My Scope of Practice: Minding Your P`s (Protocol) and Q`s (Quality)

 Even after more than a quarter of a century in nursing, Marietta Glazer, RN, PhD, CWOCN, celebrates the fact that “it never gets old – there is something new everyday.” She has directed her energy and enthusiasm toward creating a supportive and efficient environment in which she, colleagues, and staff can facilitate care. Marietta’s southern Florida constituency includes many senior citizens who have passed the 100-year mark. The challenges of treating the aged as well as the special needs of ostomy patients are special priorities in Marietta’s scope of practice.

  Memorial Regional Hospital, Hollywood, Fla., is a 684-bed acute care hospital and designated spinal cord trauma center for the area. Marietta, with the assistance of a part-time ET nurse, is responsible for ostomy and wound care patients in the entire hospital facility and the Joe DiMaggio Children’s Hospital, a part of Memorial Regional Hospital. Until recently, she was also the only full-time ET nurse for two other hospitals affiliated with the Memorial Healthcare system. Some of her duties include nursing orientation, teaching, educating staff, and overseeing an ostomy wound team to promote collaboration and division of work.

  As part of her educational efforts, she currently is collaborating with the National Pressure Ulcer Advisory Panel on an initiative entitled, “Avoidable versus Unavoidable Pressure Ulcers,” the first such program, which will be presented in South Florida at Memorial Regional Hospital on February 15, 2002. Marietta also was instrumental in the development of the first ostomy outpatient clinic in the tri-county area.

  “Developing and instituting wound care policies and procedures for an entire healthcare system has become a big chunk of what I do,” Marietta says. “I helped institute AHCPR guidelines on the prevention and treatment of pressure ulcers throughout the system. I also fashioned protocols related to administrative forms, standing order sheets, and quality monitors. It is so gratifying to see nurses take these programs and apply them because they know what to do, how to do it, and why they are doing it and how to document their efforts. This education has empowered them to go forward and elevate the quality of care they provide for their patients.”

  Ostomy patients are especially important to Marietta. She brings them to the forefront by providing pre-operative education on working with stomas, championing pre-operative stoma marking, and counseling patients on how to facilitate a return to a “normal,” if different, lifestyle. After the AHCPR published its guidelines in 1994, Marietta developed an ostomy wound resource team comprised of a nurse from every unit in the hospitals and home care agency in the healthcare system. The team also includes inpatient and outpatient physical therapists, nutritionists, infection control specialists, geriatric specialists, and nurses who work in the OR, Recovery, ER, administration, and education. The team meets on a monthly basis for an hour-long round robin that addresses problems on and among the units and has become a model for other teams under development in the hospital.

  “If, for example, Recovery has a problem with a particular unit, we will do a mini- quality improvement forum to address the issue,” Marietta explains. “The last 5 minutes of the meeting are set aside for new product review.” Minutes from the monthly meetings are sent to nurse managers and the medical director.

  Mandatory skills labs, held four times a year, also nurture on-going educational efforts. They are arranged by the ET department and serve as refresher courses on ostomy and wound care. Participants move from table to table, enhancing their comfort and familiarity with skills and products. Nursing orientations are also held to provide information on ostomy care, ulcer prevention, skin assessment, and documentation. When product representatives want to detail new hospital products, nurses have a say regarding scheduling a convenient time for inservice. “All of this has given the nurses a sense of ownership,” says Marietta. Nurses also have been empowered to initiate treatment with more efficacy through use of standing doctor order sheets, revised to differentiate more clearly what can and cannot be performed without a physician’s order. Asked how receptive physicians are to the increased degree of nurse involvement in decision-making, Marietta replied that she married her most severe critic – her surgeon husband. Once he had been a skeptic, but now better respects, appreciates, and embraces the abilities of his wife and those like her. “There is a great deal of collaboration,” says Marietta. “Memorial Regional Hospital philosophy is directed at quality and safe patient care.”

  To further foster empowerment, only representatives from companies whose products are in use may make presentations. This has resulted in greater standardization and brought down the cost of products such as mattresses and overlays.

  Marietta was instrumental in developing a wound care protocol poster that takes nurses from admission assessment to discharge. The at-a-glance format is less cumbersome and more accessible than traditional wound care books and has become the wound care bible in Marietta’s facility. This poster was presented at the Skin and Wound Care Clinical Symposium in Lake Buena Vista, Fla. in September 2001.

  In 1987, Marietta created Project BABI with the Broward County Medical Association Alliance. Through donations and events, funds are generated to provide supplies for financially challenged children and adults with ostomies and wounds. In 1988, this program was recognized by the Florida Medical Association Alliance as the best youth-oriented program.

  Like most nurses, Marietta faces the challenges of dealing with short hospital stays, limited time and resources, reimbursement, litigation, and the need to teach patient self-care in less time. In addition, she focuses on the special needs of the elderly, neonates, ostomy, wound, and bariatric patients. When treating chronic wounds, she advises staff to “keep in mind that they take a long time to heal and some patients never heal completely.” Marietta emphasizes the need for nurses to collaborate, delegate, adhere to simplicity, utilize listening skills, and stay current. Nurses also need to take care of themselves and take time to re-energize to prevent burn-out. In the past, Marietta has facilitated a nurse support group at her hospital that meets twice a week over lunch to allow nurses to vent. She sees roles and jobs expanding and evolving, for many nurses are not staying in one area. She is a prime example, moving from an ET nurse into the wound care arena and now grooming others to do the same.

  Marietta also enjoys being involved in many community projects, such as the American Cancer Society, Henderson Mental Health, Kids in Distress, and Broward ostomy associations. She has been the recipient of many awards, including Woman of the Year for the American Cancer Society, Woman of the Year for the Weitzman Institute of Science, Eckerd 100, Outstanding ET of the Southeast Region (awarded by the International Association of Enterostomal Therapists), and The Spirit of Excellence in Healthcare from the America Association of Business Women.

  “Live in the moment,” Marietta says, “but be prepared for the future and respect the past. ET nurses have skills, heart, and knowledge. We can ensure quality if we work together.” With her focus on caring, quality, community and evidence-based practice, Marietta has reason to feel proud of her professional mission and her scope of practice.