My Scope of Practice: The Power of Many, The Power of Two

   When the patient is also a professional peer, treatment has the potential to get... complicated. But Laurie Rappl, PT, CWS, is one patient and peer who is grateful for the care she receives from fellow ET nurse Laura Shafer, RNC, BSN, CWOCN, who modestly disclaims the impact she has on patients and protocols as just one of the rewards of being part of an effective wound care team.

   Earlier in her career, Laura, a graduate of nursing programs at Clemson and Emory universities, was a medical/surgical clinical instructor at Dekalb Medical Center in Decataur, Ga. Because she missed treating patients, she went into enterostomal therapy and has been involved in healthcare in that capacity for 12 years, 11 of them at her current facility, Gwinnett Medical Center, Lawrenceville, Ga. "When I started as an ET at Gwinnett, I was part time and temporary," she says. "They weren't sure they needed my services. Now we have 3.5 ETs who cover the hospital system's three hospitals, plus an 89-bed long-term care facility and a wound treatment clinic. That adds up to approximately 400 patients monthly."

   The Wound Treatment Clinic opened as a result of a proposal Laura wrote in 1998. At first, the clinic only saw 50 patients a month. That figure has grown to 250. Six years before that, Laura was instrumental in starting a skin care committee to enhance the nurses' decision-making responsibilities. Two nurses from every floor are involved. As part of the committee, nurses handle product selection (for example, mattress replacement). Laura facilitates inservices for staff as well. The group now meets bimonthly; originally, meetings were held once a month but the nursing shortage has increased demands on everyone's time.
Her interest in ostomy patients inspired Laura to start several support groups. Since May 1991, eight to 10 patients have gathered (now bimonthly) to hear physicians, other educational speakers, and sales representatives discuss relevant subjects as part of the ostomy support group she initiated. Laura also started a Crohn's/colitis support group that attracts an average of 25 people per month. "We have lots of buzz sessions," she says. "We discuss, among other topics, what medications work. We also present physician speakers and advice from dietitians."

   Laura is also the facilitator of the Promina Product Committee comprised of representatives from 14 metropolitan Atlanta hospitals. They make decisions regarding all wound ostomy continence product use, including recommendations for purchase. Laura finds this aspect of her responsibilities fun because she "gets to know all the metro Atlanta ETs."

   What Laura enjoys most about her job is working with the patients, which is one of the reasons she wanted to open the wound clinic. "In the clinic, I get to see wounds completely heal," she explains. "In the hospital, you don't see full healing." Her ostomy patients offer the same kind of satisfaction. "It's a thrill to see them change and empty pouches on their own -- to see them coping well. Seeing patients and families successfully handling new challenges are where I find the true rewards."

   Her efforts have been documented in reduced prevalence rates. According to a Hill-Rom pressure ulcer prevalence study, Laura's long-term care facility went from a 16.2% nosocomial prevalence rate to a 0% nosocomial prevalence rate in a 1-year period from March 2000 to March 2001. She credits the skin care committee and staff for effecting a decrease from 9.4% to 1.6% in nosocomial pressure ulcer prevalence at her acute care facility for the same time period. "The national average for pressure ulcer prevalence is 16%," she says. "We're at 0% and 1.6%. For an 89-bed long-term care facility, that's wonderful! It just takes lots of education."

   Laura's duties do not come free of challenges. Staying within budget, reimbursement issues, and keeping up with changes could take their toll. Laura credits a strong team effort and some great accounting people for the positive outcomes of her efforts. She is particularly grateful to Gregory Schlegel, MD, vascular surgeon and the Medical Director of the Wound Treatment Clinic; Maurleen Fincher and Kelly Scoggins, both WOCNs; Brian Brake, PT; Laura Zanolla, WOCN; and Lisa Lovelace, office coordinator. Laura repeatedly emphasizes that it's not just one person -- you have to recognize everyone's effort. "I'm so lucky," she says. "The hospital has supported our endeavors while allowing us to remain autonomous.”

   As much as Laura's role and responsibilities have broadened in the past dozen years, she knows that wound treatment in her arena will continue to evolve. "The volume of patients continues to increase, so even with an increase in staff, I'll still be handling management duties on my own time," she says. "From now forward, my long-term goal is to get more involved in continence management, time permitting. For now, I find this profession extremely rewarding. You just have to remember that results often aren't immediate. It can take months for a wound to heal. It can take months for an educational program to have an effect."

   Laurie Rappl knows that all too well. With Laura's compassionate and knowledgeable care, Laurie can heal and carry out her own nursing responsibilities. Teamwork may involve many staff or simply the cooperation and understanding between patient and nurse…all within one scope of practice.

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