My Scope of Practice: A Shining Star in Incontinence Care

Whoever renders service to many puts himself in line for greatness— great wealth, great return, great satisfaction, great reputation, and great joy. – Jim Rohn

  Jeannine McCormick, RN, MSN, CRNP, is the 2010 recipient of The National Association For Continence’s (NAFC) premier Shining Star Award. Supported by the NAFC and funded by Pfizer Global Pharmaceuticals, the award acknowledges contributions in research, education, and the advancement of clinical practice — in Jeannine’s case, 9 years of dedication to patients dealing with the physical and emotional challenges of urinary and fecal incontinence.

  Jeannine earned her associate’s degree in nursing in 1992 from Wallace State University (Hanceville, AL). She started her nursing career in med-surg and 6 months later she was working 7 on/7 off in the hospital’s emergency department. She decided to pursue her bachelor’s in nursing degree at the University of Alabama (Huntsville, AL), doing most of her clinical hours on her “off” week. After completing her BSN, she worked at a regional medical center; in 2 years, she became an Assistant ED Director and the Education Director for the Department. She also was a part-time clinical instructor at WSCC’s nursing program.

  Although teaching was fulfilling, Jeannine decided to further her education and pursue a master’s in nursing. “It was not long before I realized I wanted to get back to the bedside,” she says. “I obtained my degree in May 2000 to become a family nurse practitioner. I was not immediately sure what to do. One of the physicians I worked with suggested a company performing continence management in the nursing home setting. After one day of shadowing in the nursing home, I knew this was what I wanted to do.” Jeannine has been working with patients with incontinence since 2001. “I never dreamed I would be a pee and poo nurse, but I love it,” she says. “It is the second greatest job I have ever had — right after being a mother.”

  Eventually, Jeannine was recruited by the University of Alabama at Birmingham (UAB) Continence Clinic, located in the Kirklin Clinic in Birmingham, where she has worked for nearly 6 years. The clinic was founded in 1992 to evaluate and treat men and women with urinary and fecal incontinence and to conduct research to improve care for these patients. The clinic provides a multidisciplinary approach that includes nursing, behavioral medicine, geriatrics, urogynecology, colon and rectal surgery, urology, radiology, and gastroenterology. Treatment options range from behavioral therapy to the latest in robotic surgical procedures. Ongoing research protocols, as well as those that have been completed, are advancing the field. For Jeannine, this facility comprises the perfect combination of clinic, research, and teaching.

  Jeannine’s job description and duties have evolved over the years. Advancing her education and gaining invaluable experience allow her to function as collaborator, educator, facilitator, patient advocate, researcher, clinician, and behavioral interventionist. Monday through Thursday, Jeannine devotes most of her time to patients. “Our staff consists of two physicians, myself, one medical technician, and a scheduler,” she says. “I handle all nurse calls for myself and the two physicians that have clinic a ½ day a week. I am the primary pessary fitter for our practice. I precept WOCN students, interns, residents, and fellows. We perform several procedures including cystometrograms, uroflows, ultrasound for post void residuals, biofeedback, anal rectal manometry, and percutaneous tibial nerve stimulation.”

  Research patients and conference calls are interspersed with the regular clinic patient responsibilities. Each study requires adherence to a very specific protocol, which at times can be rather limiting. Jeannine often has to remind herself that the best method for the particular study at hand is not known — that is why they are conducting the study. For example, after attending a Society of Urologic Nurses and Associates (SUNA) conference, Jeannine realized that one of her ailing patients was most likely having pelvic muscle spasms and needed evaluation and special treatment, which led to her researching pelvic floor dysfunction and trigger point release. She then was able to establish and implement treatment options her clinic had not previously offered. “The clinic now receives many referrals from GI, urology, and urogynecology when pelvic muscle dysfunction is suspected,” she says. “Also, I am the only nurse who provides continence care to a local affiliate nursing home. I work with facility nurses, physicians, CNAs, and family members to improve the residents’ bowel and bladder function.”

  Jeannine says some of the most gratifying aspects of continence care are developing intimate relationships with patients, a closeness borne of the sensitivity of their conditions. “Patients have to feel they can trust me and feel comfortable sharing their most upsetting and embarrassing moments,” says Jeannine. “I like that I have a part in changing patients’ lives. I love that I can take the time out to listen to them and empathize with what they are going through. I love being able to help them help themselves, empowering them to change their lives. Continence is something we all take for granted until we lose it.”

  As with any medical career, Jeannine must overcome barriers to providing optimal care. Nocturia is one of the most challenging problems to conquer because it can be caused by a variety of issues. Limiting nighttime fluids and decreasing caffeine is a huge challenge. A common misconception is that patients leak because of old age and nothing can be done. It takes a great deal of time and effort to convince family members this notion is incorrect and that helpful options exist.

  The social stigma of incontinence is another obstacle. Many people find it difficult to admit they have a problem — as such, they do not mention bladder leakage or bowel accidents to their primary care physician. Persons brave enough to seek treatment or talk about such problems with physicians most likely had the problem longer than they are willing to admit. Whenever she has the opportunity, Jeannine encourages physicians to initiate conversations regarding bowel or bladder control.

  Additional challenges are patient unwillingness to do necessary exercises, use recommended vaginal hormone cream, or take medication appropriately. “Patients with dementia who are not agreeable to a toileting schedule have limited treatment options,” she says. “The cost of medications and protective undergarments is often very prohibitive. The social services department and programs offered by the drug companies make it possible for patients to have their medication and groceries and not have to choose between the two. In addition, limited mobility can result in incontinent episodes that normally could be prevented.”

  Jeannine provides her patients numerous strategies. She often has them complete a bladder diary to identify problems and track progress. She reinforces the importance of limiting bladder irritants and encourages reducing caffeine consumption. “I help with sample medications and drug assistance programs and fight with insurance providers for non-formulary medication that has fewer side effects,” says Jeannine. “For patients with dementia, an alarm clock set to prompt them to void every 2 hours can be less offensive than a ‘nagging’ family member. Arranging for family members to help with bedside commodes and trips to the bathroom can often be the difference between an accident and a void.”

  Overall, Jeannine believes information offers the best answer in any difficult situation. She suggests that all care providers educate the family, hospital staff, nursing home staff, physicians, and the patient as best as they possibly can. Giving options and assisting with the formulation of a care plan that will work based on specific patient needs will yield favorable outcomes.

  Jeannine has witnessed significant changes in her practice environment and work responsibilities in the past few years. In Alabama 10 years ago, nurse practitioners were treated as glorified nurses and employment options were scarce. Today, Jeannine is a vital member of the care team and physicians often ask her advice. One of the physicians in her facility tells his patients that Jeannine is quite the expert in constipation and pelvic floor dysfunction. “This was the pinnacle of my career— being deemed ‘Queen of poop’!” she says. “I sincerely hope nurse practitioners continue to fulfill their role as providers, earn physician respect, and be counted as team players and not as the competition.”

  Two particular patient stories have a special place in her work-related memories. One involved a patient relocated to Jeannine’s area following Hurricane Katrina who was suffering with fecal incontinence. After having issues with bowel and bladder incontinence for 4 years (she was having 20 or more bowel movements daily and multiple episodes of fecal incontinence), she was able to get her life back after a few months of dietary modification, pelvic muscle exercises, and use of Beano®. Her condition improved so drastically that she was able to return to work as a nurse instead of going on disability due to the incontinence. The other inspiring story surrounds a woman who had almost given up hope after a stroke. She was wearing diapers and had absolutely no control of her bladder and had been told that nothing could be done to help her. “We tried a step approach to treatment and she improved with exercises and an anticholinergic,” explains Jeannine. “When I fit her for a pessary for the stress incontinence, she regained the majority of her control and now has only two or three leaks a month. Her hard work and dedication to reach her goal demonstrates the success that can be achieved by not giving up.”

  Jeannine’s work has taught her valuable lessons. First, she realizes the gift the elderly population can be to our society. “The golden years are golden because of the great worth of the thoughts, ideas, and experience of those who have lived longer than us,” she says. Jeannine also touts the value of listening, even when you don’t have time, and treating her patients as sweet and tenderly as if they were her own children. “Pay attention to the details,” she says. “Guide in helpful ways — give them the tools they need and let them do things themselves, no matter how much you want to do for them. Reinforce what you taught them because they may not get it the first time. Celebrate their successes and celebrate them. Support them through the set backs, encourage them during the tough times. You both have an investment in their success, but ultimately it is up to the patient.”

  Looking ahead, Jeannine anticipates continuing her work at The Kirklin Clinic to both service and study patients. She also is planning a clinic to see ambulatory patients at the assisted-living facility and nursing home and increasing nursing home services. She hopes to write grants and articles and to establish a better evaluation system for nursing home residents. “I love what I do but it can be challenging,” she says. “You must be compassionate and truly care about each person that you meet. If you like working with people (especially the elderly), have the patience of Job, enjoy teaching, love a mystery (diagnosis), and don’t mind structure (research), this could be your scope of practice.”

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