My Scope of Practice: When Prevention is Possible

Vision without action is a daydream, action without vision is a nightmare. — Japanese proverb

     As many as 60,000 patients die each year as a result of conditions related to pressure ulcers. To recognize the tremendous impact pressure ulcers have on mortality rates, patient quality of life, and hospital costs, the Forsyth Medical Center (Winston Salem, NC) launched a special initiative in July 2008 to reduce its already lower-than-average pressure ulcer incidence rate, which had averaged 3.6% and plummeted to 0.5% once the initiative was put in place.

     The recent drop in pressure ulcer incidence symbolizes success for Forsyth staff and Shirley D. Matthews, RN, MSN, CWOCN, CNS, Regional Wound, Ostomy, and Continence Nurse (WOCN) Coordinator for Forsyth’s parent company, the Triad Market of Novant Health (Winston Salem, NC). Shirley and a team of four additional WOCNs usually see 30 to 50 patients per day at the Forsyth Medical Center and Medical Park Hospital to follow-up initial skin assessments performed by staff RNs and other wound ostomy patient consultants. Because of the emphasis on early detection and aggressive treatment, Shirley and her team have watched the number of pressure ulcers continue to decrease.

     Shirley received her Bachelors degree in Nursing from The University of North Carolina Greensboro (UNCG) in 1980. She began her nursing career at Forsyth as a medical surgical nurse, eventually serving as head nurse. She later became involved in the educational aspect of nursing and enjoyed teaching and working closely with patients. Her experiences sparked an interest in ostomy and wound care. In 1990, Shirley completed her course on Enterostomal Therapy at Emory University Woodruff Medical Center (Atlanta, GA) and later that year she received her WOCN certification. She earned a Masters degree in Nursing Education from UNCG in 1997.

     Throughout the early phase of her nursing career, Shirley was mentored by her dear friend, Judy Bell, NP; Shirley credits Judy for her interest in the multifaceted field of wound care. Whenever Judy was absent and needed shift coverage, Shirley stepped in and educated patients, preparing them for the outpatient process of their healing. Shirley says helping patients transition through the phases of healing is one of her greatest professional pleasures. “The ability to see a patient go from an inpatient to an outpatient is definitely one of the job’s most gratifying aspects,” she says. “Seeing how well patients can do with a little help and encouragement is amazing.”

     Shirley says numerous factors turn a problematic wound into a success story. One pearl for practice is that every aspect of the person’s physical health must be taken into consideration. She quotes Nikki Hampton, one of her WOCNs. Nikki, who had previously been a critical care nurse, said, “I was often too busy saving lives to really worry about the skin.” Shirley asserts that every part of the body should be handled with the utmost priority — including the skin. “Having learned this over the years, I am now able to help people put the whole puzzle together,” Shirley says. “You can excite your staff nurses — although they may have this idea that skin care is very basic, it isn’t basic at all. Skin care becomes more and more complex when the patient has multisystem issues.”

     Skin is an important care component at Forsyth. Teamwork and communication among WOCNs and staff nurses yield favorable patient results. “We WOCNs cannot possibly see every patient who comes in the door,” Shirley says. “We are a 961-bed tertiary care facility offering acute care and rehabilitation. Our relatively small WOCN department has grown over the years. When I first started working as a WOCN, there were only two of us. We now have five WOCNs in our department. Part of this growth resulted from our present-on-admission process, where WOCNs and staff nurses work closely together. The staff nurse inspects the patient’s skin thoroughly from head to toe immediately upon admission. If there is an area of concern, a WOCN is called to examine the skin in further detail. Pressure ulcers are promptly distinguished. This process also involves physicians — WOCNs have done a great deal of physician education — in turn, they ensure we’ve identified things correctly and that we have provided the appropriate therapy for the patient.”

     In addition to overseeing the four staff members at her facility, Shirley also conducts consultations at Medical Park Hospital and works closely with Thomasville Hospital, striving to make decisions that can be applied to the Triad market. Shirley also focuses on both inpatients and outpatients with ostomies as part of a very active ostomy census and outpatient ostomy clinic. A completely separate outpatient wound care center, under the direction of Judy Bell, provides additional wound care after patients leave Shirley’s facility.

     On being a WOCN, Shirley notes, former Emory instructor Dorothy Doughty said it best: “You have to love pee, poop, and pus!” Shirley says the complexity of wound care may be one reason she was drawn to the field. “Wound care allows you to have an important impact on someone’s life. If you help someone’s wound heal and he/she gets back to living a normal, healthy life, the gratitude you are shown is overwhelming.”

     In addition to relishing the challenges of WOCN nursing, Shirley also has an exciting, family-oriented life. Happily married for more than 31 years, she has a 14-year-old son she describes as “quite the joy of my life.” Shirley also enjoys camping, boating, spending time outdoors, and reading dog magazines to keep her a step ahead of her “severely spoiled but incredibly adorable” whippet Moe and Doberman, Max. The “boys” don’t know it yet but their mom has secret plans to get them both therapy-certified so that they can work onsite at Forsyth. The hospital has a rehab therapy program where dogs come in specifically to attend therapy with patients. With a new program that revolves around the elderly, Shirley is constantly brainstorming ways to get her furry friends involved to make a difference.

     Shirley also appreciates that as a WOCN no two days are ever the same and there is always a different challenge. Having thrived in this industry for more than 20 years, she has learned many lessons through experience — ie, professional rapport among staff and physicians, time management skills, and flexibility are critical. She also appreciates the autonomy in making care decisions.

     Shirley’s job duties have evolved significantly over the last 10 years. Although clinically and educationally she is still very hands-on, her role as a consultant is growing. “When I first started, I would at a minimum perform the first dressing and demonstrate to staff how to do it,” she explains. “Now with time constraints, I find myself seeing the patient and writing and reviewing recommendations to ensure the staff nurses are comfortable carrying out the instructions. Then I have to trust these nurses will do everything WOCNs would have done and they have to trust that the WOCNs provided appropriate instructions.”

     Like many nurses, Shirley also faces the barriers of reimbursement. “We have to very carefully review everything we do, making sure our efforts are cost-effective but provide the best possible outcome,” Shirley says.

     Looking ahead, Shirley believes that because of increasing numbers of patients and the success of Forsyth’s pursuits, her team’s role and size will continue to expand. Shirley also hopes to have a voice in proving that some deep tissue injuries are unavoidable. “In the past, so many wounds have been diagnosed as pressure ulcers just because they were located on the backside of the body,” she says. “Research is beginning to disprove this belief. As nurses, we walk a fine line in terms of preventing pressure ulcers; nurses often are held accountable for situations that may be unavoidable. So while it is not humanly possible to fix everything, we can fix the blame game associating pressure ulcers with poor care quality. Anything you can do to help improve a patient or clinician’s quality of life provides much gratification in my scope of practice.”

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