My Scope of Practice: Home is Where the Heart Is

   Marsha Davidson, RN, MSN, CWOCN, is a home health nurse who wears a plastic, disposable apron because she wants to be able to "hug the wounded area if necessary while working and not have to worry."

   Seeing her in action, one gets the feeling hugging is an integral part of her practice - that her successful outcomes are as much dependent on the warmth and caring she offers as on the expert wound care she provides.

   Marsha began her career as a staff nurse. She pursued her Bachelors in Nursing at Pennsylvania State University, received her Masters of Science in Nursing from Gwynedd Mercy College, and earned her ET from the Harrisburg Area Enterostomal Nursing Education Program, all in Pennsylvania. Her pursuits evolved from an inauspicious beginning. "I saw an ET place a hydrocolloid dressing on a wound and how quickly the wound improved. It was like magic! From there, I fell in love with ostomies - being able to take people devastated by their new circumstances and help them gain back their independence." She now is a wound ostomy continence nurse for Jefferson Home Care (part of the Jefferson Health System), a Medicare-certified, Joint Commission-accredited organization that services five counties in the metropolitan Philadelphia, Pa. area.

   They serve, onaverage, 22,000 home care patients per year, which translates to 240,000 visits. Marsha works with an ET to provide care and assessment. "I'm fortunate that I have a counterpart. I appreciate our working relationship and the opportunity to share ideas and expertise." For most of the week, Marsha works in the western Philadelphia suburbs while her counterpart coordinates care throughout Philadelphia and its eastern counties, unless an emergency occurs elsewhere.

   Marsha also is the contract ET for one of the healthcare system's hospitals where she is involved in pressure ulcer rounds and long-term care and she does ostomy care at another system hospital. "I also provide ET services to clients on the medical/surgical, oncology, cardiac, orthopedic, and hospice programs."

   Marsha sees patients after a generalist provides assessment and makes recommendations for the primary nurse to follow. She has become "passionate" about home care because of the opportunity to offer very patient-focused, individualized care. It also yields the kind of insights not readily available in other care settings. "I see clients in their own environment," she says. "I get a picture of the factors that affect wound healing and health and disease processes that you cannot gain in the hospital setting. This has made me a patient advocate, increasing my awareness of the role reversal that occurs as I provide care." Another asset is working with staff nurses and other clinical nurse specialists.

   Marsha is active in Delaware Valley Enterostomal Therapy (DVET), the local affiliate of the Wound Ostomy Continence Nurses (WOCN) Society, and currently serves as treasurer of the chapter. She also regularly attends conferences and programs to continue the didactic, clinical, and practical learning that began when she studied for her ET certification. She appreciates knowing she can rely on the organization, especially because she works independently. "This is a great professional society with great support - a very sharing group." Not only a lifelong learner, Marsha is also a teacher, precepting students interested in her field.

   Among the challenges Marsha faces is dealing with situations where people have a horrible disease process or life event, limiting what she can accomplish. "What you cannot control can be frustrating, because as a nurse you want to fix the problem or empower the patient to fix it," she says. "Mostly, though, providing home care is a humbling experience, seeing the strength that my patients exhibit. The worst day on my side of the bed is better than the best day on their side of the bed."

   Another challenge is dealing with insurance. Marsha says home care nurses are more "tuned in" regarding authorized visits, distributors, and products, but everything must be approved by insurance.

   One patient near and dear to Marsha's heart is an elderly woman who was her first leg ulcer patient. She requires continued treatment for the residual effects of a childhood injury. Marsha has been involved in her care since 1994. On a recent visit, they celebrated the success of a new ointment and dressing regimen that produced visible reduction in wound size and severity and decreased pain. Care visits also include chats about family and introductions to furry family additions.

   Looking to the future, Marsha can envision a day when home care will involve sitting in an office, viewing wounds via a television monitor and only having to travel to see significant wounds. She believes great opportunities are available for nurses competent in handling continence, ostomy, and wound-related cases in acute, home care, and clinic settings.

   Marsha is grateful for the opportunity her agency affords her to practice her specialty without requiring her to perform nonspecialty-related responsibilities. She says, "My clinical director is supportive of advanced practice nurses and values my expertise. Plus, I work independently. I offer an important service. I can use my ability and knowledge to reach out to people and improve their quality of life. I provide the ability to self-care." Marsha has enhanced her already rich sense of humor and jovial, easy-going nature in the course of doing treatments, lending a new and interesting take on a vital and demanding scope of practice.

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