The Evolving Role of Advanced Practice Nurses in the Outpatient Wound Clinic

WATCH: Author Jennifer Hurlow, GNP-BC, CWOCN, discusses the article. 

Wound care is defined as any technique that enhances secondary healing of skin defects such as abrasions, blisters, lacerations, necrosis, and/or ulcers. Modern wound care, as we know it today, is the art of maintaining optimal wound moisture to support uncomplicated moist wound healing. This art involves a keen ability to choose among many wound dressings within cost restraints of a patient’s insurance or post-acute setting/home health agency and to best manage wound exudate over an acceptable time frame. Cost-effective management of this process requires a comprehensive understanding of advanced dressing options and actions. 

Wound care in the “outpatient setting” can be guided by providers in a local wound care clinic, by home health nurses, or, quite commonly, by clinicians located in both of these venues. Logically, the most cost-effective and clinically optimal wound healing outcomes are achieved when the guiding providers have successfully completed specialty training in the treatment of chronic wounds and skin care.

The human skin represents the largest barrier to environmental pathogens, which are becoming more virulent just as the United States population is becoming more compromised. Furthermore, complicated healing represents a significant burden to both the patient and to our struggling healthcare system.^1,2

This reality highlights the importance of an appropriately educated provider. Unfortunately, there are no current mandates in place in this country that confirm this expertise on a universal scale. Another equally unfortunate challenge to ensuring the highest level of wound care is that significant training on secondary wound healing interventions remains conspicuously absent from most current nursing and medical training programs. This fact makes it crucial that any healthcare provider who is interested in entering wound care practice must earn a wound certification if their goal is to fulfill today’s need for cost-effective and clinically sound care.  Appropriate providing of cost- and clinically effective wound healing is a multifactorial process, often far more complicated than many consider it to be. That said, the utilization of multidisciplinary healthcare teams is becoming more common and necessary to care for this patient population in response to a healthcare system that is medically and financially becoming more focused on care quality. The ideal wound care provider, whether practicing within a group or as an individual, should be both a wound-specialized clinician and an educator — one who understands the medical and nursing processes of wound closure. Wound care providers must also perform patient assessment of healing potential as well as conduct procedures required to prepare the wound bed for healing. Additionally, these clinicians must have the knowledge needed to order appropriate testing and to make referrals, to triage differential diagnoses, and to devise the best wound care strategy while offering motivational, patient specific self-care instruction to support the healing process. Simply stated, an effective wound care team from a clinical and financial perspective must be able to diagnose and effectively treat various types of wounds as well as communicate effectively and teach patients about their wounds and myriad comorbid conditions all at once. For this reason, nursing-led wound care staffs are becoming more common in outpatient clinics. Specifically, the role of the advanced practice registered nurse (APRN), or nurse practitioner (NP), has become a more integral component within these multidisciplinary wound care teams. This article will discuss the increasingly comprehensive roles that APRNs are serving in the wound care industry and how the nursing scope of practice aligns with the goals of the multidisciplinary approach to wound care.

The Nurse’s Place in Wound Care

Nurses are educators. Nurses are taught to support and communicate with their patients. Nurses understand nursing theory, such as Dorothea Orem’s Self-Care Deficit Theory — which seeks to help patients overcome human limitations and effectively participate in their own healthcare in order to sustain life and health, recover from disease or injury, and cope with the effects of treatment.³

APRNs are mid-level providers who understand basic medical theory, pathophysiology, and when timely referral for specialist intervention is required. With this added certification, wound care can be a more rewarding and satisfying career choice, and increasing numbers of nurses with a wound care specialty will only benefit the care of patients in outpatient clinics.

At the current time, APRNs must complete a master’s level education program in order to become credentialed. In most cases, they must also gain certification in a specialty before practice can begin. Adult, family, and geriatric care are key specialty areas of focus that are conducive to potential involvement in the outpatient wound care clinic. Attaining wound care certification is a crucial addition to the education for any APRN who seeks to work with the wound care population due to important details regarding chronic wound diagnosis, treatment, and secondary healing. Wound care certification programs will also often provide education on other procedures conducted in the outpatient setting, such as layered compression and negative pressure wound therapy application. Some programs will also include instruction on application of total contact casting systems for the offloading of diabetic foot ulcers (DFUs). 

Furthermore, many of the procedures performed within a wound clinic are required to be performed by a licensed provider in order for tasks to be safely and appropriately executed. Tissue biopsy and sharp debridement are two skills that are especially essential to the practice of effective wound treatment. Though there are several high-quality wound certification programs, none provide the practical skills that clinicians need to attain competency in sharp debridement.

However, both sharp debridement and tissue biopsy are procedures that can be performed by an appropriately trained APRN in the outpatient clinic setting.

A recent clinical privilege white paper on wound debridement⁴ recommends that any provider who performs sharp debridement must have advanced understanding of anatomy, physiology, pathophysiology, and pharmacology as well as the principles of secondary healing before attempting these procedures. The paper also recommends that a clinician complete an apprenticeship with an experienced wound care provider who already performs these procedures. Of an interesting note, the United Kingdom all outpatient wound care is fully guided by “tissue viability nurses” (TVNs) who refer to physician specialists as needed. The one exception may be DFUs, for which UK health officials recommend immediate podiatry involvement. The advanced practice TVN must complete a formal course on sharp debridement before being deemed able to safely and effectively perform surgical sharp debridement. Some wound certification programs in the US do provide education on conservative sharp wound debridement (CSWD), which is defined as the sharp removal of loose, avascular tissue only. Wound-certified RNs in some US states are allowed to perform CSWD. Unfortunately, because this authority is not consistently supported in all states, the delivery of wound care can be inconsistent and can be significantly compromised in the home healthcare setting, in some states.

Independent & Team Practice

Committing full time to the specialty of wound care can be a fulfilling choice for any nurse who’s seeking to work with a staff or in independent practice as a career goal of advanced education. Currently, 21 states as well as the District of Columbia support full autonomy of APRNs. Of the remaining 29 states with restricted practice, nine allow APRNs to independently diagnose and treat patients without formal physician involvement. Most of the wound care processes that occur in the clinic involve diagnosis and non-pharmaceutical treatment, guidance of outpatient testing, various procedures, specialist referrals, ordering of durable medical equipment, and a significant amount of patient education. Therefore, NPs in 30 states as well as Washington, DC, who gain wound expertise can practice without significant need for physician involvement. 

Despite the ability for autonomy, there are significant difficulties inherent for any specialized wound care provider to effectively manage all comprehensive processes conducted in the wound clinic. Having other nurses on staff, whether that be RNs and/or licensed practical nurses, as well as physical therapists, who can play equally important roles as members of wound care teams, can further enhance the patient and provider experience. Within such a team dynamic, it’s typically the wound-specialized RN who will be tasked with dressing removal and application as well as performing the initial patient assessments while giving special attention to uncovering and communicating any health problems/concerns related to the patient. Most often acting as patients’ “case managers” in today’s clinic setting, RNs are also going to be responsible for taking referral calls and providing education to patients and families during and between clinic visits. These nurses will also frequently place orders for wound dressings and other supplies and manage test results. In the home health setting, the wound specialized RN will often play the actual leadership role, performing initial wound assessments and guiding the care provided by the generalist nursing team. 

While the multidisciplinary team approach to care is easily a benefit to patients, it is not without its challenges to those providing the care. Effective communication becomes extremely important when two (or more) professionals share the responsibility of one or more patients. Challenges noticed in the home setting and in the clinic are often related to the demands of self-care, adherence to one’s plan of care, and/or availability of a support system. As wound care providers of varying disciplines, our primary goal remains the same — to support cost-effective wound healing by achieving best outcomes through secondary intention. Beyond the actual wound care, the process of wound healing requires a full assessment and understanding of patient-specific systemic factors that are known to impact and compromise wound healing potential. This includes assessment of conditions that exist in addition to the wound itself, such as cardiovascular disease, diabetes, immunosuppressant conditions, psychosocial conditions, medications, and nutritional status. Support of wound healing also includes patient and/or caregiver instruction related to behavior and self-care to promote adherence to the prescribed wound care treatment.

Beyond The Clinic

Approximately 40-50% of all care delivered by any US home health agency will involve patients living with chronic wounds.⁵ Ongoing decreases in government funding of these agencies mandates that they involve a wound specialized nurse to encourage cost-effective care delivery.  When handling referrals of patients from the outpatient clinic into home health, the wound specialized RN holds a prominent role in establishing care plans, communicating goals to patients and caregivers (including home health medical staff), and, ultimately, affecting outcomes.

References

1. Sen, C. et al. Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-771.

2. Nguyen L, et al.  Prospective cost analysis and implications of wound complications in lower extremity vascular surgery procedures. Jnl of Vascular Surgery. 2014;60(3):813.

3. Overview of Orem’s Self-Care Deficit Theory of Nursing. Accessed online: https://sites.google.com/site/oremstheory/description-of-the-model.

4. HCPro Advisory Board. Clinical Privilege White Paper: Wound Debridement. Supplement to Credentialing Resource Center Journal. 2014. 1-15.

5. Schwien T, Long C. Changes in Wound Care Outcomes Analysis—New Home Health Compare Measures. OCS Inc. 2008. 1-9. Accessed online: www.ocshomecare.com/OCSHomeCare/media/OCSHomeCare/White%20papers/Wounds_08-002.pdf.  Last accessed 7/29/15.

Jennifer Hurlow owns her own practice: Wound Practitioner LLC, Germantown, TN, and may be reached at jenny.hurlow@gmail.com.