My Scope of Practice: Practice Makes Perfect

If you want others to be happy, practice compassion. If you want to be happy, practice compassion. - Dalai Lama

     Irene Jankowski, MSN, APRN-BC, CWOCN has been a registered nurse since 1979. She later obtained a Masters of Science degree in Nursing from the City University of New York Lehman College (Bronx, NY) and post-Master’s Certification as an Adult Nurse Practitioner from New York University (New York, NY). In 1989, Irene completed a certification program in wound, ostomy, and continence nursing at the Harrisburg (PA) Hospital School of Enterostomal Therapy. Shortly after, she obtained board certification as a WOC nurse. Her experience as a RN has included pediatrics, critical care, medical/surgical nursing, clinical nurse specialist, and nurse practitioner. As a nurse practitioner, she focuses specifically on patients with wounds, stomas, and continence issues.

     A preceptor for graduate school nurses pursuing WOC certification and teaching experience at the associate and baccalaureate degree levels, Irene has a keen respect for learning. Presently Beth Israel Medical Center’s (New York, NY) WOC-Nurse Practitioner, Irene has both clinical and administrative responsibilities. Clinical duties include direct management of patients with wounds, stomas, or specific continence-related problems; collaboration with colorectal, urological, and general surgery; and management of an outpatient ostomy clinic. Administrative responsibilities include management of a pressure ulcer prevention program, developing patient programs and initiatives, and overseeing costs related to the care of patients within her specialty. In addition, Irene regularly educates nurses, physicians, and other healthcare providers who care for patients with wounds and stomas.

     When Irene first began working as an enterostomal therapist (ET, now referred to as a WOC nurse), her main focus was patients with stomas or pressure ulcers. The ET clinical specialty has since expanded from a RN patient-centered focus to a more advanced practice role that combines direct patient and administrative responsibilities with facility-wide programs specifically geared toward improving patient outcomes and safety. “Since I became a nurse in the late 1970s, healthcare and nursing in this country have gone through many changes,” Irene says. “We are moving from reactively identifying and treating disease to health promotion and disease prevention. Wound healing practice also has changed over the past 20 years to a more science-driven process. This has led to a greater understanding of the complexities of wound healing.”

     With impending healthcare reform, Irene believes WOCNs may be in for some major role changes. “We are already seeing changes as a result of the new CMS ruling that eliminates reimbursement for the care of hospital-acquired injuries like pressure ulcers,” she says. “Hospitals are stressing the importance of patient safety and patient satisfaction. This is very positive for the nurse who becomes a WOC specialist because of our focus on quality, preventing avoidable injuries, and adding to the satisfaction of patients receiving WOC care. I am hoping the CMS will follow this ruling with a plan to provide reimbursement support for prevention and reimbursement for nursing specialists who can help patients avoid complications and injuries. Unfortunately, at this time, pressure ulcer prevention products often are not covered.”

     One major focus of WOC nursing is working with facilities to develop and implement programs to prevent pressure ulcers, an all too frequent complication of hospitalization for certain at-risk individuals. This year, Irene applied for and was awarded a scholarship funded by a partnership between Hill-Rom (Batesville, Ind), a company that engages in research and produces products designed for pressure ulcer prevention, and Joint Commission Resources* ([JCR] Oak Brook, Ill), a not-for-profit affiliate of The Joint Commission dedicated to providing quality and safety innovations to healthcare organizations. Irene currently is engaged in a project designed to identify barriers to bringing best practices in pressure ulcer prevention to bedside practitioners.

     Professionally, Irene finds it particularly rewarding to be able to help patients who are suffering with wounds and patients who are fighting cancer and bowel diseases such as ulcerative colitis and Crohn’s Disease. “Helping these patients provides an opportunity to offer practical solutions to everyday problems that may cause patients anguish and embarrassment,” she says. “Plus, because WOC nurses work very closely with patients, wonderful long-term relationships develop. Preventing wounds such as pressure ulcers in vulnerable patients by mobilizing colleagues and bringing state-of-the-art products to patients also is fulfilling.”

     WOC nursing also comes with challenges — for Irene, these include limited resources, lack of insurance reimbursement for needed supplies, and a lack of reimbursement for outpatient services provided by nurses. “Through working with the experts at JCR and Hill-Rom, I am learning how to help facilities refine their processes for pressure ulcer prevention and to identify gaps in their prevention programs,” she says. “One example of a gap in many pressure ulcer prevention programs is the common practice in hospitals to provide pressure ulcer prevention education only to nurses and nursing assistants. Prevention strategies typically are not taught to other members of the healthcare team such as physicians, interns, and ancillary staff even though they spend a significant amount of time with patients. Education for patients, families, and other caregivers also often is missed.”

     Irene enjoys another aspect of her title. “WOC nurses have a facetious sense of humor in addition to all their brainpower,” she says. “WOC nurses have probably heard every bathroom joke! You have to have a good sense of humor and our patients with stomas frequently learn to use humor in order to cope with difficult times. We are referred to as ‘decubitus nurses’ and ‘bag ladies’.” A story that still elicits laughter involves an incident when Irene was asked to check the heel of an elderly, bedridden patient for what seemed to be a pressure ulcer. When she entered the room with another nurse, the patient was positioned on her back with feeding pump and IV in place. The nurse indicated to Irene that the patient had been unresponsive for a few days. The only sound in the room came from the air conditioner. The two clinicians gently pushed the covers back from the patient’s feet as quietly as they could. As Irene began to lift one foot up to examine the heel, the patient suddenly screeched, “Hey! Who’s down there messing with my feet?” Irene and her colleague jumped in complete shock. The patient was no longer unresponsive and although the heel was a little red, there were no signs of a pressure ulcer.

     Irene has built numerous friendships and memories throughout her nursing career. “A young man was admitted to the hospital after suffering gunshot wounds to the abdomen,” Irene recalls. “After surgery, he had a large open wound with multiple fistulas pouring out fluid. He was a mess when I saw him but he was alive, awake, and wanted to live. Because I was with him so much, applying and changing his dressings and constantly devising ways to keep the drainage contained, we used to joke that I spent more time with him than with my husband. He called me ‘Mr. M,’ the character who designed James Bond’s spy equipment in the Bond films, because of all the gadgets I had to use to keep him dry. He was in the hospital for nearly a year and suffered various complications and infections but he kept hanging on. Finally, he was well enough to go to rehab and I lost track of him. A year later, I was working in the hospital and heard someone call my name. There he was, looking strong and healthy. He gave me a hug and told me he wanted to come and say thanks and to let me know that he was all right. Working in this specialty may not be glamorous but it is definitely rewarding.”

     Over the years, Irene’s work has taught her to never believe people who say no money is available when it comes to patient safety. She now understands what her mother meant when she used to tell her, “The money is there, you just have to find it.”

     Irene makes time to read wound care journals such as Ostomy Wound Management and JWOCN for all the latest knowledge and news in her practice. Her guilty pleasure is downloadable fiction — “I download it onto my iPod so I can listen when driving, commuting, or flying,” she says.

     Irene encourages nurses who are interested in this specialty to secure basic bedside experience and then apply for an advanced practice program. WOC nursing affords advanced practice nurses looking for a niche an excellent way to use their skills to make a difference. “Our patients suffer with difficult problems that impact their daily routines and overall quality of life,” Irene says. “WOC nursing epitomizes what a nurse is trained to do. As one colleague put it, ‘medicine tells the patient what they have and nurses help the patients to live life with what they have’.” Her ability to apply her practical knowledge with years of hands-on experience are bonuses to Irene’s warm and caring spirit, which shines everyday in her scope of practice.

     *More information about the JCR project is available by clicking on the nurse scholar section of the JCR website – www.jcrinc.com.

This article was not subject to the Ostomy Wound Management peer-review process.