My Scope of Practice: Above All, Patients Come First

  As part of tradition and culture, Japanese are taught to respect and revere the older members of their families and society. Despite a recent popular groundswell of less-than-sympathetic thoughts about the burdens of old age taking place in her country, perhaps influenced by a youth-oriented Western culture, one practitioner has followed the old ways and dedicated herself to improving the quality of life for Japan's older citizens. Her research and teaching are focused on pressure ulcer prevention and management as well as providing better ostomy care for the elderly.

  Hiromi Sanada, PhD, ET, WOC, is a professor in the Department of Nursing, Kanazawa University, one of the oldest national universities in Japan and the only Japanese facility to offer a nursing doctorate degree in wound management. "Kanazawa is a traditional Japanese city located on the coast of the Japan Sea," says Hiromi. "It has a population of approximately 450,000 people. The university has campuses around the city. The School of Health Sciences, situated within walking distance of some of Japan's most famous historical sites, includes lecture rooms and laboratories. My outpatient clinic, located in Kanazawa University Hospital, is affiliated with our university. I am also the supervisor of wound care at Sengi Hospital, a geriatric facility in the city."

  Educated in Japan, Hiromi spent one year as a special international student at the University of Illinois, where she was involved with clinical pressure ulcer research. "I was amazed at how advanced nursing care was in the United States compared to Japan," she says. "It was at least 10 years ahead." She earned her Bachelor of Nursing degree from St. Luke's College of Nursing in Tokyo and her nursing PhD from Kanazawa University, where she was a research student for 10 years and has been working for the past 20 years. Her extensive experience includes chairing the 4th Annual Japanese Pressure Ulcer Society (JPUS) Convention, a 2-day event held last August that attracted 3,900 attendees. She is also Chief Editor of The Journal of the Pressure Ulcer Society of Japan, a board member of both the Japanese Stoma Rehabilitation Society and the Japanese Pressure Ulcer Society, a volunteer for the Japanese Ostomy Society, and the author of several textbooks in Japan, most notably, Pressure Ulcer Prevention and Treatment.

  "At the university, I lecture and advise Masters and PhD students," Hiromi explains. "In addition, I lead a clinical wound care research group that focuses on preventing and managing pressure ulcers in our elderly. The group comprises one associate professor, two clinical associate professors, three assistant professors, and 15 postgraduate students enrolled in our Masters and doctorate programs. I have received grants for the research group from the national government and various projects are funded by private corporations. Some of our results include developing a new support surface (Tricel®, Cape Ltd., Yokosuka, Japan) and a new interface pressure measuring device (Cello®, Cape Ltd., Yokosuka, Japan), along with creating the K-Scale, a tool used to predict the risk of pressure ulcer development specific to Japanese elderly. Extreme Bony Prominence (EBP) is a key factor that has been included in this scale. Because most Westerners do not exhibit this trait, it is not included in the Braden Scale; however, EBP is very common among elderly Japanese who suffer from pressure ulcers."

  Hiromi says she enjoys the continuous challenge of seeking new ways to better the quality of life of elderly Japanese as well as the responsibilities involved in educating students to strive to provide better nursing care in Japan. An extra plus is the government and private sector's growing awareness of issues related to pressure ulcers that has occurred over the past 5 to 10 years. "The seriousness and social impact that pressure ulcers have on our society has risen significantly," she says. "In addition, due to the heavy burden on our medical system, the government is demanding that researchers like myself develop new methods of preventing and treating pressure ulcers. According to the latest Report of Comprehensive Research on Aging and Health, Japan has a pressure ulcer prevalence of 5.8%. Although these figures are similar to those in the US and Europe, 70% of all pressure ulcers are either Stage III or Stage IV. This extraordinarily high ratio can be attributed to the EBP characteristic of Japanese elderly who are frailer, as well as bedridden for longer periods, than Westerners. The concern over pressure ulcers has reached a level where the Ministry of Health, Welfare, and Labor has introduced an unprecedented penalty system that is levied on hospitals that fail to comply with a newly implemented legislation that requires all hospitals to meet the following criteria based on risk assessment, wound assessment, and treatment:
• All hospitals are to establish a "team" of pressure ulcer specialists to prevent and treat pressure ulcers
• All hospitals are to establish an assessment and treatment protocol for pressure ulcers
• All hospitals are to provide adequate support surfaces for pressure ulcer patients.

  This legislation came into effect as of October 1, 2002. The protocols can be viewed by visiting www.shaho.co.jp/shaho/yotei/yotei.htm.

  The penalty involves a 0.5% reduction in the basic daily coverage of all patients that can be claimed for reimbursement from the government for hospitals in violation of this legislation. Needless to say, this has spurred the interest of all hospital administrators to comply with the standard.

  "With a demographic shift taking place and an aging society becoming more prominent, the demands to increase the quality of care in the elderly will continue," Hiromi says. "In our field, I see an already present shortage of qualified nurses and other certified caregivers. This problem will only become greater."

  Hiromi believes one way to overcome the problem is to give specially trained nurses the authority to prescribe dressings and perform sharp debridement—practices still under the total control of physicians in Japan. She adds, "I feel there is a need to establish a course that specializes in wound management only. This would shorten the study period required, making the course more accessible and feasible for full-time nurses who are working in this field. I hope I can contribute somehow to making these solutions a reality, with the ultimate objective to increase the quality of life of the elderly."

  For those considering entering the nursing profession, Hiromi cautions, "Make sure the reason you want to be a nurse is the right reason. 'Above all, patients come first' is a philosophy that I cannot emphasize enough - something that I preach to anyone who aspires to become a nurse. As an educator, this is the most important responsibility in my scope of practice."

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