Finally, Data Supporting the Impact of WOC Nursing Practice
I am always intrigued and challenged by the discussion that occurs during the society's Strategic Planning Session. Like most everyone else, I beam when I hear about positive results from a project in process or one that has been done well. At the same time, my heart sinks when the discussion turns to projects not completed or those with less-than-positive outcomes. During 2003, the center was challenged to produce data supporting the efficacy and cost effectiveness of our practice, with particular emphasis on wound care. At first glance this task seemed relatively straightforward, but closer inspection and consultation with WOC wound care experts revealed otherwise. Specifically, we were challenged with designing a study that teased out the WOC nurse contributions to what is frequently a multidisciplinary effort, to measure this effect across multiple healthcare settings, and to measure both clinical outcomes and cost. This challenge emerged as a first-line goal when I met with the Advisory Board of the Center for Clinical Investigation. We explored several ways to tease out the needed data, but each strategy proved expensive and complex.
I clearly remember struggling with this problem as I sat through the podium research presentations in Cincinnati. Then I heard Dr Laura Bolton present findings and data about wound healing outcomes using an evidence-based standardized assessment and management algorithm and the influence of WOC nurses on these outcomes. The more I considered the data Dr Bolton and her colleagues had generated, the more I realized that this study provided precisely the type of data that we were seeking. Immediately after the meeting, I approached Dr Bolton and asked her to compile these data into a manuscript and to consider submission to the journal. Thanks to Dr Bolton and her colleagues, this has happened, and I want to review what I believe are some of the most relevant points concerning the effect of WOC nursing in the management of chronic wounds in the long-term care, long-term acute care, and home care settings.
The Naturalistic Design Is Ideal for Measuring WOC Nursing Impact
When you think about participating in research, the word naturalistic may not immediately come to mind. Instead, you are probably more familiar with randomized clinical trials that emphasize strict inclusion and exclusion criteria, tightly controlled interventions, and rigidly timed outcome measurements. In contrast, a naturalistic research design reproduces a more "real-world" setting, where all patients presenting with a particular problem are assessed, diagnosed, and managed, and outcomes are measured across all patients. If we want to evaluate the effect of WOC nursing on wound care management, a naturalistic design is ideal precisely because it more realistically reproduces a real-world setting, with all of the complexity and variability that comprise our daily clinical practice.
In addition, the study's use of WOC nurses as clinical experts is helpful because it provides an increasingly realistic portrayal of our practice extending beyond one-on-one patient consultation. It reflects the larger scope of a WOC nursing presence in a large and complex health system by measuring outcomes when WOC nurses interact with staff nurses in multiple settings to achieve superior patient outcomes while minimizing the needless costs associated with misuse of wound care products resulting in delayed or stalled healing.
Evidence-Based Assessment and Interventions Reflect WOC Nurse Strengths
A second advantage of the design selected by Dr Bolton and her colleagues is their use of a standardized but flexible system for assessment and management that is both evidence-based and content validated. The commitment to evidence-based practice permeates both the society and our daily practice. This commitment is clearly illustrated by the ongoing production of Clinical Practice Guidelines, Evidence-Based Report Cards, Best Practice Documents, the existence of a Center for Clinical Investigation, and the daily practice of WOC nurses. In a traditional randomized clinical trial, a narrowly defined and highly focused intervention is undertaken to determine its efficacy and safety. However, to document the effect of a WOC nurse, it is essential that assessments and interventions are evidence-based but sufficiently flexible to allow for the individualization of care that happens in any real-world setting. Not only did Bolton and colleagues provide evidence-based protocols, they also subjected the protocols to extensive content validation.
The Principal Investigator Was Not a WOC Nurse
A final point of importance is the professional background of the principal investigator. Dr Bolton is director of scientific affairs at ConvaTec. She is not a WOC nurse, nor was she employed or funded by the WOC Nurse's Society to complete this study. Dr Bolton did not set out to prove the effectiveness of WOC nursing practice; she set out to determine the effectiveness of standardized protocols on chronic wound care outcomes.
Critical Results
The results reported by Dr Bolton and colleagues are best understood by reading (and rereading) the original research report. Nevertheless, I want to highlight what I find to be some of the most pertinent findings, taken from the perspective of documenting the effectiveness of WOC nurse management of chronic wounds.
[black small square] Nursing staff actively seek consultation with a WOC nurse when managing deep wounds and those unresponsive to traditional interventions.
[black small square] When guided by WOC nurses and an evidence-based assessment and intervention protocol, more than 95% of topical care avoided gauze dressings. Instead, they used advanced wound care products that maintained a moist wound care environment and led to reduced healing times when compared to published standards for gauze based wound care protocols. This trend held true even when gauze dressings were combined with a prescriptive gel containing a growth factor in one study.1
[black small square] Using telemedicine technology, WOC nurses enabled patients and caregivers who were remote to the WOC nurse to achieve significantly decreased wound healing times while simultaneously reducing the number of visits required for healing a wound using gauze base by 50%. These findings replicate the results of a pilot study using the same protocols in a sample of 76 patients managed in a home healthcare setting.2
[black small square] When compared to traditional wound care using a gauze-based protocol, access to a WOC nurse and evidence-based standardized protocol resulted in a savings of $969.00 for every pressure ulcer and $766.00 for wounds healed during a 12-week period.
As we move into the 21st century, justification of our practice will be increasingly based on our ability to document cost savings while maintaining optimal clinical outcomes. In my opinion, the work of Bolton and colleagues represents precisely the type of research needed to measure the broad based effects of WOC practice in multiple care settings.