WOC nurses are recognized for their skills and expertise and are frequently called on to serve as consultants. This chapter presents an overview of consultation and its relevance to WOC nursing. The process of consultation and the characteristics and skills that consultants should have are presented. The chapter also discusses types of consultative roles, how to conduct consultations, how to establish and maintain a consultant role, ethics and legal implications of consulting, and considerations in contracting for services and reimbursement as a consultant.
The concept of consultation is often introduced in basic WOC nursing educational programs. During the educational process, the concepts of consultation are further defined and knowledge of the process is enhanced during the supervised experiences of the practicum. Consulting relationships can be either internal or external. An internal consultant is a member of the organization (ie, employee). An external consultant can be an independent contractor or self-employed from outside the organization. Consultants function in various roles, including patient advocate, technical specialist, educator, collaborator, researcher, process specialist, and subject or product expert (Dyck, 2002). There are many definitions of consultation including the art of influencing people at their request and providing assistance to the client to enable them to problem solve and manage their work, health, or psychosocial issues (Dyck, 2002). The concept of consultation is different from that of collaboration, comanagement, and referral. The key difference between these concepts is the degree of responsibility that the consultant assumes for the problem. Yet, in many instances, these terms are used interchangeably due to lack of clarity about the consultative process (Barron & White, 2005).
Care provided by multiple disciplines through the process of consultation can be complementary and beneficial to the patient. Consultants are often called on for their expertise in specific areas that may be outside of the primary provider's scope of practice. When making or responding to requests for consultation, the WOC nurse consultant should be mindful of situations or circumstances that affect a patient's ability to be compliant with the recommended care such as unemployment, lack of insurance, inability to afford medications, lack of transportation, inadequate caregivers, etc.
The health care delivery system is currently in the midst of change involving cultural and value shifts, economic constraints, and political mandates, which are creating a shift in the responsibility for care (Tomajan, 2012; Waters, 1998). With these changes, nurses are expected to provide professional leadership, education, and expert clinical practice. Consultation is viewed as an essential role component for WOC specialty nurses and advanced practice registered nurses (American Nurses Association, 2010; Wound, Ostomy and Continence Nurses [WOCN] Society, 2010). Advanced practice registered nurses have acquired the knowledge and practice experience to prepare themselves for specialization, expansion, and advancement in the practice of health care (Ellerbe & Regen, 2012; Robert Wood Johnson Foundation, 2012; Waters, 1998) and are expected to influence patients, other providers, and the systems in which they work.
It takes creativity and knowledge to be able to balance the demands of the consultant role (McSherry, Mudd, & Campbell, 2007). McSherry and colleagues conducted a small descriptive, qualitative study in Britain and found that some ambiguities existed regarding the nature, function, and value of the nurse consultant's role. Factors that influenced the role of the consultant included poorly defined roles, workload expectations and demands, the degree of support for the role, the role's impact on practice, and relationships with other staff, peers, and colleagues.
The process of consultation in nursing borrows from the consultative process that is practiced by business and other helping professions (Wilson, 2008). WOC nurse consulting is similar to nursing consultation in other areas such as psychiatric nursing, occupational health nursing, and legal nurse consulting. A key concept in the consultative process is that the consultant may be involved with the problem, but they do not “own” the problem or solution; the client (physician) owns the problem and makes the final decisions (Dyck, 2002). According to Dyck, consultation involves the following process:
The consultant must strive to establish a warm, respectful, and accepting relationship due to a potential sense of vulnerability on the part of the consulter. The consultant should communicate that the consulter's problem is important and worthy of consideration. During the process of consultation, self-awareness and interpersonal skills are essential. To be a successful consultant, the WOC nurse must first value himself or herself and the specialized body of knowledge and expertise that characterizes the specialty. More specifically, the WOC nurse consultant must be aware of his or her personal strengths, weaknesses, and motives. Additionally, a good consultant must be able to withhold judgment, avoid stereotyping, and see the issues realistically without prejudice (Barron & White, 2005). Dyck (2002) offers the following tips for consultants to follow:
Nursing consultation involves many nursing activities such as teaching, assessing and monitoring, evaluating outcomes, and developing policies and procedures (Wilson, 2008). When consulting, knowing the level of responsibility that is being requested from the consultant is important. Developing consultative skills allows the WOC nurse to utilize acquired expertise to enhance their colleagues' nursing practice. The consultant should utilize evidence-based recommendations and should act within established guidelines of practice. Recommendations should result in efficient use of products to provide cost-effective care.
It is helpful for the consultant to possess operational expertise, health care knowledge, and network capabilities. Frequently, the consultant works independently and without administrative support. The WOC nurse must be comfortable with the process of obtaining and interpreting data. Objective analysis of the data is essential to present a nonbiased recommendation to the client (Smeltzer, 2002). The consultant should also be aware of characteristics about the systems, relationships, and changes within the organization. These include but are not limited to the quality of relationships and interactions between patients and staff, time pressures, lack of adequate resources, organizational politics, power imbalances, and rapid or frequent systems changes during the consultative process (Barron & White, 2005).
Traits that are particularly desirable in a consultant include being optimistic, forward-looking, flexible, and adaptive (Waters, 1998). A summary of the characteristics and skills with associated behaviors or activities that are important for consultants to possess is given in Table 4.1.
| Characteristics/Skills | Behaviors/Activities |
|---|---|
| Interpersonal skills | 1. Listening 2. Assertiveness 3. Conflict management 4. Issue resolution 5. Support 6. Reassurance 7. Giving feedback |
| Business skills | 1. Strategic planning 2. Project management 3. Project evaluation 4. Cost and benefit analysis |
| Analytical skills | 1. Data gathering 2. Management 3. Analysis 4. Interpreting and reporting skills |
| Consulting skills | 1. Knowledge 2. Ability to use the process to adhere to professional ethics |
The role of the WOC nurse may involve both consultation and comanagement. It is important to understand which role is being sought when services are requested by another professional. In comanagement, both professionals manage different aspects of care, whereas, with true consultation, the recommendations of the consultant may or may not be instituted by the consulter. Knowledge of the purpose of the consultation and the goal or desired outcome anticipated from the consultation is essential.
The concept of consultation was first clarified by Gerald Caplan (1970), who is now thought to be the “father” of mental health consultation theory. Caplan defined 4 different types of consultation:
Consultations between fellow WOC nurses occur so that a WOC nurse can also be the consulter at times. Consultation between fellow WOC nurses offers the benefit of collegial networking, which has the potential to enhance knowledge, practice, and collaborative opportunities for all involved. In the role of the consulter, the WOC nurse must be able to identify and articulate the nature of the problem. The WOC nurse consultant provides a detailed assessment and evaluation along with recommendations to achieve the expected outcomes.
The WOC nurse specialist may provide formal, direct patient consultations or consult only with staff to assist with general problem-solving to enhance the patient's care. It is important for consultants to establish good working relationships with the staff nurses. If positive relationships are established, staff should perceive the consultant as approachable, respectful, and helpful so that they will initiate contact with the consultant when complex issues arise.
WOC nurse consultation at the request of physicians involves identifying the nature of the patient's problem, performing a detailed assessment, and thoroughly evaluating the problem. Recommendations are provided to the physician with expectations for outcomes. This type of consultation can result in a trusting relationship where the physician, confident in the WOC nurse's abilities and previous good patient outcomes, consults the nurse repeatedly for future patients with challenging WOC problems.
The consultative process begins with assessment of the problem for which the consultant's expertise is requested. It should include a review of the patient's records, interviews with staff, and direct assessment of the patient. The consultant must confirm that the problem falls within the consultant's expertise. The consultant also confirms that the consulter will remain clinically responsible for the patient.
The next step in the consultative process is to consider interventions. The consultant may intervene directly (ie, comanagement) or assist in the clinical decision-making process by providing alternative perspectives and recommending specific interventions. For example, more data might be required and further testing may be recommended by the WOC nurse consultant. If the consulter accepts the consultant's recommendations, a decision is made about carrying out the interventions and by whom. Also, a time frame for the consultant's service needs to be determined as to whether the consultation is only for one time or will be ongoing.
The WOC nurse consultant should document the consultation in a standard and easily retrievable form, which varies among different practice settings and institutions. The consultant should seek guidance about documentation forms/format from the facility's administration and/or medical records administrator.
Following the interventions, a review and evaluation of the care and confirmation of the patient's outcomes are performed. Reassessment is conducted as needed.
When initially developing the role as a consultant, the WOC nurse should establish priorities and identify alternative resources for the staff when the consultant is not available. Requests for consultations may increase as the services become more recognized and valued. To be successful as a consultant, it is very important to clarify when/how the WOC nurse is available and to respond in a timely fashion to referrals. The consultant should have backup resources for emergencies, and the consulter should know whom to contact in those situations.
For the established consultant, frustration can occur when the staff attempts to over utilize the consultant's services or refers patients for basic care that does not warrant the specialty nurse's services. To minimize unnecessary referrals, educational programs that address common needs and written guidelines, protocols, and sample care plans can be developed to share with consulters. A satisfying aspect of the consultant's role is seeing consulters grow and become more confident in managing problems. A primary goal of a consultant is for the consulter to manage future, similar problems independently. For example, after a consultation with a WOC nurse, the staff nurse in a subsequent situation is able to identify the presence of redness on a heel as a stage 1 pressure ulcer and initiate proper pressure redistribution and appropriate skin care. To enhance the learning and development of skills by consulter, discussion and evaluation of the consultation process are very important.
To determine the overall effectiveness of the consultation role, the WOC nurse needs to conduct an ongoing evaluation of the consultation services and processes. To assess the consultation role, a WOC nurse might consider the following questions:
The WOC nurse often works in collaboration with a physician. The establishment of a collaborative practice between a physician and a specialty nurse can improve quality, continuity, and cost-effectiveness of care (Waters, 1998). Collaboration is also believed to improve patient satisfaction, and personal and professional satisfaction for clinicians.
Collaboration involves 2 or more individuals interacting constructively and learning from each other to solve problems and accomplish goals, purposes, and outcomes. Good interpersonal skills and behaviors are important for successful collaboration in which responsibility and expertise are shared. Clinicians can derive many positive benefits from effective collaboration including improved communications, enhanced trust and respect, and avoidance of duplication or gaps in service, which can lead to improved patient outcomes.
Failure to communicate and collaborate has deleterious effects on patients and staff satisfaction and becomes a source of stress for nurses. Job satisfaction and staff's attitudes are negatively impacted when territoriality and competitiveness occur, and this usually causes a negative impact on patient care. WOC nurses, physicians, and other providers share a common purpose in providing good patient care. Each group has unique, complementary, and overlapping skills, which benefit patients. Comprehensive and complex care plans to meet patients' needs can be developed more effectively by combining the skill sets of various providers.
Clinical competence is also essential for successful collaboration. Clinicians must be able to rely on each other through mutual trust. A respect for each other's practice enhances shared decision making. Nurses must appreciate the knowledge, skills, and abilities that they bring to the table as valuable members of the health care team.
Another aspect of collaboration to consider is the use of “appropriate” humor to provide a setting that is positive and nonthreatening. Properly used and timed, humor can help decrease defensiveness, invite openness, relieve tension, and deflect anger. It can set the tone for trust and acceptance so that difficult situations can be reframed.
Consulting relationships should remain ethical and professional. Contractual/consultant arrangements can lead to areas of conflict from actual or perceived bias, concerns over undue influence or favoritism, access to insider knowledge, ethical concerns, etc. There are potential conflicts if a consultant has multiple contractual agreements with competitive organizations.
Also, ethical dilemmas occur if consultants mix professional and personal roles. “When nurse consultants blend a professional and nonprofessional relationship or assume professional roles that conflict, they have entered a multiple relationship in nursing consultation” (Wilson, 2008, p. 63). Personal involvement in the consulting relationship can be problematic, because the consultant can become overinvolved and unable to separate personal from professional issues. Blurring of boundaries and roles results in decreased efficacy of the consultation practice and can lead to exploitation or harm to the consulter and/or consultant. Particularly problematic relationships involve bartering for goods or services, accepting gifts, entering into a purely social relationship, or becoming emotionally or sexually involved with a consulter.
Additionally, there can be difficulties from serving in combined, dual roles such as a consultant and supervisor, which can interfere with the nurse consultant functioning effectively as a supervisor. The roles and responsibilities and relationships in a dual role can be blurred and confusing to subordinate employees who are also consulters (Wilson, 2008). To avoid potentially conflicting relationships, Wilson suggests that nurse consultants should:
Nurse consultants are expected to follow the Nursing Scope and Standards of Practice put forth by American Nurses Association (2010) and Wilson (2008). However, the standards and codes for implementing a consultant's role are not well defined. WOC nurses are expected to apply the code of ethics of the nursing profession and the standard for ethics presented in the Wound, Ostomy and Continence Nursing Scope & Standards of Practice (WOCN Society, 2010).
Although the consulter remains clinically responsible for the patient, WOC nurses are also responsible for their own practice related to the problem for which they were consulted. Responsibilities of the consultant include gathering accurate data about the problem, documentation of data, making reasonable recommendations, and giving competent and reliable advice. Consultants working in the same place where they are employed might be considered to have more accountability than a consultant from outside the organization.
WOC nurses within their organization may be expected to identify and follow through on urgent concerns and problematic situations for which outside consultants would not be responsible. Knowledge of the organizational structure and job responsibilities is important. Adherence to standards of practice for the WOC nursing specialty is vital. When making a direct patient consultation visit, documentation in the patient's record is appropriate and necessary. Assessment of the problem and recommendations should be clearly stated. When the patient is not seen directly, the WOC nurse should consider if documentation in the patient's chart is appropriate. If the consultation involves only education of the consulter in relation to a problem, documentation on the patient's chart is not necessary. For example, a staff nurse asks if a foam dressing is a good choice for a heavily draining leg wound and the consultant only provides information about the dressing to the nurse and does not see the patient.
Consultants should maintain their own records of their consultations, outlining the issues, assessment data, and recommendations (maintaining compliance with the Health Insurance Portability and Accountability Act of 1996). When an informal consultation seems inadequate for the problem (ie, if in the previous example, the patient also had multiple draining leg ulcers with odor, pain, and infection and was admitted for cellulitis), advise the consulter that more information is needed and suggest that a formal consult be done.
The increased responsibilities of the WOC nurse also bring increased liabilities, and specialists may be held to higher standards than generalist nurses. If the consultant finds that the patient is in a dangerous situation and at risk for harm, but the consulter is unable or unwilling to intervene, the consultant should then follow the organization's process for assuring that the patient's safety needs are met (eg, reporting up the chain of command to a supervisor, director, or chief of the service that requested the consultation). Additional information about legal implications for WOC nurses is included in Chapter 3.
Due to the increase in health care lawsuits, especially those in cases related to skin and wound care, the WOC nurse/certified wound care nurse has increased opportunities to participate in the legal process. Determination of the merits of a potential lawsuit requires a complete review of the medical records, conferences with lawyers, possible depositions, and testifying in court (Milazzo, 2007a). As an expert witness, the WOC nurse/certified wound care nurse will be asked to speak to deviations from the standard of care related to prevention and care of wounds and pressure ulcers. While these activities may be required of any nurse, if the WOC nurse's employer is involved in a lawsuit or he or she is serving as a legal consultant or expert witness, the WOC nurse needs to have the following information in place (Milazzo, 2007b):
When seeking to work as an outside or independent consultant, a written contract should be drafted. An employment contract helps identify parameters of the position and should include a clause for ending the professional relationship. The goal of the contract is to protect the WOC nurse by outlining the specific expectations, objectives, and the nature of relationship. The nurse must always follow certification/licensing requirements in the specialty area of practice and in the state where he or she practices, respectively. Elements that should be clarified and addressed in the written contract include the following (Dyck, 2002):
WOC nurses often consult in the institution where they are employed as part of their role expectation. Consultation might be a daily activity for many WOC nurses and in some cases issues and questions regarding reimbursement arise. The WOCN Society has developed some informational documents regarding reimbursement for services that are available to members (Member Library, http://www.wocn.org/MemberLibrary, Public Policy section), including the following:
Other revenue-generating activities can be developed to increase awareness of a WOC nurse's services and exposure to the WOC nurse consultant. These activities could include speaking engagements for educational activities, or the development of informational tapes and books about topics that are relevant to WOC issues/needs. Exchanging consultative services with another network of providers is another option to gain exposure and access to opportunities for increased reimbursement.
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Barron, A., & White, P. A. (2005). Consultation. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach (3rd ed., pp. 225–255). St. Louis, MO: Elsevier Saunders.
Caplan, G. (1970). The theory and practice of mental health consultation. New York, NY: Basic Books.
Dyck, D. (2002). Internal and external consulting. American Association of Occupational Health Nurses, 50(3), 111–119.
Ellerbe, S., & Regen, D. (2012). Responding to health care reform by addressing the Institute of Medicine report on the future of nursing. Nursing Administration Quarterly, 36(3), 210–216. doi:10.1097/NAQ.0b013e318258bfa7
McSherry, R., Mudd, D., & Campbell, S. (2007). Evaluating the perceived role of the nurse consultant through the lived experience of healthcare professionals. Journal of Clinical Nursing, 17(10), 2066–2080. doi:10.1111/j.1365-2702.2006.01594.x
Milazzo, V. (2007a). The role of the nurse as a testifying expert. In Core curriculum for legal nurse consulting (Module 13, pp. 381–406). Houston, TX: Vickie Milazzo Institute.
Milazzo, V. (2007b). Business development principles. In Core curriculum for legal nurse consulting (Module 19, pp. 573–595). Houston, TX: Vickie Milazzo Institute.
Robert Wood Johnson Foundation. (2012). Implementing the IOM future of nursing report—Part III: How nurses are solving some of primary care's most pressing challenges. Retrieved March 2013 from http://www.rwjf.org/en/research-publications/find-rwjf-research/2009/01/charting-nursings-future-archives/issue-18-implementing-the-iom-future-of-nursing-reportpart-iii.html
Smeltzer, C. H. (2002). Can I be a healthcare consultant? The Journal of Nursing Administration, 32(1), 12–14.
Tomajan, K. (2012). Advocating for nurses and nursing. Online Journal of Issues in Nursing, 17(1). Retrieved March 2013 from http://www.nursingworld.org/OJIN. doi:10.3912/OJIN.Vol17No01Man04
Waters, T. (1998). The role of the nurse practitioner in the gastroenterology setting. Gastroenterology Nursing, 21(5), 198–206.
Wilson, D. W. (2008). Multiple relationships in nursing consultation. Nursing Forum, 43(2), 63–71. doi:10.1111/j.1744-6198.2008.00097
Wound, Ostomy and Continence Nurses Society. (2010). Wound, ostomy and continence nursing scope & standards of practice. Mt. Laurel, NJ: Author.