My Scope of Practice: Aristotelian Logic in Home Care

  Despite logic and foundation in evidence-based practice, protocols are as challenging to implement as they are to develop. No one condones a cookie-cutter approach to wound care, but certain aspects of assessment, diagnosis, and treatment jive with the "if-then" reasoning of care protocols. Just ask Lidia Garner, CWCN, OCN, BSN, RN. She pursued development of "wound tiers" to help clinicians select appropriate dressings for particular wound types so wounds would heal quicker and with less scarring and pain. Plus, Lidia thinks the implementation of prospective payment systems, because they encourage a methodical, cost-conscious course of action, are an impetus for improving care.

  Lidia has been affiliated with Johns Hopkins medical facilities in the Baltimore, Maryland area her entire nursing career. As a nursing student at Villa Julie College (Stevenson, Md.), she was chosen over 175 people for a 9-week medical ICU intensive internship at Bayview Medical Center and later (still as a nursing student) worked on a surgical/burn ICU. "After I watched my first debridement, I couldn't even touch a pimple on my face," she says. Lidia wasn't deterred from pursuing wound care, however; she became an ICU burn nurse. While working in that capacity, she received an offer of a job in the cardiac cath lab, began working on an "as needed" basis, and attended graduate school at Bowie (Maryland) State College, intending to obtain family nurse practitioner certification.

  A friend from graduate school opened the door to home care. "At first, I was at a loss," Lidia confesses. "As an ICU nurse, I was accustomed to being surrounded by technology. I had to hone my skills. As a staff nurse for John Hopkins Home Care Group, I was seeing eight to 12 people a day, doing huge quantities of paper work, and dealing with many late nights. I also became a member of the wound team. Meanwhile, I had pulled out of graduate school due to the demands of marriage and motherhood. I guess at that point I wasn't ready to go after my degree."

  When her WOCN colleagues began leaving for other opportunities, Lidia decided to follow the advice of Johns Hopkins Home Care lead WOCN Brenda Hensley and seek her WOCN certification. She participated in a home study program through Wicks Educational Center, Harrisburg, Pa., where her enthusiasm and previous experience allowed her to finish the wound section in 3 weeks. She admits the ostomy section took longer and that the incontinence section was the most difficult part for her to master. Completing the work and obtaining certification took about 4 months. She now provides home care throughout Maryland, often putting 100 miles on her car per day.

  "We are terribly short staffed," Lidia says. "Plus, we have to deal with the beating home care is taking as a result of OASIS (government "bundling" of care, therapy, and services under a prospective payment system). Before OASIS, we could 'chart by exception'." Inspired rather than hampered by such restrictions, Lidia is a disciple of developing protocols for caring for different types of wounds. In 2000, her impending yearly evaluation spurred her to validate her efforts; she reviewed her patients' charts, looking for cost savings that would justify her care decisions in dollars as well as good care. When she calculated her findings, she realized a more than $217,000 savings along with confirmation of successful healing. She, along with the previous home care WOCN, eventually created a system of "wound tiers" for various products - eg, if a wound is shallow, use this product and so on, and if all else fails, contact the clinician. Because Lidia is always looking for better ways to care for her patients, she continues to weigh "tried-and-true" against new and improved. "Give me 2 weeks, and I'll prove the efficacy of a product," she says.

  Lidia is gratified that physicians appreciate her efforts. "They understand the crunch of PPS and trust that we have researched the products to make recommendations based on clinical experience. Thanks to PPS, nurses have the opportunity to evaluate products and help physicians change practice that is outdated and inept. Wound nurses must be strong advocates for patients. Not all products are right for every patient. Betadine dressings, normal saline wet-to-dry dressings, and peroxide, for example, can be detrimental under certain circumstances. We need to alert physicians, bombarding them if necessary with evidence-based practice."

  Lidia says the ability to influence practice decisions is, in large measure, dependent upon the demeanor of the nurse. "Nurses need to exude competence, confidence, and professionalism. We must always put our best feet forward as well as admit when we don't know or when an issue is beyond our areas of expertise." Modifying practice decisions is also a factor of product and technology availability. "Using the newest gadget may appear to be a 'best practice' when actually, existing protocols may be more likely to be employed and yield the same good practice result," Lidia explains. In addition to home care, Lidia has worked in long-term and hospice care. She says, "Hospice is the ultimate... it completes the care evolution that starts at birth. Plus, it is an honor to be allowed into someone's life in the last days. It is a selfless act and humbling. More than anywhere else I've worked, in hospice I feel it is my duty to be the best nurse every day, all day."

  In addition, she fills in for the wound ostomy nurse at two hospitals and provides care in all settings and to all ages. She also does inservices (including CPR), is a fund-raiser and By Laws Committee Chair for the Mid-Atlantic chapter of the Wound Ostomy Continence Nurses Society, is a member of the Clinical Practice Wound Care sub-committee, and volunteers at the Johns Hopkins Free Clinic of the Health Alliance that offers free medical care to indigents and immigrants. She fulfills her civic duties through her local women's club and as a board member for her local county.

  Far from complacent about her accomplishments, Lidia still hopes to earn an MSN, or even a PhD, in the educational or business side of nursing - perhaps becoming a nurse practitioner and opening a wound clinic. "I'd like to assume more of a teaching role and enhance what nursing students are learning in nursing school," she says. "Maybe I would go back to Villa Julie and teach." Other possibilities include missionary work and involvement in Operation Smile, which provides care to indigents in Third World countries. Closer to home, Lidia aspires to have a bigger role in the Johns Hopkins Clinic. She is also proud to have a chapter on the importance of developing skills "as a nurse and a human being" in an upcoming Johns Hopkins' publication - a journal on home health care - and would like to publish more frequently.

  Like many nurses, Lidia subscribes to the belief that God is moving her and that "opportunities keep falling in my path." Home care has allowed her to "evolve within herself " as she touches people and helps restore their quality of life. "I love going to people's houses, seeing how they live, and finding ways to help them," Lidia says. "I think home care completes your practice. It makes you a better person as it compels you to approach care in a clear, focused, logical manner. All nurses at every level should experience home care as part of their scope of practice."

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