Guest Editorial: Staying Power

   As a registered nurse case manager with a hospital-affiliated wound management program in central Pennsylvania, my responsibilities include care coordination as well as clinical care. I chose nursing because of its diversity and many opportunities. I love wound care primarily because of the patients and also because I enjoy the challenge of discovering why an individual has a wound and providing the appropriate care. Wound care creates a continuous learning environment.

   My patients are my mentors. They are what keep me feeling good about myself and my career. I also work with exceptional physicians - compassionate people who are willing to share their knowledge and expertise with staff.

   In light of the recent nursing shortage - brought about, in part, by hospital "re-engineering" efforts in the 1990s followed by an exodus of nurses who have either reached the age of retirement or who are frustrated by their unanswered concerns - I have begun to take stock of my own experiences. This personal assessment has given me interesting insights into why I choose to stay a nurse, as well as why others may decide otherwise.

   Throughout my career, I have cared for patients with wounds secondary to surgery, trauma, burns, vascular deficits, and pressure. Recently, the number of non-nurse clinicians who provide wound care, such as physical therapists, has increased substantially. Certainly, physical therapists have an important role to play in wound care; eg, they are able to provide much-needed treatment and training to maintain and/or improve patient mobility. Yet, physical therapy no longer appears to be their focus for patients with wounds.

   Skin and wound assessment and care have always been an important part of nurse's education, training, and responsibility.^1,2 Although many of us are dealing with long hours, heavy patient loads, and ever-expanding clerical and other extraneous duties, we want to care for those we have the skill, desire, and duty to help. The observed shift of wound care duties away from nurses appears to be a reimbursement, not a patient care or outcomes, issue. Indeed, the increase in non-nurse clinicians providing wound care coincides with recent trends in wound care reimbursement. However, at least in the state of Pennsylvania, RNs have not been able to benefit from the improved reimbursement rates since they do not receive reimbursement for services in outpatient settings as do PTs, OTs, and SLPs. Similarly, in the acute care setting, care provided by non-nurses can sometimes be billed separately - nursing care cannot. This has had a double negative impact on our profession - emotionally, nurses must cease-and-desist providing wound care, limiting their ability to treat and heal and experience the satisfaction this brings; and regulatory/financially, they are excluded from compensation. Moreover, it seems curious that PTs and OTs with 4-year college degrees can be reimbursed for their professional services, while RNs with BSNs or even 6-year Masters degrees cannot unless they are Certified Registered Nurse Practitioners (CRNPs). Nurses have to work harder and obtain more education/certification before being "recognized" than many other healthcare professionals and, unless nursing reimbursement issues undergo some reform, I fear the profession is going to continue to decline in numbers.

   In addition, nursing salaries in the area of wound care are lower than in other "high tech" specialties such as cardiology, and opportunities for career advancement are limited. The work, however, can be grueling. Most of us have not chosen to be nurses for the money, but there are days when the inequities of the healthcare system and pay scale are felt more acutely. Long hours, increasing numbers of patients, feeling dissatisfied, and shouldering responsibilities while lacking authority are the main ingredients for burn-out.

   An outreach email from the Society of Urologic Nurses and Associates (suna_outreach@inurse.com) suggests that even a small career move might combat unsettled feelings. Changing careers across clinical specialties or between administrative disciplines helps sharpen skills and restore work-related satisfaction. Pursuing additional certifications in a wound care niche or seeking positions in administration and/or education - much needed in this nursing shortage crisis - may be a viable solution for rejuvenating interest and satisfaction in your chosen field.

   But on a personal level, why have I chosen to stay? The answer is: my patients. I stay because I feel I have an impact. I stay because although I do not have the authority to make specific decisions as to how our program is run, I do have the autonomy to make decisions about treatment choices. I stay because I work with healthcare professionals who trust my experienced judgment. I stay because I am learning to better manage my time. I stay because I want to obtain certification.

   I do not plan on leaving my profession any time soon. As a matter of fact, I would like more decision power and have decided to pursue further education as a nurse practitioner; thus ensuring, at least under the current system, that I will be reimbursed for the expertise and experience inherent in my services. As long as I am able to interact with and help patients and find challenge in the treatment of wounds, I will appreciate my career choice and its many satisfactions, knowing I have the staying power required of a wound care nurse.

1. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. Commemorative edition. Philadelphia, Pa.: JB Lippincott;1992.

2. Robinson C, Gloeckner M, Bush S, et al. Determining the efficacy of a pressure ulcer prevention program by collecting prevalence and incidence data: a unit-based effort. Ostomy/Wound Management. 2003;49(5):44-51.