My Scope of Practice: Resolution for All Year

    Resolution. Not the new year’s kind but rather the determination to achieve a goal despite the obstacles.

Diane K. Newman, RNC, MSN, CRNP, FAAN, wants other nurses to emulate her vision and mission — she wants them to pursue a career working in the sometimes elusive and often misunderstood realm of incontinence care. Diane acknowledges the hurdles inherent in this career choice: the limited availability of training programs, the lack of trained practitioners, and the fact that incontinence and related pelvic disorders are still viewed in many cases as “women’s problems” and not given the attention they warrant. To Diane, these hurdles are not insurmountable. As Co-Director of the PENN Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, Philadelphia, Pa., as well as teacher, author, and international presenter, Diane brings her knowledge and experience — and, yes, her resolution — to the bedside as well as the blackboard and podium to help heal and to help inspire.

    Diane is Philadelphia educated — she graduated with an RN from the Hospital of the University of Pennsylvania in 1975, earned her BSN from LaSalle University in 1983, and achieved a MSN from the University of Pennsylvania and Adult Nurse Practitioner certification in 1986. After receiving her Masters, she began working with a urologist who was interested in helping women with incontinence. Surgery to cure incontinence, however, wasn’t always successful. Diane began researching nonsurgical alternatives, but answers were not readily forthcoming. “I had to find out where to go to learn more about nonsurgical incontinence treatment and eventually found Kathy Burgio, a psychologist who was researching behavioral treatments for urinary incontinence at the Geriatric Research Center (GRC) in Baltimore,” Diane says. “I learned what I needed to achieve positive outcomes with patients and applied those principles to my practice. In 1986, when Medicare expanded nursing home reimbursement to include nurse practitioners, I started an independent practice. Physicians, particularly, urologists began referring cases to me and my practice grew to include a staff of six direct providers, all nurse practitioners, who practiced in all settings, including nursing homes, home care, and ambulatory care.”

    Seeing that incontinence-oriented services were in demand, Diane began setting up similar practices around the country. She missed hands-on patient care, however, and returned to Penn’s urology department, developing the position of Co-Director of its continence/pelvic health center.

    “Urology provides a comfortable model for incontinence,” Diane says. “This specialty tends to have a large patient base of pelvic heath problems, incontinence, overactive bladder, pelvic pain, and interstitial cystitis and for me it has been a wonderful fit. Nurses have the basic skills to care for patients with incontinence and related disorders. They just need the clinical training. Unfortunately, wound care certification programs vary on subject matter and instructional time, often offering only a few days on these topics. This means nurses may graduate from these programs not knowing enough of what they need in practice. They need postgraduate education as well as the ability to think independently and the motivation to establish a bladder/pelvic health model within their practice or to seek collaboration with like-minded providers. Physicians willing to instruct them in necessary skills are also essential.”

    Medicine offers several practice models for incontinence practitioners to follow. In gastroenterology, for example, nurse practitioners work as “physician extenders,” receiving training to perform procedures such as flexible sigmoidoscopies. In the area of diabetic education, physicians refer patients to Diabetic Nurse Educators for on-going instruction and monitoring. “With physician and administrative support, there is no reason why a similar model would not be effective in most urologic practices in the US,” Diane says. “Incontinence is a growing problem and most of the bedside care is performed by nurses. In turn, nurses could initiate and expand collaboration with urology centers by stepping up and demonstrating what they could bring to the practice. We have sellable experience and need is growing. Plus, once such a practice is established, pharmaceutical and device companies are likely to seek your services for research on new medications and products (eg, urethral inserts, absorbent products, catheters, and devices to contain urine). There is a large potential for growth and professional and financial independence.” As proof of her point, Diane has served as principal investigator and co-investigator in many research studies on the treatment and management of urinary incontinence, overactive bladder, interstitial cystitis, and erectile dysfunction.

    In addition, Diane is a member of a panel of experts of the CMS Scope and Severity of Nursing Care Deficiencies that is addressing issues in long-term care on “Guidance to Surveyors on Incontinence and Catheters.” “Regulations will impact the market and increase the need for qualified nursing care,” she says. “This will open opportunities for nurses who specialize in this population to expand their practice.”

    Diane’s center schedules more than 20 patients per day who have problems that cover the whole gamut of pelvic floor health: general urological concerns, voiding dysfuction, pelvic pain, interstitial cystitis, overactive bladder, and incontinence, just to name a few. Physicians offer instruction and training when necessary (as with dilating catheters). Even with her extensive training and experience, Diane says, “Every day I learn something new.” The Center also allows clinical observations, training nurses who want to better understand the field. Diane also has a website (www.seekwellness.com) to facilitate dissemination of information.
Diane has taken her cause on the road, speaking across the globe on topics related to urinary incontinence. She authored three books (The Urinary Incontinence Sourcebook, Managing and Treating Urinary Incontinence, and Overcoming Overactive Bladder, which she co-authored with Dr. Alan Wein); serves as guest faculty at the Wound, Ostomy, and Continence Nurse Education Program at the University of Texas MD Anderson Cancer Center; holds editorial positions on several journals, including Ostomy/Wound Management; and she is the 2002 recipient of the National Association for Continence (NAFC) Continence Care Champion Award. But her professional priorities remain steadfast —that is, providing patient care and recruiting nurses to become trained, active participants in incontinence care. “I find it difficult to understand why more nurses are not involved in this aspect of care,” she says. “Is it because incontinence care is seen as a more palliative than rehabilitative? Is it the unavailability of education programs? Physicians want someone who is willing to provide the time-consuming bladder health services that will augment their practices. Who are better suited than nurses to address the behavioral, noninvasive approaches to continence care? It’s a wonderful area of nursing. People do get better in my scope of practice.”

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