My Scope of Practice: Individualized Care

   At Rochester General Hospital, a 526-bed acute care facility in upstate New York, all wound, ostomy, and continence patient care is based on existing evidence-based protocols for skin integrity and ostomy care that are customized according to individualized patient needs. For WOC Nurse Educator Christa M. Heinsler, RN/NP, CWOCN - a nurse at the facility since 1987- that translates into the need for flexibility, ingenuity, persistence, and a willingness to constantly think outside the box to provide optimal patient care.

   With bachelor's degrees in both biology and nursing, Christa pursued a Master of Science Degree in Nursing with an oncology focus. She secured a position as a clinical nurse specialist and found herself treating a number of ostomy patients. In order to effectively provide their care, she realized she needed more training and experience. In 1994, she graduated from the Albany Medical Center's Enterostomal Therapy Nurse Education Program (since closed) and achieved national certification as a Wound, Ostomy, Continence Nurse. As a NYS Nurse Practitioner, she continues to update her education through attendance at pertinent conferences, inservices, and clinical experiences.

   Christa considers herself a nurse consultant for the hospital as she sees patients across all of the many hospital services. "When I first started, my position was 20 hours or half-time, but it quickly grew to full time," she says. "The staff call me for consults on complex wound, ostomy, and continence cases- for example, management of chronic wounds, fistulae within abdominal incisions, ostomies, and wounds from trauma cases. As an NP, I have prescriptive privileges to write orders. I find that I prescribe many topicals, such as antifungals and barrier creams, and also write orders for appropriate nursing care of complex patients. This care is very much hands-on and often requires continuous revisions as patients' conditions change."

   To assist staff with the complexities of ostomy care, Christa wrote a teaching booklet , "Nursing Interventions for the Ostomy Patient," to provide staff with guidelines for caring for an ostomy patient. The contents include assessment and care of the post-op patient with a new ostomy as well as patients with existing stomas and how to manage challenges such as fistulae and recessed stomas. Staff can refer to this booklet for information regarding in-hospital and special order ostomy supplies. Instructions for the use of this specialized equipment and lists of community resources to assist the ostomy patient after discharge from the hospital also are included. Christa gives the booklet to nurses and other staff only after they attend one of her educational sessions on the needs of ostomy patients.

   In addition to in-hospital patient care, Christa also responds to consulting calls from off-site facilities that include independent living centers for seniors, nursing homes, and other hospitals. At Rochester General Hospital, Christa manages specialty bed use, conducts quarterly prevalence surveys, chairs the Skin Care Team, serves on the Oncology Committee, and has chaired the Geriatric Teaching Day Committee for the last 5 years.

   Education is a major component of her job. She has been a speaker at Cleveland Clinic, presenting on the psychological impact of ostomy surgery. She has lectured at St. John Fisher College on wound and ostomy care to nursing students at the undergraduate and graduate levels, and she serves as a preceptor for Emory University Enterostomal Therapy Nurse Education Program. She is part of the hospital nursing orientation program, presenting sessions for new staff on pressure ulcer prevention and the recognition and appropriate treatment of pressure ulcers. Recently, Christa's course was added to the hospital's Critical Care Nurse Education Institute's curriculum to educate students on the special skin care needs of the critically ill patient. She inservices staff at all levels, including nurses, nursing students, and residents, on various aspects of wound, skin, and ostomy care. "I like the interaction with staff, either one-on-one or in a group," she says. "The feedback gained from these interactions is mutually helpful."

   But patient care is her first source of satisfaction. "I love seeing patients get better," Christa says. "With all my educational duties, I am still very much 'bedside'. I enjoy the challenge of knowing which dressings go where and when to change care - to keep trying until something works. I provide pre-op instruction and care to ostomy patients, marking the site for the stoma and offering reassurance and information. Patients do much better if they are educated as to what to expect. They have to be able to adjust to this life-changing situation but, -and this can be hard for staff, - at their own pace. Even though I see more and more temporary ostomies, the adjustment can be difficult if patients are not prepared and/or supported at this sensitive time."

   Christa emphasizes that clinicians must recognize their patients' feelings. She says, "I tell my patients they don't have to like what has happened. The surgery may improve their lives overall, but they don't have to like their ostomies. You need to allow the patient to grieve. One of my patients was diagnosed with bladder cancer and within 3 weeks had a urostomy. Her family told her she should be glad she survived cancer. When I met her, she was struggling with the impact of all the changes that had occurred since she was first diagnosed with cancer. I told her she didn't have to be happy about what had happened. She responded, 'Do I have your permission to cry?' Despite the many challenges of ostomy care, very few patients fail to adjust once they recognize that this big change in their lives is a bump, a different path they have to take."

   A natural bent for psychology (she scored highest in Psych on her Nursing Boards) has made Christa a "huge believer" in the mind-body connection with regard to healing. She tells reluctant patients anticipating non-emergent surgery that that they should not go into surgery thinking this is the worst thing that can happen to their bodies. "It is important that patients understand the surgery that needs to be done and have confidence in their hospital team - surgeon, nursing staff, and others with whom they will interact. When I see anxious patients before surgery, I try hard to reassure them, explaining ostomy care and answering any questions they have. In a few cases, I have called their surgeons, alerting them to specific patient concerns that need to be addressed before the surgery. I also encourage patients to take an active part in their preparation and recovery from surgery by coming to the hospital well nourished (lots of protein foods and fluids before surgery), confident that this surgery will help them gain better health."

   Because the job, as she says, "keeps getting bigger," Christa finds it increasingly challenging to perform her duties according to her self-set high standards. "I never want to lose the patient perspective. With all of my responsibilities, I want to keep skin, wound, and ostomy patient care on the front burner. To keep focused, I remind myself daily that it could be me or a family member in that bed. It helps me be there for the patient. I also find it especially gratifying to care for a population many people don't want to talk about."

   Ingenuity and persistence, along with the earned recognition and respect of both physician and nursing staff and her patients, continue to provide enough rewards to offset the heavy work load. Christa notes two cases in particular: the first involved a 60-year-old obese woman with venous stasis ulcers on whom she used compression and silver dressings to achieve complete healing. "We were both so delighted when she came in for her last appointment and left laughing - totally healed - with no dressings," Christa says. In the second case, a young man with complex physical problems needed an ostomy appliance that he could manage with a minimum of assistance. With the support of other hospital staff and a company vendor, Christa found an ostomy appliance that fit his needs and allowed him to maintain some independence. "I continue to grow in my clinical role and as a person," says Christa. "I am able to impact the well being of so many people in this specialized scope of practice."

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