My Scope of Practice: Getting Patients on Board With Care

“The only source of knowledge is experience.” — Albert Einstein

Mary Haddow, RN, CWCN, has deemed herself a poster child for delicate, at-risk skin. “As an Irish-Catholic redhead, I have struggled with managing delicate, at-risk skin all of my life,” she says. “Self-preservation was and remains an underlying motivator for why I decided to focus on wound care.”   Despite her concern regarding her skin, Mary didn’t step into the role of nurse until later in life. After taking a pause in her college education to be a stay-at-home mom, Mary started a home-based business using her sewing skills with a focus on custom work that kept her busy until the age of 40. At that point, she returned to college to pursue a career as a nurse. She earned her Associates in Arts degree in nursing from Montgomery College (Rockville, MD) in 1994, became certified in Gerontological Nursing in 1997, and became a Certified Wound Care Nurse in 1998. Since then, her experience has spanned the healthcare continuum. She has worked in long-term care, as a clinical educator for a pharmaceutical company, and as a home health wound care nurse. For the last decade, she has been in primary care. As an active member of the Association for the Advancement of Wound Care — the AAWC — as well as the Wound Ostomy and Continence Nurses Society — the WOCN, Mary is a frequent attendee of the Symposium on Advanced Wound Care as well as local and regional WOCN educational conferences. “Being a ‘conference junkie’ may not sound interesting or exciting,” Mary says. “But that is where the education, contacts, networking and ever-so-important time in the exhibit halls happen.”

Caring for frail, elderly patients underscored Mary’s recognition of the need for aggressive preventive care across the continuum. “The adage ‘an ounce of prevention’ cannot be underestimated or ignored, especially where skin is involved,” Mary says. “I want to be ahead of the curve, preventing rather than dealing with wounds, but also be able to competently deal with the inevitable wounds that occur for a variety of reasons.”

Treating wounds can sometimes be difficult because of the number of extenuating factors that influence wound care, such as money. “It is necessary to be creative, inventive, and fiscally responsible in wound care, but there is a difference between frugal and cheap,” Mary says. “There is no comparison between buying the least expensive product and buying the most affordable product that will provide the features necessary to achieve the desired outcome in a timely manner with minimal performance issues. Because wound care is bundled into the office visit in Primary Care, we are not bound by any formulary restrictions, but we cannot afford to waste money or time on ineffective products.”

Mary states she is honest with the vendors in the conference exhibit halls. “I am happy to purchase their product if it meets our needs,” she says. “But not until we can trial the product to be sure it performs as advertised. This is even more critical with uninsured patients with complex wounds, because their care may actually be totally on the house. In those rare cases, I reach out to my industry colleagues for help; their generosity where patient care is concerned is very heart-warming. If the patient needs a particular product to improve or maintain progress toward healing but does not meet the criteria to receive the product at home, some families will purchase the product on their own rather than use a less effective product that is ‘covered’. Some cannot and may rely on more frequent office visits to achieve a good outcome. Sadly, a patient’s wound may deteriorate due to this type of formulary restriction; the silver lining is the patient then may qualify for the more effective product, if only for a short time. It is not always a matter of a ‘better’ product but rather of choosing the best product for this patient at this point in time, if such a product exists. If not, we ‘cut and paste’ to create what will work.”

However, sometimes navigating the course between cheap and frugal to find the right product isn’t nearly as difficult as dealing with a patient who is apathetic to his/her own cause. “Overcoming and dealing with a patient’s denial of responsibility or reluctance to make lifestyle changes are perhaps the most challenging obstacles,” Mary says. “Patient rationalization regarding his/her personal role in the treatment plan is frustrating and illogical. This is often more difficult to work around than limited financial resources. Ultimately, empowering patients to take an active role in their healing process is quite gratifying.”

Much of Mary’s success in the wound care field comes from her belief that getting patients invested in their own care is just as important, if not more so, than most other aspects of healing. “Without patient buy-in, you are dead in the water,” Mary says. “Sometimes it is necessary to bend the rules to gain patient cooperation. Choosing your battles carefully is the first step to gaining cooperation. Acknowledge that change is not easy; give credit for effort. Don’t dictate. Negotiate one issue at a time. Speak with the patient rather than to or at the patient. You might say, ‘We really need to get more protein into you so your body can build new tissue. What are some of your favorite foods?’ Discussing a variety of protein-rich foods and suggesting ways for caregivers to punch up the nutritional value in preferred foods — even candy bars — can make a big impact. Be sure to give the patient credit for any progress and change. If the patient is particularly rigid, you may get minimal cooperation, in which case you make the best of the situation (and document it). If patients remove their compression dressings as soon as they get home because now their shoes don’t fit and they are not willing to wear slippers, you may have to adapt the dressing to accommodate the shoe, if you can’t adapt the shoe. Sometimes, increasing the wound care frequency (and inconvenience of an office visit) is enough incentive to gain cooperation. Toe-to-knee compression may be indicated, but midfoot-to-knee may be all you will get. A partial intervention — if not harmful — is better than nothing, in my opinion. It may not exemplify best practice, but gentle compromise is preferable to patient discharge for noncompliance. This may lengthen treatment time, but sometimes experimentation sparks a new intervention.”

Mary continues, “It is also critical the patient know he/she is the care team captain. Patients must understand that without their cooperation and participation in the plan of care, the goal changes from wound closure to maintenance and infection prevention. The patient is free to choose and is aware the decision will become part of the medical record. A clinician can’t force care on a patient, nor can we wave a magic wand and compensate for poor lifestyle choices. This discussion with the patient may be revisited whenever it is appropriate based on the situation at hand, but it must be nonconfrontational and nonjudgmental.”

Anyone who knows Mary’s spirit, humor, and straight-talking approach to life and provision of care can respect her management style. If her relationships with colleagues and other wound care professionals are any indication, she is forceful yet friendly, spunky yet sensitive, no-nonsense and knowledgeable — attributes that probably can convince even the most ornery patient to shape up and do what is necessary to heal and stay healthy. In her work, Mary gladly takes the role of advisor, offering the real person in charge — the patient — the information and guidance needed to achieve the best possible outcome. As the Irish redhead with the at-risk skin, Mary has used her heritage and experience to help guide her patients and her scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.