My Scope of Practice: Good Counsel on Continence

    She calls herself a huge patient advocate — a gatekeeper for urinary incontinence. In addition to her responsibilities in a hospital-based outpatient wound care center, she helped establish an incontinence clinic at a women’s healthcare center that features a straightforward, practical approach to treatment. Although she sees mostly women, she also has earned the trust of male patients by respecting their concerns regarding problematic urinary issues. In short, JoAnn Ermer-Seltun has, as she puts it, “a passion for pee.”

    When JoAnn Ermer-Seltun, RN, MS, FNP, CWOCN, graduated from the Tucson (Ariz.) Medical Center’s Enterostomal Therapy program in 1999, she was “totally ostomy and wound.” Doing home care in Mason City, Iowa, she saw that many skin issues were related to incontinence. She used simple behavioral techniques to address these problems, which gradually increased her knowledge and her ability to manage patients who suffered from incontinence. She pursued a Masters degree and certification as a family nurse practitioner in order to obtain greater autonomy and better impact the care of patients with incontinence or wounds.

    Two afternoons a week, JoAnn works at the continence clinic she and Susan Sieh, MD, established at Mercy Medical Center- North Iowa Women’s Health Center in Mason City. JoAnn has come to believe that urinary incontinence is the most under-reported and under-diagnosed medical condition. She follows basic pharmacological and behavioral approaches to manage incontinence and often prescribes a pessary. Adjunctive therapies or diagnostics such as biofeedback and urodynamics are outsourced.

    “You can’t and don’t have to do it all, “ JoAnn says. She works with Urology and an OB-GYN when she feels she has done everything she can for a patient when advanced diagnostics or surgical evaluation are necessary.

   “Women come to me having had UI for long periods of time,” JoAnn says. “They’ll tell me they’ve been ‘managing’ when actually they’re just tolerating the situation. Frequently, their healthcare providers aren’t sure what to do, especially when these patients may have more pressing medical problems. Incontinence is comparatively a quality-of-life issue. By addressing some of the small, intricate details of management, I can make their lives better.”

    Every patient participates in a fluid modification program; fluid amount (too little or much) and the types of fluids consumed affect continence. Before JoAnn evaluates patients, she has them keep a 3-day “uro-log” that documents types of beverages, frequency and quantity of consumption, and quantity and frequency of voids and leakage. She also has patients complete a questionnaire about bladder control. She compares the uro-log to the questionnaire to see if they match and recommends behavioral modifications accordingly. “Sometimes, simply increasing or decreasing fluids or changing the type of beverages consumed can make a big difference,” she says. “This is within the scope of WOC nurses.”

    Her other “ace in the hole” (as she calls it) is urge inhibition and bladder retraining — ie, encouraging patients not to respond every time their bladders give them a little twinge while retraining the bladder “to go” according to a prescribed schedule. She says most of the time, no medication is needed if patients are attentive to bodily signals and follow the bladder-retraining schedule.

    If a patient is experiencing severe overactive bladder symptoms, JoAnn will prescribe an antimuscarinic agent such as tolterodine tartrate (Detrol™, Pharmacia & Upjohn, Peapack, NJ). “The patient may not have to be on it forever,” JoAnn says. “Once the bladder is retrained, he/she may be able to wean off the medication. Unfortunately, some clinicians simply hand the patient a prescription pill and do not discuss urge inhibition or a fluid management program. Or healthcare providers will prescribe oxybutin, unmindful of the fact that this is a difficult medication for the older patient to tolerate; it is short-acting, causing peaks and dips in medication blood levels which alters its efficacy, and it produces side effects such as dry mouth or eyes, constipation, and central nervous system consequences. Polypharmacy is problematic for the elderly — adding an anticholinergic with a strong side effect profile can put patients in jeopardy regarding fecal impaction, urinary retention, and confusion.

    JoAnn is also a fan of another underutilized treatment for stress incontinence — the pessary. “It’s a wonderful option at any age,” she says. “Traditionally it was used only for cystocele and uterine prolapse and never considered for stress incontinence. Some women’s surgical risks may far outweigh the benefits of the procedure; a pessary may be an excellent alternative. For women in childbearing years who want to exercise and play with their children without leaking, it provides an easy option. If a patient is overweight and has difficulty with insertion, the clinician can place the pessary, have the patient wear it for the prescribed period of time (JoAnn’s patients average about 2 months), and come back to the clinic for cleaning and replacement. Because it takes trial-and-error time to fit, urologists and OB-GYNs often may not use the pessary. This provides a good opportunity for WOCNs to become involved — you don’ have to be an advanced practice nurse to do the things I do.”

    Men also seek help from JoAnn’s continence clinic. “It takes guts to come to a women’s health center,” she says. “But sometimes men are too embarrassed to tell their male healthcare provider about their urgency or frequency problems or may have spoken to someone else but received little assistance. Sometimes they are afraid they have prostate cancer and just need someone who will listen to their fears and symptoms. If their concerns are valid, I will tell them they need to talk to a urologist, but often I’m the one they come to first.”

    JoAnn is also an Associate Director and Faculty member, directing the Bowel and Bladder Continence Course for webWOC Nursing Education, an online education program accredited by the Wound, Ostomy, Continence Nurses Society (www.webwocnurse.com). The program is offered in partnership with the School of Nursing at Metropolitan State University, St. Paul, Minn. When students meet at the beginning of the course, many think incontinence doesn’t fall within their scope of practice. JoAnn explains the many opportunities for nurses in this arena in outpatient and inpatient settings as consultants and providers of acute, extended, and home care and how much their services are needed. “I try to turn on the light bulbs in people’s heads to the possibilities of incontinence management,” she says. For students who think studying the relevant anatomy and physiology is beyond their grasp, JoAnn breaks down the subject matter into easy-to-learn building blocks, always emphasizing the students’ potential to affect quality of life. In addition, JoAnn is among distinguished faculty who give presentations on behalf of the Collaborative to Support Urinary Incontinence in Women’s Health (cSUIwh; visit www.stressui.org), a group that, thanks to grant money from Boehringer Ingelheim, Eli Lilly, the Annenberg Center for Health Sciences, and CogniMed, Inc., concentrates on disseminating information on treatment options in primary care settings for women with stress urinary incontinence.

    A speaker for Sage Products, JoAnn touts the benefits of preventing pressure ulcers in patients with incontinence. A poll conducted among attendees to the Wound Ostomy Continence Nurse Society’s annual meeting in June 2004 found that of the 191 survey respondents, 84% said that nurses and technicians did not fully comply with incontinence skin care protocols, despite the fact that the skin breakdown they see occurs most often (75% of the time) on the sacrum, perineum, and coccyx/buttocks. Specifically, although almost all incontinence skin care protocols include preventive use of skin protectants, nurses could cite several reasons why staff are not fully compliant with hospital protocol, including products not being readily accessible; process variation; staff shortages; time constraints; employee turnover; and lack of education. JoAnn addresses these issues in her presentations.

    Still, treating patients in the least invasive, most efficacious way possible is JoAnn’s priority. For instance, a woman in her late 50s sought JoAnn’s help for severe urge incontinence rather than receive a sacral nerve stimulator implant. She was soaking four to five diapers per day and her husband was commenting on her odor. “I didn’t know if I could help her but I completed her work up, initiated behavioral modification, and prescribed an offlabel double dose of tolterodine tartrate,” says JoAnn. “After 3 days, the woman was completely dry with 3 to 4 hours between bathroom breaks.” Additional success stories include two younger women who suffered bladder control symptoms after childbirth as well as quality-of-life issues: A female police officer with cystocele and a mom with toddlers. JoAnn fitted the officer with a pessary to keep her dry until surgery would be convenient. The young mom was fitted with a pessary as well and now is no longer reluctant to exercise and play outside with her young children.

    JoAnn quotes Bryan D. Biro, Leadership Coach and Speaker, by saying, “Life is filled with ‘WOO’ or windows of opportunity.” She says, “Incontinence care offers a window of opportunity for many in our field, yet few people are taking advantage of the potential available for professional and personal growth.” Practitioners and patients should be aware there are numerous “ways to go” in this scope of practice!

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