My Scope of Practice: Still Rewarding After 24 Years

   Jan Avakian-Kopatich, BSN, ET, COCN, CWCN, has no trouble explaining what she likes best about her position as a Certified Ostomy/Wound nurse at St. Luke's Medical Center, Aurora Health Care, Milwaukee, Wis. She values the independence the specialty has afforded her.

She enjoys developing close, professional, long-term rapport with her patients and their families. She feels appreciated by physicians who respect her expertise and treat her as a valuable team member. She likes experiencing the gratitude of the nurses she relieves of time-consuming wound/ostomy duties. Patients trust her. Vendors provide educational support. For Jan, attending ET school was the best career choice she could have made as a nurse.

   Jan's was a straight path in ostomy and wound care. A 1975 graduate of the University of Wisconsin, Milwaukee School of Nursing, she earned ET certification 4 years later and has been at St. Luke's, a 600-bed acute-care facility, since 1980. "I am one of two certified ostomy/wound nurses," Jan says. "For the past 3 years, I have been based in the Center for Comprehensive Wound Care and Hyperbaric Medicine, which boasts a nurse manager, five hyperbaric/wound care physicians, 12 RNs, three LPNs, four hyperbaric techs, two wound care assistants, and three secretaries, in addition to the two ostomy/wound nurses. In 2001, 21,503 wound/ostomy visits were made in the inpatient and outpatient settings served by our department."

   The high volume is largely the result of the addition of two physicians. Jan explains, "A colorectal surgeon who came on board 5 years ago is drawing patients not only from the greater Milwaukee area, but also from other parts of the state and outside of Wisconsin. He successfully performs the ileal pouch anal anastomosis (IPAA) procedure with temporary ileostomy for a high volume of patients. We're seeing fewer permanent ostomies, which is uplifting - patient satisfaction is high."

   Three years ago, a hyperbaric/wound physician arrived, dramatically changing wound care services at St. Luke's. "Before he came, the wound care team consisted of one other certified wound care nurse and myself performing all of the inpatient wound care," Jan says. "Now, we are a department of 32 serving four patient populations: patients using the hyperbaric chamber with and without wound care needs, the outpatient wound clinic, the physician-driven inpatient wound team, and the RN-driven wound team of which I am a part.

   "The growth has been phenomenal, thanks to the vision and drive of Dr. Jeffrey Niezgoda, the medical director of our department. In 3 years, he developed a state-of-the-art, nationally-recognized Wound Care/Hyperbaric Center that provides services not only at St. Luke's (the flagship hospital), but also at three sister hospitals." St. Luke's has two large multiplace hyperbaric chambers, "Bonnie and Clyde," that are used to treat multiple patients in one hyperbaric run. The three sister hospitals have monochambers for single patient use.

   Jan says that while the changes have increased patient volume, her responsibilities have basically remained the same and include ostomy management/teaching for new and existing ostomy patients as well as wound care. In the Outpatient Test Center, she provides pre-op instruction and stoma site selection for new ostomy patients having planned ostomy surgery. These patients are followed postoperatively until discharge for teaching. The Visiting Nurse Association is under the Aurora Health Care corporate umbrella and their two CWOCNs follow Jan's ostomy patients post-discharge, allowing for great continuity of care. Patients with older ostomies receive assessment of their ostomy regimens, and, if necessary, assistance with appliance changes while they are hospitalized. Ostomy patients are seen on an outpatient basis if problems arise. Jan also provides ostomy care lectures to nursing students every semester.

   Naturally, wound care is a big part of Jan's daily routine. "As a member of the nurse-driven division of the wound center, I provide inpatient wound consults that do not require the wound physician's intervention," Jan continues. "We evaluate and treat pressure ulcers, vascular ulcers, diabetic ulcers, skin problems related to incontinence, skin tears, tube-related issues, and other miscellaneous skin/wound problems. The recommendations we make to the attending physician are usually followed with no questions asked. If I feel the patient requires the expertise of the wound physician, I will make that recommendation and the attending physician will write the consult. My team re-evaluates wound patients one-to-two times a week, and the nursing staff performs the recommended treatments in-between our visits. Our services do not require a physician's order, although most of our consults come from the medical staff." Jan's wound care duties also include planning and participating in the annual Pressure Ulcer Prevalence Survey for the hospital.
Product selection also falls into Jan's domain. "The hospital allows us to stock the ostomy products necessary to perform our job," she says. "Having the appropriate tools is mandatory for maximizing job performance and for problem-solving challenging ostomy issues so we can deliver optimal patient care. Wound care products are primarily trialed/selected by the wound physicians/nurses in the outpatient clinic, where progress can be monitored closely on a long-term basis. Product vendors are invaluable in educating us about new and innovative products on the market."

   Jan doesn't foresee any major changes in the near future in her institution's program, but she acknowledges that as the population ages, need for her services will grow. The challenges of reimbursement, high patient loads, and shorter hospital stays affect the time available for care and teaching. Still, the rewards are numerous in both ostomy and wound care. "This specialty offers opportunities in acute care, home care, and independent practice," she says. "As a practitioner, you are a valuable member of the healthcare team, working closely with physicians and nurses and providing personalized care to the patient."

   Partial to her role as an ostomy care provider, Jan feels she truly impacts a patient's life during a healthcare crisis. "Having an ostomy changes one's life," she says. "My goal is to help the patient cope so the ostomy doesn't rule his or her life. Only then can a sense of normalcy be resumed. Obviously, this can't be accomplished in one short week in the hospital, but if presented in a sensitive way from the start, the nurse can set the stage for positive rehabilitation following ostomy surgery. I've definitely found my niche in nursing. The hugs and the thank you's at discharge say it all in my scope of practice."

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