My Scope of Practice: One Title, Many Hats
Brenda Hensley, MSN, RN, CWOCN, has made a name for herself in the field of wound ostomy continence care - probably because, as she says, she "has her fingers in everything" (no pun intended).
As a Clinical Nurse Specialist/WOC nurse with Johns Hopkins Bayview Medical Center, Baltimore, Md., her responsibilities encompass policies and procedures, finance, patient care, and staff education related to ostomy, wound, and skin care. She collaborates with other ET nurses throughout the Johns Hopkins system, including an outpatient wound care center staffed by ET/WOC nurses and nurse practitioners. She has successfully implemented a hospital-wide wound/ostomy care program and serves as expert consultant to medical and nursing staff. "People think I'm the contact for everything," she laughs.
Early in her nursing career (before finding her current niche in ostomy wound care), Brenda repeatedly encountered ostomy patients who needed a specialist. "I felt badly for these people I couldn't help," she says, and subsequently went on to earn her ET certification. She has been involved at many levels with the WOCN Society since 1983 and is currently the President of the Mid-Atlantic Region. "This specialty impacts many departments and disciplines. Wound/skin care is challenging, interesting, and immensely satisfying."
Brenda is happy to have full-time partner Sharon Brady, BSN, RN, CWOCN, but she didn't always have help. To demonstrate the need for an additional "Brenda," she gathered statistics on patient care for a 3-year period. Her patient visits had tripled in that time and had reached a point where she wasn't able to meet everyone's needs. The physicians were not happy when she wasn't able to see all of their patients. "The powers that be listened," Brenda says. Now, in addition to having Sharon on board, a revised system generally sends all outpatients to the clinic, freeing Brenda and Sharon to focus on inpatients.
Brenda cites specific examples from each of her duties. "Regarding policies and procedures, a current project concerns implementing the use of knee-high instead of thigh-high TEDS. In order to make a change in policy, I initially spoke with staff and physicians in many specialties. Before implementation, appropriate hospital committees must approve, materials management and purchasing made aware, the policy updated, and multiple inservices provided. To provide continuity throughout the hospital, new protocols need to be communicated with the other clinical specialists and educators. Whether we are dealing with bathing systems or incontinence products, we have to present information to thoroughly support the proposed protocol. We have to make sure no little piece is left out."
In matters of finance, Brenda knows that supplies and billing are huge issues. She works with the Product Standards Committee to ensure that new items brought into the system will be cost effective and clinically efficacious. "Materials management in wound and ostomy care requires discussion with different suppliers who provide specialty items like pumps and beds," she says. "We must work with all departments to make certain that equipment is used appropriately and properly billed. In addition, we review invoices for accuracy. When we request a specific item, the purchase must be warranted and the documentation valid."
Brenda's educational position carries no strictly administrative responsibilities. "As a Clinical Nurse Specialist, I consider myself to be a peer to staff. I want them to feel free to come to me. My role in performance improvement has taken on an educational approach. I teach rather than discipline. For example, if a Braden scale assessment is not performed two times a week, there may be negative consequences for the patient. I help staff understand the importance of their role. In order to implement a successful wound and skin care program, everyone - from the bedside Patient Care Techs to the managers and administrators - needs to be involved. It truly takes a team."
This attitude synchronizes well with her status as an educator and role model. "I depend on the Patient Care Managers and administrators for their support of my activities and programs (which sometimes impact their budget, staffing, or supplies). They need to believe that I am doing the right thing - not because I have the authority, but because of my experience and knowledge." Physicians and staff obviously depend on her judgment: once, in the middle of an incidence/prevalence study, she had to run to the OR to mark an ostomy patient before the surgeon would proceed with surgery.
"The best part of my job is the patient contact," Brenda says. "Traditionally, the more experience a nurse has, the farther removed she or he is from patient care. I usually spend about 50% of my time providing direct patient care." Brenda also enjoys nursing education. One well-received effort is the medical center's Skin Care Resource Team. A large group of staff members (20 people) meet for 8 hours, once a month, for education, case studies, and performance improvement work. They address products and problems and take the information back to their individual units. "It's like extending me 20 times," Brenda says. Physicians and Patient Care Managers are kept informed of decisions made by this group, which effectively helps the teamwork. One recent concern was wound documentation. Suggestions were presented to the group and over 4 months a new form was developed, trialed, and revised. Brenda says a successful resolution was reached because staff nurses assumed ownership of the problem and made the decisions on what needed to be changed. In a related effort, wound/ostomy nurses from all over the Hopkins system also have planned meetings to discuss similar issues. "Patients go all through the medical center," Brenda says. "The system should work for them no matter what facility provides care."
Brenda also enjoys treating the international patients who come to Hopkins from all over the world. "I've helped treat people from Boca Raton to Bermuda to Saudi Arabia," she says. "Before they return home, I talk to them about their care after discharge. They need follow-up in their home countries, but the resources aren't always there." Brenda's solution was to find an organization that distributes excess ostomy and wound care supplies to countries where they are sorely needed.
For 1 week each summer, Brenda lends her expertise to a United Ostomy Association-sponsored summer camp for 10- to 18-year-olds with specialized medical needs. The Youth Rally is staffed entirely by volunteer ET nurses and counselors and is held on different college campuses across the country. Sites have included the University of Colorado at Boulder, Miami University in Ohio, and the University of San Diego (Calif.). This year's camp will be in St. Paul, Minn. "It's great to work with these kids," says Brenda. "What a difference a week makes in their lives. They are able to spend time with other children who share the same challenges and who really understand. For instance, a 13-year-old shared with one of the youth counselors that she was having a problem with gas. The counselor got a group of seven other teens together and they happily exchanged ideas on managing this common problem. The 13-year-old left camp not only with a solution to her problem, but also with the knowledge that she wasn't alone and that the other campers truly understood. Many youngsters have such a good camp experience that they come back as counselors."
Among Brenda's challenges is the dilemma of trying to provide optimal wound care in a system that is based in tradition. "Clinicians seem instinctively to lean toward saline and gauze dressings. I try to coordinate moisture-based products and appropriate dressings for each wound. Also, orders need to be standardized in order to simplify the process." As a new computer-based system is introduced, she has been working with the implementation team to ensure that wound care orders are accurate, consistent, and easily understood by all.
Ideally, Brenda hopes her role will evolve to the point where she will be free to see only the most complicated patients and that routine patient care can be appropriately managed through standardized treatment plans and unit resources. But she is adamant that she wants to stay by the bedside, no matter where her reputation and additional responsibilities take her. Brenda says, "When people ask, 'Are you the Brenda Hensley?' I can answer proudly, 'I am in my scope of practice."
