My Scope of Practice: Paging Nancy Chatham

    Speculation is rife at Passavant Area Hospital whether anyone gets paged more than wound ostomy continence nurse (WOCN) Nancy Chatham. She developed the WOC inpatient/outpatient program and its services for her hospital; recently, she was appointed Director of the program, which provides educational programs, consultation, and support for nurses, physicians, and the community, along with quality care.

Nancy’s direct responsibilities include caring for patients with ileostomies, colostomies, urinary diversions, pouching problems, leg/foot ulcers, wounds, and drainage/feeding tubes. She performs debridement, chemical cauterization, fistula management, bowel education, pelvic floor retraining, and incontinence management and she is adept at complex treatment modalities and topical therapies. Under her charge, the program has grown from a staff of one to a staff of 12 in the past 4 years. Nancy also started a collaboration between local nursing programs and the hospital to educate nursing students on various aspects of WOC nursing throughout their curriculum, better preparing them for the standards of care they will be expected to achieve at Passavant, a small but technologically savvy institution.

    Nancy Chatham, RN, CWOCN, earned her nursing diploma from the St. John’s School of Nursing (Springfield, Ill.) in 1986 and began working in the home care setting. She transferred to a local visiting nurses company in 1994 where her interest in wound care was kindled and fanned by the fact that not many clinicians in her area had a wound care focus. Plus, she had the support of the company’s director who wanted her to pursue specialization. “I started reading everything about wound care I could get my hands on and attended conferences,” Nancy says. “In order to gain admission to the renowned University of Texas MD Anderson Wound Ostomy Continence Nursing program, I pursued a BS degree (quicker to earn than BSN) at the University of St. Francis, Joliet, Ill. I also earned CWS certification. I was still a field nurse and there was no guarantee I would be employed in the WOCN capacity but at least now I was trained and qualified.”

    Nancy’s reputation spread among the physicians at Passavant, a rural licensed 100-bed acute care facility that also has a 12-bed a Transitional Care Unit. They called on her to treat their wound and ostomy care patients but she was as yet unable to gain a position or title at the hospital. One night at 3:00 a.m., Nancy had an epiphany. “I woke up and started developing a plan to propose the WOCN position to the hospital. I already had the physician contact. After polishing my CV, I created a WOCN business/marketing plan, composed a brochure explaining the services I could provide, and met with the physicians, who offered their support. The Director of Nursing had heard about me and was eager to talk — the hospital had just completed a pressure ulcer study and the results suggested that my ideas deserved championing. To address business concerns, I also approached the Business Office to set up a billing/tracking system that coordinated providing and charging for services as well as to justify our presence to those who maintained we weren’t needed. Until my arrival, the hospital was relying on four basic dressings and no pericare products. Some changes were necessary.”

    With her plan and the new WOCN position approved, Nancy hit the ground running. “I started marking ostomies and my responsibilities grew from there,” she says. “I wrote policies and began seeing outpatients with Dr. Fred Scott, a Doctor of Osteopathy and board-certified general surgeon. I soon proposed that we open a wound care center and was provided a few rooms in the Physical Therapy department — a logical step because PTs also were interested in patients with wounds. Physician support of our efforts grew and we soon needed a waiting area. The hospital conducted a professional evaluation to substantiate need for the center and found we’d surpassed the original potential for the center to positively impact care. They were willing to oblige.”

    The Center is based out of Educational Services (not nursing) — a good thing, says Nancy, because education is so much a part of wound and ostomy care for both patients and staff. It also means the Center is not included in nursing staffing. “This gives us the opportunity to use non-staffing days to develop our educational programs and work with the nurses and the community on presentations.” Nancy helped design the department and office, which feature three treatment rooms and three wet rooms with accessibility to whirlpool and recently requested and received vascular equipment. “We are so busy with wound care, we may be expanding again,” Nancy says.

    Mindful of the need to perpetuate the legacy and availability of well-trained nurses, Nancy developed a collaborative educational program to initiate specialized training of future nurses earlier in their curriculum. She put the materials she had been using to orient new nurses (1 hour each of wound, ostomy, and continence training) onto the computer and originally shared the same information with senior students enrolled in the MacMurray College Nursing Program, Jacksonville. Nancy believed this training should be offered even sooner and the adjustments were made — now students are taught basic skin care in their freshman year, ostomy care in their junior year, and management skills in their senior year. The specialty lectures allow the nursing students to build on these skills from one year to the next. They can utilize their knowledge base and apply it to specifics of various types of wounds (eg, venous ulcers). “By the time they do their clinical hours in their junior year, they will have had their basic skin courses,” Nancy says. “By their senior year, they can pull it all together into diagnosis and treatment plans. They should have more patient contact before they take the Boards.” Nancy also precepts other WOCNs, grateful for the opportunity teaching provides for self-motivation and to “stay fresh.” Nancy’s endeavors are paying off — she sees a difference in the students’ and nurses’ patient notes and assessment skills. “They know how to properly culture a wound,” Nancy notes. “They don’t culture goo.”

    Nancy doesn’t let the challenges of hospital and physician politics detract from her sense of fulfillment and determination to provide care or from the pleasure she feels when the staff and students she mentors attain that same enthusiasm for the craft of specialty nursing. “I like making a difference when most think it’s impossible — from the refractory wound on an extremity recommended for amputation to the development of a profitable outpatient clinic. Research, quality assurance/quality improvement studies, tracking revenue and productivity, education, and utilizing people who support your program are effective means of overcoming barriers to providing optimal care. It’s no longer acceptable to ‘settle’. We must seek the best for our patients and our profession. We must find cost effective ways to benchmark our services with others in comparable markets. Fiscal responsibility has become increasingly important; providing cost effect quality outcomes by utilizing protocols and standards is a high priority for our program.”

    Divine intervention also may have had a role in Nancy’s calling. Recently, her husband had ruptured diverticuli that resulted in a diverting ileostomy. “I wondered how a lay person would be able to provide care for someone in this situation,” Nancy says. “My husband had an open abdominal wound that had to be packed along side a complicated ileostomy. He was receiving IV antibiotics and had a PIC line. After three surgeries in 6 months, he is better but I have to think I was guided onto this career path for a reason. I guess my strong desire to administer my dream helped my clinical side to build and market a care and educational program from which others also can derive benefit.”

    Looking at the big picture, Nancy foresees her role evolving as a consultant for the establishment of wound ostomy continence services in the small market setting, hopeful that what she has established at Passavant will serve as a standard for other programs. Personally, she would like to have her own consulting business. In the meantime, she is kept busy running from floor to floor, managing her various responsibilities. A recent hospital productivity study found that she was working as two people. She says, “It’s no wonder, then, that I have many pages to answer in my scope of practice.”

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