The Important Role Nurse Practitioners Play in Wound Care

Nurse practitioners (NPs) are valuable members within the field of wound management. As licensed, independent clinicians, NPs practice autonomously and coordinate with other health care professionals and individuals. Half a century of research definitively demonstrates that NPs provide high-quality health care services across a person’s lifetime and in diverse settings. Nurse practitioners receive graduate-level education, with master's or doctoral degrees, and possess the knowledge and clinical competency to provide health care beyond their initial registered nurse preparation.¹ As providers that blend clinical expertise in diagnosing and treating acute and chronic health conditions, emphasizing disease prevention, health management, and patient education, NPs bring a comprehensive perspective to health care.²

In just a few short years, the Institute of Medicine has projected a non-primary care physician shortfall of 28,200 to 63,700 providers and a primary care physician shortfall of 12,500 to 31,000 providers by 2025; this equates to a total physician shortage between 61,700 and 94,7002.³ We need providers to care for the 8.2 million people with chronic wounds in the United States alone and that statistic is just regarding Medicare beneficiaries.⁴

A critical limiting factor in the ability of nurse practitioners to provide care according to their education is licensure and compliance with the state board of nursing and practice limitations. This includes issues like role delineation and practicing within one's scope. Most states are independent practice states,⁵ meaning that nurse practitioners are primarily without limitations on their practice. Some states, however, continue to impose sanctions on nurse practitioner practice that range from requiring collaborative relationships with an MD or possibly a DO to limiting the prescriptive authority of narcotics or the ability for NPs to order certain imaging. These limitations can significantly impact patient outcomes, an issue that is exemplified in the federal limitations on the ordering of diabetic footwear.

The role overlap between physicians and nurse practitioners is approximately 70%.⁶ Nurse practitioners can perform surgical debridement in the wound clinic setting, including those of fascia, bone, and tendon. Other advanced procedures NPs perform include applying cellular- and/or tissue-based products (CTPs) like allografts and xenografts. They assess and diagnose medical conditions, order and interpret advanced imaging, develop and implement care plans, and provide integral preventative care at wound closure to prevent recidivism. In wound care, that 30% gap in role overlap can be seen positively when considering the operating room (OR)-based surgical procedures that NPs are primarily unable to perform. When the goal of wound management is limb preservation having an extra step in the performance of surgical intervention can be beneficial. Most states do not grant nurse practitioners OR privileges. This also limits the provision of advanced surgical debridement that requires general anesthesia and split-thickness skin grafts. An additional limitation related to OR privileges is the reimbursement on skin grafts and CTPs applied in wound clinics (hospital outpatient departments and physician clinics). These grafts are limited in the size of the grafts that can be used while maintaining a positive fiscal balance. The cost of grafts applied in the OR are bundled into the surgical procedure, allowing for larger graft sizes to be used in this setting. Some states offer advanced practice providers OR privileges, which is useful for advanced procedures like dermatome and autologous regeneration of tissue harvesting.

Collaborative practice is integral to any profession in the field of wound management. Wound care is a multidisciplinary field, and referrals to general surgery, vascular surgery, plastic surgery, dermatology, podiatry, orthopedics, infectious disease, physical/occupational therapy, and lymphedema therapy specialists are common regardless of the provider education preparation that is providing that referral.

A critical consideration in the practice of nurse practitioners in wound care is the health care system's culture regarding not only advanced practice providers but specifically the role of the nurse practitioner and wound specialist. The system culture regarding wound care is also critical to the providers' ability to deliver evidence-based care. Organizations that do not support provider-led research, evidenced-based practice, and quality improvement projects may facilitate burnout, care limitations, and turnover of their advanced practice providers. Without executive support and team-based approaches, providers can be extremely limited in the extent of wound management they can provide. This can also occur in any silo of common referrals that wound care providers rely upon. For example, if vascular surgeons do not respect wound management, the team-based approach to managing arterial ulcers is limited.

Advanced practice providers like nurse practitioners can deliver the same high-quality care as physicians. We utilize the same evidence base and clinical guidelines. Therefore the term mid-level is considered antiquated and can be somewhat offensive.

Nurse practitioners undergo rigorous educational and practical preparation prior to certification. NPs have been found to improve care quality, decrease emergency room use by patients with ambulatory care sensitive conditions, and decrease administrative costs for physicians and NPs as well as patients' indirect costs of accessing medical care.⁷ While board certification is not necessary to practice wound care, many nurse practitioners obtain board certification to add a layer of rigor, education preparation, and clinical practice requirements as wound care providers.

References

1. American Association of Nurse Practitioners (AANP). Quality of Nurse Practitioner Practice. Revised 2020. Accessed February 23rd, 2022. https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice
2. Couch K. The expanding role of the nurse & the NP in chronic wound care. Today's Wound Clinic. 2017;11(5):10-11. https://www.todayswoundclinic.com/articles/expanding-role-nurse-np-chronic-wound-care.
3. Dill M. The state of the physician workforce and policy implications. Session presented at: Health Workforce Conference. November 4, 2017. Accessed February 23, 2022. https://www.aamc.org/media/8811/download
4. Sen CK. Human wounds and its burden: an updated compendium of estimates. Adv Wound Care (New Rochelle). 2019;8(2):39-48. doi:10.1089/wound.2019.09463
5. State Practice Environment. American Association of Nurse Practicioners. 2018. Updated August 4, 2021. https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment
6. Bauer JC. Not What the Doctor Ordered: Reinventing Medical Care in America. Probus; 1994.
7. Traczynski J, Udalova V. Nurse practitioner independence, health care utilization, and health outcomes. J Health Econ. 2018;58:90-109. doi:10.1016/j.jhealeco.2018.01.001