My Scope of Practice: A Salute to an Army Nurse, First Class

   This year, people in uniform - all uniforms - have been increasingly recognized and appreciated. Their sense of duty, their sacrifices of time and (sometimes) life and limb for their towns, cities, and country, once perhaps taken for granted, are now acknowledged and celebrated.

No one is more cognizant or respectful of these men and women than the people who support them in their efforts to serve and protect. Joseph B. (Jody) Warren, RN, BSN, CNRN, ET, CWON, is the Chief, Wound/Ostomy Service, Brooke Army Medical Center (BAMC), Fort Sam Houston, Tex. He is also a lieutenant colonel in the Army Nurse Corps and serves as the Officer in Charge (OIC), Critical Care Nursing for the 5501st US Army Hospital, an Army Reserve Hospital, San Antonio, Tex. Jody is one of only four certified ET nurses in the Army Nurse Corps. He says providing care to people who have provided service to this country is "humbling. I am proud to come to work."

   Jody didn't always want to be a nurse. After active duty with the Army as a corpsman, he thought he would become a physician, but the fates intervened. Looking back, he says his "God-given gifts" put him into nursing. He earned a BSN from the Medical College of Virginia (MCV) in 1980 and his ET certificate from MD Anderson in 1997. Rock music helped him decide the department for his first job at MCV. "I visited several critical care units in the hospital and they were all calm, with "musak" playing in the background. I walked into neuro-ICU and it was absolute bedlam as nurses and physicians were working together in caring for patients with music from the Rolling Stones as the backdrop. The need in that ICU atmosphere was great for nurses who wanted to provide good patient care and I knew that's where I wanted to be."

   Now at Brooke - a 450-bed hospital where 198 beds are occupied on a routine basis - Jody is one of two ET nurses for the 43 armed services medical treatment facilities in the mid-United States. They reach north to south from Canada to Texas and west to east from Denver to Louisiana. As one of three Level I trauma centers for San Antonio, 20% of Brooke's patients constitute civilian emergencies, which include hand care, burn care, general surgery, and trauma surgery. "With most length-of-stays shortened to 3 days, we see lots of outpatients and 'pull-throughs'," says Jody. "I also do many phone consults."

   Jody's responsibilities involve inpatient and outpatient wound and ostomy care and teaching (40% of his time is spent teaching). He provides instruction in-house as well as to Army physical therapy students and post-graduates, to BSN students from the University of Texas, San Antonio, and to Army Nurse Corps nurses in the Critical Care/Emergency Nursing Course at BAMC. He says teaching is both inspiring and frustrating due to the challenges of educating his students and colleagues. "It's difficult for nurses to secure the information needed to do their jobs. Getting to conferences, even trying to learn the basics, isn't easy. There is so much information to absorb that important facts are sometimes glossed over. But many instructors and Army Chief Nurses have made me promise to train every single person to the utmost. We need ways to teach exportable training - offering knowledge applicable to whatever the circumstance." One of his teachers and role models at MD Anderson was Beverly Hampton, featured last month in "My Scope of Practice."

   As a former employee of KCI, Jody gained a unique understanding of the importance of clinicians and industry working together. "Industry representatives are an important part of the teaching process, through their product knowledge and support of nursing education" he says. "Nurses need to know the resources for care. Brooke has representatives come in and teach and 'co-op' with the ET nurse. The results are that nurses can go anywhere in the world and do wound care and not be brand specific."

   For Jody, standardization is far from an Army cliche. He has examined the role of the wound/ostomy nurse in the delivery of high quality, cost-efficient care and notes the value of having a gatekeeper who appreciates both the clinical and financial ramifications of product use. He is involved in standardizing processes for wound care and ostomy products throughout his region. "Standardization is a continuous enterprise," he says. "Having a formulary for products eliminates redundancy, which brings down costs. Ward 7 should be the same as Ward 5, both in practice and in products used. Nurses can play an active role in resource allocation for good outcomes - identifying the problem, applying their knowledge, and demonstrating stewardship."

   Jody cites examples. "We used to have small bar soaps and shampoos on supply. We realized that we also had another single product on hand that served both purposes. We switched to the dual-purpose product and saved thousands of dollars. We also had been using a low-air-loss bed as "standard of care," then realized that a particular overlay had the same characteristics at a reduced cost. We made the switch and decreased costs more than $100,000 over a year. Standardization increases efficiencies and puts money back in the general budget. If we can cut the funds spent on certain products, we can increase the number of patients served. Nurses have to monitor product use to ensure that the resources are available when they are needed. Otherwise, a certain product could be eliminated, affecting outcomes. Materials managers and logicians need our clinical input, not only to control costs but also to ensure our patients have the resources they need to heal."

   What does Jody like most about his job? "The variety of patients, the patient-focused environment at BAMC, my colleagues in all disciplines, and the great people I provide care for," he quickly replies. "I have a great deal of freedom to do what's necessary, to provide what a patient needs and worry about the paperwork later. No case is 'routine'. The Navy says, 'It's not just a job. It's an adventure'. I say, 'It's not just a job. It's a privilege'."

   But it's not a job without challenges. "Providing total care in circumstances that prevent it, like short lengths-of-stay, can be difficult," says Jody. We know the value of doing pre-op with ostomy patients - counseling them, even for just an hour or two, and marking the stoma site - but we can't always do it. Early-on intervention makes a huge difference. It changes the patient's approach to and acceptance of the ostomy. One woman went from referring to her ostomy as 'this thing' to giving her ileostomy a name proper for an unpredictable stoma (Mount Helena). She decided to take control of the situation and drive on. But there are always more patients than hours in the day."

   Demands on his time will continue to expand. "We'll need to seek creative ways to fit our responsibilities into a 40-hour work week," Jody says. "I think we'll continue to see more outpatients coming back for care. This means the need will be greater for better training and knowledge of technologies to impact outcomes. Nurses must strive to be good stewards of resources and avoid listening to the money managers who think 'cost-effective' means cheapest product. We need to share our knowledge and experience to find ways to do things better."

   For Jody, nursing occurs in the U.S. or anywhere in the world - including active duty in Bosnia, which is where he is now as Chief Nurse at Task Force Med Eagle. He did his "recon" in advance to ascertain what materials would be available and what education needs exist and looks forward to providing knowledge and care to those in need, care which Americans assume is routine. "I've been told, with a smile, that ETs get to know their patients from the bottom up. But I prefer to convey a more serious piece of advice I learned from my mother. She said nurse is a verb as well as a noun, that to be a good nurse requires action. I think that's a great philosophy to incorporate into my scope of practice."

   My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.