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:
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.
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:
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).
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.
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:
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.
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:
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:
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).
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.
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.
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 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).
| Wound Management | Ostomy Management | Continence Management |
|---|---|---|
|
|
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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):
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):
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.
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.
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:
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:
When deciding on whether to develop or adopt existing literature, several factors must be considered such as:
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.
| Guidelines for Development or Review of Educational Materials (WOCN Society, 2005, p. 5) |
|---|
| 1. Keep the layout simple. Avoid presenting multiple ideas or concepts on 1 page. |
| 2. Use large print (at least 14-point type). Use a solid. Use dark black ink on matte white paper. |
| 3. Use simple illustrations that reinforce the message. |
| 4. Use simple language. A fifth- or sixth-grade reading level is recommended for the general population. |
| 5. Use specialized software or the McLaughlin SMOG Readability Formula to determine the reading level (Hedman, 2008). |
| The SMOG Formula for Determining Reading Level |
| 1. Select 10 sentences toward the beginning, 10 sentences in the middle, and 10 sentences toward the end of the material. |
| 2. Count the total number of words having ≥3 syllables in the 30 sample sentences. |
| 3. Calculate the nearest perfect square of the number of polysyllabic words. |
| 4. Add a constant of 3 to obtain the reading level. |
| Example: If the total number of polysyllabic words is 36, the square root is 6. When 3 is added to 6, a reading level of 9 is obtained. |
| Guidelines for Keeping the Reading Level Low |
| 1. Use short, simple sentences. |
| 2. Use 1- or 2-syllable words. |
| 3. Express only one idea in each sentence. |
| 4. Use the second person (ie, you). |
It is part of the WOC nurse's role to remain abreast of new developments and trends in product development unique to the practice setting. When considering development or evaluation of a supply formulary, the WOC nurse considers several criteria for the products such as safety, effectiveness, availability, cost and benefit, patient preference, and the impact on practice (WOCN Society, 2010).
A record-keeping system is essential to provide a record of the WOC nurse's time and efforts and to document the services provided to patients and the staff. In addition, a comprehensive record-keeping system can provide data to answer important questions that might arise in role and employment negotiations with a superior such as the following: How does the WOC nurse's role contribute to the goals of the organization, and how does the WOC nurse's role contribute to positive patient outcomes and cost-effective care?
An effective record-keeping system contains several components or types of information:
To establish a record-keeping system, it is advisable for the WOC nurse to consider the following actions:
In addition to other duties and role functions, a WOC nurse is responsible for reviewing and revising policies and procedures related to WOC disorders. Policies and procedures should be kept current and consistent with national guidelines for facility accreditation/certification, reimbursement requirements, and current best practices.
WOC nurse should establish appropriate task forces and nurse resource groups to help with planning, developing, and implementing programs and procedures/protocols to optimize patient care and outcomes (eg, prevention and management of skin breakdown; guidelines for ostomy and continence care). Involving other staff in teams or task forces is an effective strategy for developing staff and extending the impact of a WOC nurse's role.
Career development is the planning and implementation of career plans and involves both the individual and the employer. Employers as well as individual nurses recognize and benefit from career development programs. Career development promotes nurse empowerment and may include self-appraisal, clinical ladder programs, tuition reimbursement, and educational leave (Marquis & Huston, 2006). Supporting career development programs can be justified for organizations because the programs:
The WOC nurse can shape and define his or her role within the organization by participating in construction or revision of position descriptions and performance appraisal forms. A position description is a working tool that describes the requirements for a specific position (eg, educational background, clinical experience, leadership experience, and board certification) and the expected performance standards for the position. Most organizations have a standard format for position descriptions. It is essential that a description of a WOC nurse's position accurately reflect the types of patients seen, the level of involvement with each type of patient, the setting in which care will be provided, and the professional responsibilities. Also, it is important that the duties and responsibilities in a position description are consistent with state board of nursing licensing requirements in the state(s) in which the nurse practices.
A performance appraisal form is developed from a position description. The performance appraisal form lists activities that demonstrate accomplishment of the specific expectations in the position description, including organizational, departmental, and/or individual goals. The position description and performance appraisal forms should be congruent.
Sample position descriptions and performance appraisal forms are provided in Appendices A to N, which can be adapted to meet individual needs or to meet a specific employer or institution's requirements (WOCN Society, 2005). Appendices A to L provide position descriptions for nurses in varied roles and settings such as WOC nurse in a hospital/acute care setting, WOC nurse consultant/clinical expert in a hospital/acute care setting, WOC nurse consultant/clinical expert in home health care, WOC nurse clinical nurse specialist, WOC nurse practitioner in adult health, WOC nurse in independent practice, WOC nurse in industry, certified wound care nurse, certified ostomy care nurse, certified continence care nurse, certified foot care nurse, and wound treatment associate. Sample performance appraisals for a WOC nurse in acute care and a nurse practitioner are provided in Appendices M and N, respectively.
These sample position descriptions and appraisal forms are not intended to be all inclusive but are representative of information that might be included. The forms can be modified and adapted to fit other roles and settings (eg, extended care, ambulatory care, palliative care).
Centers for Disease Control and Prevention. (2010). Simply put: A guide for creating easy-to-understand materials. Retrieved October 2012 from http://www.cdc.gov/healthliteracy/pdf/simply_put.pdf
DeWalt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K. A., Hink, A., Rudd, R., & Brach, C. (2010). Health literacy universal precautions toolkit (AHRQ Publication No. 10-0046-EF). Rockville, MD: Agency for Health Care Research and Quality. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research. The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) Retrieved October 2012 from http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf
Hedman, A. S. (2008). Using the SMOG formula to revise a health-related document. American Journal of Health Education, 39(1), 61–64.
Marquis, B., & Huston, C. (2006). Leadership roles and management functions in nursing: Theory and application. In E. Nieginski & H. Kogut (Eds.), Career development (pp. 246–251). Philadelphia, PA: Lippincott Williams & Wilkins
Wound, Ostomy and Continence Nurses Society. (2005). Wound, Ostomy and Continence Nurses Society professional practice manual. Mt. Laurel, NJ: Author.
Wound, Ostomy and Continence Nurses Society. (2010). Wound, ostomy and continence nursing scope & standards of practice. Mt. Laurel, NJ: Author.
Wound, Ostomy and Continence Nurses Society. (2012). Scope and standards for wound, ostomy and continence specialty practice nursing: A white paper from the WOCN Society. Mt. Laurel, NJ: Author.