and increasing sophistication of technology have necessitated master's degree programs that prepare APNs to expand the number of didactic and clinical hours far beyond the requirements of master's education in virtually any other field. Furthermore, even with the additional requirements, practicing nurse practitioners (NPs) identify content areas, including practice management, health policy, use of information technology, risk management, evaluation of evidence, and advanced diagnosis and management in which they perceive the need for additional training.5 The DNP is AACN's response to the changing needs of the US health care system to produce a health provider who can adapt best to promoting high-quality, cost-effective care.
A WOC nurse with a DNP, in addition to having the advantages of the advanced practice role, could also profit from benefits specific to DNP education. By acquiring the advanced competencies needed to fulfill the increasingly complex clinical, faculty, and leadership roles within health care, they will be better prepared to provide both direct and indirect health care to patients coping with an increasingly more complicated healthcare delivery system. In addition, he or she will also have the ability to serve as graduate-level clinical educators and further encourage the growth of WOC-certified APRNs.
What Would a WOC-DNP Do?
To answer this question, I wish to describe the fictitious but realistic case of Norma Nightingale, a WOC-DNP. Norma has positioned herself well to adjust to changes in the future of health care and is considered a leader in her field. She has her own wound, ostomy, and continence clinic within her community. Her goal is to provide state-of-the-art, cost-effective care to her patients, with a focus on prevention to high-risk clients. She sees patients regardless of their ability to pay, and often they qualify for reduced fees using community health grant funds that she requests yearly.
Norma has authored a small book titled Wound Care Myths and What Your Doctor May Not Know About Wound Care. It is written for the layperson in 5th-grade language using many illustrations to teach signs to report, and simple things people can do at home to care for their skin and wounds. Citing a study from 2006, she teaches her patients how to prepare normal saline using a jug of distilled water and ordinary table salt.9 She is constantly on the lookout for low-cost, effective solutions for wound, ostomy, and continence care for her clientele.
According to the Institute of Medicine,10 it now takes an average of 17 years for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven. An important part of Norma's practice is using the latest, tested, evidenced-based techniques and applying them to her patients. In addition to reading the latest and most pertinent journals to her practice, Norma is active in her local WOCN chapter and regularly attends conferences where she learns about the latest in wound, ostomy, and continence care to bring to her practice.
The Institute of Medicine states that information technology, including the Internet, holds enormous potential for transforming the health care delivery system.10 Taking advantage of technology, Norma has a secure Web site where patients and their caregivers can remain involved in their care. Patients in Dr Nightingale's practice and their caregivers can access their records over the Internet via a secure password and look at pictures of their wounds and stomas. They can upload additional pictures to their records for Dr Nightingale to evaluate and e-mail her with any questions or concerns. Based on knowledge that baby boomers prefer to be more involved in their own care,6 Norma ensures that her Web page enables both her patients and their caregivers to enjoy maximal access to her while providing self-management knowledge and skills that are easy to understand and apply. As a result, she can achieve good outcomes with lower utilization costs since her patients typically require fewer office visits.
By using information technology, Norma is able to quickly send medical records to consulting surgeons, primary care practitioners, dieticians, naturopaths, and other practitioners to effectively and efficiently provide quality care for her patients. She also sends prescriptions for prescription medications, wound care, and ostomy products to pharmacies using electronic communication. Norma's practice has blossomed since it started. Using technology and cost-effective solutions, she has found that she can provide the best balance of personal one-on-one care for her patients while keeping visit frequency low.
Anxiety and the Prospect of Change
Even though WOC nursing's evolution toward advanced practice nursing and AACN's decision about DNP by 2015 may appear to be a quantum leap in education for the WOC specialty practice nurse, it is not. WOC specialty nursing practice already encompasses many core competencies of advanced practice nursing. In addition, doctoral practice would provide a better match of a degree with the hours required to attain it, bringing parity with other health professions such as physical therapy who have already moved to a similar educational structure. Doctoral preparation will further strengthen the WOC nurse's independence to practice and ultimately improve patient outcomes. Nursing schools throughout the United States are moving to make DNP education a reality; now is the time to design your preferable future and to support a preferable future for all WOC nurses and their patients.
AACN-Cited Benefits of Practice-Focused Doctoral Programs5
* Development of needed advanced competencies for increasingly complex clinical, faculty, and leadership roles;
* Enhanced knowledge to improve nursing practice and patient outcomes;
* Enhanced leadership skills to strengthen practice and health care delivery;
* Better match of program requirements and credits and time with the credential earned;
* Provision of an advanced educational credential for those who require advanced practice knowledge but do not need or want a strong research focus (eg, clinical faculty);
* Parity with other health professions, most of which have a doctorate as the credential required for practice;
* Enhanced ability to attract individuals to nursing from nonnursing backgrounds;
* Increased supply of faculty for clinical instruction;
* Improved image of nursing.
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