Chapter 1: Design and Implementation of WOC Nursing Specialty Roles

WOC Nursing Specialty Roles and Scope of Practice

WOC specialty nurses (hereafter, referred to as WOC nurses or nurse) strive to advance health care and quality of life for individuals affected with WOC concerns through the application of nursing science and practice. When designing and implementing a WOC nurse role, it is important to incorporate the foundational principles of WOC nursing practice. According to the Wound, Ostomy and Continence Nurses (WOCN) Society (2010), the theoretical principles that guide WOC nursing practice are as follows:

• Principles of self-care.
• Self-efficacy.
• Change.
• Growth and development.
• Adult learning.
• Health promotion.

WOC nurses influence patient care both directly and indirectly across the lifespan of individuals and the spectrum of health care. They provide expertise in health care services for prevention, health maintenance, therapeutic intervention, and rehabilitative nursing care. The value of the WOC nurse's role is demonstrated by the achievement of positive patient outcomes, which is based on a comprehensive risk assessment, effective prevention and treatment strategies, and patient and staff education.

This chapter describes the primary roles, specialized skills, and functions that characterize WOC nursing. Additionally, the standards of practice for WOC nursing and role implementation issues are addressed.

Role Components

While it may be desirable to implement a WOC nursing role that encompass all aspects of WOC nursing, limitations in practice might be necessary. To implement the WOC nurse's role and determine the type and level of services to provide, the nurse should consider the following factors:

• The type and number of patients in the population.
• The staff's competence in the required care.
• The time available/allocated for the role (eg, full- or part-time position).

Defining roles

WOC nurses serve in a variety of roles. The primary roles for a WOC nurse include direct patient care provider, educator, consultant, researcher, and administrator (WOCN Society, 2010).

Direct patient care provider

A WOC nurse provides a significant amount of direct care, particularly for patients needing specialty and/or complex care (eg, patients with new stomas or fistulae), because it is not feasible to maintain competency of an entire staff for such care. As a direct care provider, the WOC nurse uses the nursing process to assess, diagnose, identify outcomes, plan, implement, and evaluate care for patients (see Appendix A). The WOC nurse must adapt the process to complement the developmental age of patients/clients and their caregivers.

Educator

A WOC nurse affects patient care by providing direct patient/caregiver education and educating other nonspecialty nurses and staff involved in caring for patients with specialized WOC needs (see Appendix A). Staff education can be provided in various ways such as the following:

• Orientation.
• On-the-job training.
• In-service education.
• Protocol development.
• Guideline development.

WOC nurses may also serve as educators in academia or other organized continuing education programs, focusing on 1 or more aspects of WOC care. Others might be faculty or clinical preceptors for a WOCN-accredited WOC nursing education program (WOCNEP). WOCNEPs can be provided in formal academic settings (eg, undergraduate or graduate programs) or can be stand-alone continuing education programs. WOCNEPs offer specialty education in 1 or more areas of the scope of WOC nursing practice.

Consultant/clinical expert

The WOC nurse can serve in the role of a consultant/clinical expert in his or her employing facility or can establish a private practice and be paid as an independent consultant, according to the terms of a contractual agreement (see Appendices B and C). Implementation of a consultant/clinical expert role is appropriate when a large number of patients require a specific type of care (eg, management of full-/partial-thickness wounds or uncomplicated pressure ulcers) and the staff has developed a level of competence and confidence in following up and providing the care. In this role, the WOC nurse partners with both the patient and other members of the health care team to coordinate individualized care that is based on the following:

• Assessment of the needs of the individual.
• Current best practice.
• Ongoing evaluation.

To maximize the effectiveness of the consultant/clinical expert role, specific guidelines should be established to clarify the responsibilities of the WOC nurse and the staff for the delivery of care and the ongoing evaluation and follow-up of the patient.

As a consultant/clinical expert, the WOC nurse might also be responsible for coordinating care for the patient population. Key considerations in planning care for specific patient populations would include the following:

• Identification of trends.
• Development of standardized treatment and prevention plans.
• Refinement of the plans based on outcomes.

Collaboration with other health care providers and groups is also an essential part of the WOC nurse consultant's role. When working in a collaborative role, the WOC nurse has the potential to increase the pool of knowledge, provide a broader perspective about problems or issues, and suggest a comprehensive solution to improve the overall quality of care (WOCN Society, 2010).

Researcher

WOC researchers are in all areas of practice including academia and industry and in direct patient care settings. The focus of the researcher's role is on the advancement of the science and/or art of WOC care. At the clinical level, the WOC nurse strives to incorporate evidence-based practice utilizing current research.

Administrator

The role of an administrator includes duties and responsibilities for management and oversight of clinical staff and services across a broad spectrum of care. WOC nurses might have both clinical and administrative responsibilities, and the specific expectations and time commitment for each role should be clearly identified.

Dual roles

A WOC nurse may be asked to assume more than 1 role (eg, WOC nurse and patient educator, WOC nurse and case manager). To minimize role confusion and the potential for overload and burnout, the WOC nurse must determine his or her supervisor's expectations for each role, and the duties and responsibilities for each role must be clearly defined and agreed upon in advance. Also, the WOC nurse must clearly delineate to the staff what the WOC nurse's specific responsibilities are and the time available for each role component.

WOC Nurse Specialized Skills and Role Functions

WOC nurses have the specific background and educational preparation to manage patients with complex WOC needs. Common wound care problems managed by WOC nurses are pressure ulcers, vascular ulcers, neuropathic ulcers, draining wounds, traumatic wounds, and surgical wounds. Ostomy management includes care of patients with fecal and urinary diversions, fistulas, and percutaneous tubes. Urinary and fecal continence issues managed by WOC nurses include muscle or nerve dysfunction, congenital abnormalities, infection, surgery, sphincter deficiencies, and psychological disorders. Table 1.1 provides an overview of WOC nurses' specialized skills and functions for managing common WOC issues (WOCN Society, 2010).

Resource management

WOC nurses play important roles in managing resources to facilitate the delivery of cost-effective care and improved regulatory compliance (eg, establishing documentation standards and/or quality outcome measures) by the following activities (WOCN Society, 2010):

• Developing a formulary for supply management.
• Developing protocols for cost-effective resource utilization.
• Using proactive risk management strategies.
• Preventing complications and reducing recidivism.
• Improving continuity and coordination of care across settings.
• Increasing staff productivity.
• Developing new revenue-producing programs.
• Enhancing patient satisfaction and loyalty.
• Advocating for supply and service reimbursement.
• Establishing documentation standards.
• Developing and educating the staff about standard protocols and quality outcome measures.

Standards of Practice

All roles that are developed and implemented by the WOC nurse should be in accordance with the scope and standards of practice as defined by the WOCN Society. The following standards of practice were recognized by the American Nurses Association in their endorsement of WOC nursing as a specialty (WOCN Society, 2010):

• Standard 1. Assessment: The WOC nurse collects comprehensive data pertinent to the patient's health or the situation.
• Standard 2. Diagnosis: The WOC nurse analyzes the assessment data to determine the diagnoses or issues.
• Standard 3. Outcomes Identification: The WOC nurse identifies expected outcomes for a plan individualized to the patient or the situation.
• Standard 4. Planning: The WOC nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
• Standard 5. Implementation: The WOC nurse implements the identified plan.
• Standard 5A. Coordination of Care: The WOC nurse coordinates care delivery.
• Standard 5B. Health Teaching and Health Promotion: The WOC nurse employs strategies to promote health and a safe environment.
• Standard 5C. Consultation: The WOC nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.
• Standard 5D. Prescriptive Authority and Treatment: The advanced practice WOC nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
• Standard 6. Evaluation: The WOC nurse evaluates progress toward attainment of outcomes.
• Standard 7. Quality of Practice: The WOC nurse systematically enhances the quality and effectiveness of WOC nursing.
• Standard 8. Education: The WOC nurse attains knowledge and competency that reflects current nursing practice.
• Standard 9. Professional Practice Evaluation: The WOC nurse evaluates one's own nursing practice in relation to professional standards and guidelines, relevant statutes, rules, and regulations.
• Standard 10. Collegiality: The WOC nurse interacts with and contributes to the professional development of peers and colleagues.
• Standard 11. Collaboration: The WOC nurse collaborates with the patient, family, and others in the conduct of nursing practice.
• Standard 12. Ethics: The WOC nurse integrates ethical provisions in all areas of practice.
• Standard 13. Research: The WOC nurse integrates research findings into practice.
• Standard 14. Resource Utilization: The WOC nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.
• Standard 15. Leadership: The WOC nurse provides leadership in the professional practice setting and the profession.
• Standard 16. Advocacy: The WOC nurse advocates for the patient with WOC care needs.

The Wound, Ostomy and Continence Nursing Scope & Standards of Practice (2010) is a valuable resource for every WOC nurse and is available from the WOCN Bookstore (http://www.wocn.org/Bookstore). To facilitate the application of the scope and standards of practice, the WOCN Society developed a white paper that clarifies the roles of WOC nurses and advanced practice WOC nurses and provides examples of how WOC nurses can apply the standards in their own settings (WOCN Society, 2012). The document also addresses how the scope and standards relate to achieving positive patient outcomes. The white paper, Scope and Standards for Wound, Ostomy and Continence Specialty Practice Nursing: A White Paper from the WOCN Society, is available on the Society's Web site in the Members Library at http://www.wocn.org/MemberLibary.

Role Implementation Issues

Implementation of the WOC nurse's role requires ongoing assessment and reevaluation. Setting and prioritizing realistic short-term and long-term goals are vital to the evolution of the role. There are several areas to address in implementing a new WOC nurse role including establishing an effective mechanism for referrals and ensuring that patients have appropriate materials and supplies to meet their care needs. It is necessary for the WOC nurse to develop/maintain an effective record-keeping system and current policies and procedures. Also, establishing teams or task forces to help plan and implement care can be beneficial to the WOC nurse.

WOC nurse referrals

It is important to establish an effective referral mechanism and educate the staff about the referral process. In an acute care or extended care setting, the referral process is usually fairly straightforward. The staff can page the WOC nurse or use the voice mail or e-mail system to leave a message. Referrals can be initiated by a staff or a physician. In a home health care setting, the referral process can be challenging. When a WOC nurse is covering several offices, a fixed rotational schedule can be established (eg, consults from office A on Tuesdays, from office B on Fridays). Procedures about the referral process must be established and communicated to the staff and patients and their families including the following specific information:

• When/what types of patients/problems to refer (ie, indications for referral).
• How to refer (eg, who to call, preferred method of contact [e-mail, fax, phone], forms to use). A simple 1-page referral form can be developed to record information about the reason(s) for requesting the consultation, the current management of the problem, specific concerns/issues, and other related data.
• What to expect after the referral is made (eg, time required for a response to the referral, type of response [telephone call or in-person visit], the WOC nurse's responsibilities vs the staff nurse's responsibilities).

Patient education materials

An important component of the WOC nurse's role is overseeing the development of patient education materials, and there are several options, which will be guided by each institution's protocols and requirements. The options for obtaining or developing patient education materials include the following:

• Developing institution-based teaching literature.
• Adopting existing industry-sponsored teaching literature.
• Adopting existing literature that is provided as part of an electronic medical record system.

When deciding on whether to develop or adopt existing literature, several factors must be considered such as:

• The accuracy, consistency, and level of evidence of the information provided.
• How well the literature meets the needs of the patient population being served.
• The literacy level of the information presented.

The Agency for Health care Research and Quality has published a toolkit to assist health care providers to structure the delivery of care and communications as if all patients have a low level of literacy (DeWalt et al., 2010). Included in the toolkit are resources and guidelines to develop easy-to-read tools and to assess existing patient teaching literature. The complete document is available at http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf. The Centers for Disease Control and Prevention (2010) also offers guidelines for creating simple and easy-to-understand educational materials that are available at http://www.cdc.gov/healthliteracy/pdf/simply_put.pdf.

To assess the reading level of patient educational materials, a simple process should be used. A few tips for developing and reviewing educational materials for readability and assessing the reading level are presented in Table 1.2.