My Scope of Practice: Confessions of a New Kid on the Block

    Robbie Sharp, BSN, RN, CWOCN, EMT-P, is fairly new to wound care. But in barely more than a year, she developed and implemented a plan to identify and manage wound care patients, helped implement a wound care group, helped plan and participated in a hospice wound care seminar, and is looking forward to conducting a study to track product use across the care continuum.

Robbie credits her interest and success in her new field to her colleagues and mentors and most definitely to Dorothy Doughty and Dot Weir — inspiring presenters who were instrumental in turning this one-time hospital volunteer into a wound care specialist.

    Robbie was the manager of a non-medical company for years before she followed her childhood dream of becoming a nurse. “I worked as a volunteer in our hospital emergency room and then as a nurse technician before deciding to go to paramedic school,” she says. “Then I went to Florida State University in 1997 to earn my nursing degree. By then I was an older student, but that was okay. I was always a solid, get-though-it kind of person.”

    Her first position as a nurse was on a respiratory/medical floor, followed by time in an intermediate step-down critical care unit at Tallahassee Memorial Hospital. From there, she began working for Elder Care Services, a non-profit social services agency, supervising adult daycare programs, providing in-home services, doing case management, and conducting educational programs.

    Sharon Aronovitch PhD, RN, ET, initially Robbie’s mentor and now a good friend, took Robbie under her wing and encouraged her to think about becoming a wound care nurse. “ I had been receiving ECPN and was intrigued by all the wound care products,” Robbie says. “As a new nurse, I remember being in awe of products like Kaltostat (Convatec, a Bristol-Myers Squibb Company, Princeton, NJ), a seaweed-based product used to pack wounds. My first exposure to the wound care arena was when Wilson Enfinger, BSN, RN, CWOCN, the wound/ostomy nurse at the hospital where I worked, recommended Kaltostat for a decubitus ulcer patient in my care. I thought, Seaweed?!”

    Dr. Aronovitch encouraged Robbie to apply for the wound care position at American HomePatient, a nationally recognized durable medical equipment company that also has a large, successful skilled nursing component at its Tallahassee, Fla. location. The nursing administration of American HomePatient believes in having a strong wound care program and continually supports the wound care team in its educational choices, conference attendance, and product selection. They were willing to send Robbie to the WOCN program at Emory University. “I worked for a few months to familiarize myself with the home health care arena,” she says. “Then it was off to Emory.”

    Robbie admits she was apprehensive. “I had just started working for a new company. Would they really send me to Emory and give me the position as promised after I finished the program? Would it be worth leaving my home and my husband for the 3 months necessary to complete the coursework? Could I really do this job? I talked about my fears with Wilson Enfinger and he told me that going to Emory and becoming a wound, ostomy, continence nurse was the best thing he ever did. He helped me realize I could do it, too.”

    “Do you know how honored I felt to have the opportunity to study under educators like Dorothy Doughty all day?” Robbie asks. “She was not only gracious but she also never made anyone feel stupid or like they were anything other than a true professional. She was supportive. She also taught me how to ask and receive on behalf of patients.”

    While Robbie was attending classes, partner Louise Bruner, BSN, RN, CWCN, COCN, who attended Emory’s WOCN long distance program, held down the fort. “She called me once a week to talk about what I learned and we’d compare notes.

    With her CWOCN certification in hand, Robbie came home to take the position vacated by a well seasoned wound care nurse. Filling her shoes was difficult, Robbie acknowledges, but she decided she couldn’t have had a better foundation for her baptism by fire. “Being a new CWOCN can be intimidating,” Robbie says. “I was prepared to come home and do the job... then reality set in. It takes a long time to gain the real knowledge that only experience can give. I am just a Dot Weir wannabe!”

    Sharon continued to mentor, support, and keep Robbie centered. “When I came back to work, I assessed our overall home care patient load. The patient census at our home health care agency averaged 350 to 400 patients. Of those, at least one third were wound care patients. We needed to determine how to manage these wound care patients and which wounds needed special attention. Plus, I needed to learn more about the products. In addition to Louise, I am also fortunate to have Joyce Armstrong, RN, CWS, on our team. She is a wealth of knowledge.”

    Robbie was astounded by the complexity of the cases in home health. For example, one woman in Miami had cancer of the face — they had moved her breast to facilitate reconstruction. Another woman, a bed-bound stroke patient, had 13 wounds (some Stage IV and quite involved) and relied entirely on her family to provide care. Robbie says by the time home health gets involved, wounds can be rather advanced. In the case of the stroke victim, the family appreciated the support of home health care providers even though only some of the wounds could be healed. In another case, a patient had a very large, dehisced abdominal wound measuring 20.5 cm x 28.5 cm. He was originally ordered to have wet-to-dry dressings twice a day but after working with the insurance company and the physician, Robbie’s staff was able to provide this patient negative pressure wound therapy, which helped to decrease the healing time. Such cases made Robbie realize a more systematic approach was needed.

    Eventually, Robbie helped develop a plan to more expeditiously identify wound care patients and distinguish them, for example, from skin tear patients. Wounds now are digitally photographed when a patient is admitted into Robbie’s home health service and every 2 weeks throughout the care regimen, which in severe cases can last several months. The patient builds relationships with a community of clinicians that includes skilled nurses, physical therapists, and other wound care specialists.

    Clinicians in the Tallahassee area now have an opportunity to be continually educated about new products to ensure everyone is on the same page. The Wound Care Wine Club, as it has been dubbed, is a new, informal wound care group that was the result of a brainstorming session between Robbie and colleague Val Sullivan PT, MS, CWS. The club meets monthly and invites clinicians who enjoy wound care from hospitals, physician offices, wound care clinics, subacute facilities, and long-term care facilities. Participants discuss products, successful wound care strategies, and difficult wounds, all in an effort to improve care. “Our agency allows use of the best products,” Robbie says. “But clinicians cling to old treatments, such as wet-to-dry. We want to foster relationships with physicians and manufacturers that will allow us to get the answers to problems we may not have the expertise to solve — questions about specific products and combining products.

    “Creating a group of wound care clinicians in our area who can collaborate and share their knowledge, experiences, and product information is key to promoting the wound care profession. But even more important is remaining focused on the patient. Our belief is that by forming relationships among the various disciplines, we will give better patient care and have better outcomes. At a recent wound care club meeting that incorporated a product demonstration, we invited 27 people and 21 attended, including one physician. We want physicians to understand that we are seriously dedicated to improving wound care outcomes. Soon we hope to use our knowledge to track wound care product use across the care continuum.”

    Robbie also conducted a day-long wound care class on documentation and assessment, basic ostomy care, and negative pressure wound therapy, as well as appropriate product use, for the nursing staff at her home health agency. Information was provided by representatives from Mölnlycke, KCI, and ConvaTec. “We practiced placing the wound vac on fruit,” Robbie says. “We have used vacuum-assisted closure on some pretty challenging wounds with some amazing results.” Robbie also was involved in planning a day-long hospice wound care seminar that had to be re-scheduled twice due to an especially active hurricane season. Despite the planning challenges, 100 people came, some from 2 and 3 hours away, to hear speakers that included Robbie’s idol, Dot Weir. “The seminar’s message? Robbie asks and answers. “Taking care of wounds is a collaborative effort. Communication is key to good care.”

    “I am honored to be in a great city that provides great care,” Robbie says. “If you can get a person healed, that’s everything. I work with some of the best home health care nurses you could ask for. They love wound care and work hard to keep up with the latest knowledge available. The truth is that if it weren’t for my colleagues and mentors, I wouldn’t be where I am in my scope of practice.”