My Scope of Practice: A Senior Professional with Youthful Enthusiasm

    Rosalie Bolton, RN, MBA, is looking forward to earning her wound care certification.

Even though she has been in nursing since the late 1940s, pursued a Bachelor’s degree in Health Service Administration, achieved a Master’s degree in Business, and put together an instructional booklet about chronic wounds and dressings, she wants formal acknowledgment of her hard-earned wound care proficiency. Rosalie’s knowledge of wound care was acquired more-or-less in a process of baptism by fire as she established a wound care program that started as a 1-day per week venture and is now a full-time adventure. Her experience and enthusiasm continue to grow.

    Rosalie works at Our Lady of Fatima Hospital, a 366-bed community facility in North Providence, RI. What she observed working in the outpatient oncology treatment center sparked a thought: why couldn’t staff handle dressing changes for wound care patients? This idea blossomed into creating a wound care center. She developed a pro forma to demonstrate the need and financial requirements for the center, which would be located in space available near the oncology department. “I demonstrated the cost-effectiveness,” Rosalie says. “We just needed to renovate a room.”

    With the help of a plastic surgeon and another nurse interested in wounds, the wound care center opened in March 1998, providing services 1 day per week. As demand grew, so did the center’s hours of operation. By March 2003, the center was operating full time with a team approach to care. On average, 30 patients are seen per day. Patients are referred by their physicians and visiting nurses. The center benefits from the services of a Medical Director as well as two other surgeons and a podiatrist. The staff includes two RNs, one CNA, and one secretary. Consultants available to the Center include a vascular surgeon, an Infectious Disease specialist, a hematologist, and a nutritionist.The center contracts out hyperbaric oxygen therapy services on site in the hospital; eventually, Rosalie says, they would like to have their own HBO equipment.

    The wound center’s location within the hospital changed as it grew. The Center now has its own wing. An important consideration was that wound care staff didn’t want the Center to share a waiting room with any other department; now they have their own.

    “I wear many hats,” Rosalie says with regard to her role with the mostly senior wound care patients. “They require a social worker, teacher, and financial planner, not simply a wound care specialist. Many patients use the state-sponsored transportation program that can provide a wheelchair van to help get patients in for treatment. We insist that the physicians come to the Center to keep care as accessible as possible. Plus, we think having the physicians come to the center makes for better patient care. The goal of the wound care center is to provide ‘one-stop’ service that keeps patient visits to a minimum.”

    Because the center uses mostly Smith & Nephew dressings, the company provides educational programs for visiting nurses. Rosalie notes, however, that no one insists on any particular brand or product type. “If finances are a problem for patients and their families, we recommend using a sanity napkin to manage heavy drainage — whatever it takes to stay within the financial confines and still provide good patient care. Included in our fiscally responsible approach are free podiatry clinics for the community to enhance prevention and education. We see a lot of diabetic foot ulcers.”

    As hospital physicians become more aware of the wound care center, inpatients in acute care are seen by wound consultants, which means hospital staff, too, must be educated. Rosalie can empathize with staff on the challenges of learning wound care. “The most difficult part of wound care for me was learning the dressings,” she says. “There are so many names for the same dressing, which complicates the decision of what to use and when to use it. Even wound care physicians who are accustomed to dealing with acute and surgical wounds needed to understand the difference between managing an acute wound versus a chronic wound. The Medical Director has become the driving force behind the growth of the Center. His knowledge and concern have been invaluable.”

    Rosalie helped establish care protocols according to wound type. Guidelines for when to get ABIs and at what point to change treatment if a wound is not responding are some of the factors considered. A formulary for dressing use is being developed. Rosalie explains, “We use the latest technology but we start with standard wound care. If a wound is not healing, we will take a more advanced approach and use, for example, negative pressure wound therapy, silver, or growth factors.”

    Nutrition is assessed and addressed “no matter what.” “Nutrition is an important factor with the elderly population,” Rosalie says. “We try to stay on top of nutrition. Even though a patient looks healthy, he or she can have a low pre-albumin which will affect the healing process. All patients are pre-albumin screened and consults and counseling are offered.”

    Non-compliance among patients with diabetes is one of Rosalie’s biggest frustrations. “We put together an educational program for each diagnosis,” she says. “But many persons with diabetes don’t follow the proper diet and wind up on medications and insulin. We try to explain that diabetes affects every part of the body but sometimes it’s hard to make headway.”

    The next step for Rosalie and the wound care center is to provide services in nursing homes in the area. “Our plan is to bring the patient to the center for the first visit to assess the wound and establish a plan of care. Then we would go out to the home to do staff education and follow-up care.”

    Do the math (Rosalie graduated from diploma school in 1946) and you might think she would more likely be anticipating retirement than expanding her services and earning another certificate. A nurse manager most of her professional life, Rosalie plans to “keep at this until they find me under my desk.” She says, “I enjoy my autonomy and I’m looking forward to broadening my horizons. There’s not a day when I’m not happy coming to work in my scope of practice.”