The JWOCN year has been robust and we (the editorial team and you, the WOCN members) have accomplished much in 2003. Many and varied manuscripts have been published relating to professional practice, wound, ostomy, and continence care; an electronic submission and tracking process is in place in the editorial office and authors now receive page proofs in PDF files. Barbara Pieper did a sterling job of hosting the July Special Issue on Wounds, providing practitioners with a fine example of the state of the science in wound care. We have added more guest commentaries on manuscripts, and this year was the first to include the abstracts from the WOCN Annual meeting. The "behind the scenes" work of the abstract reviewers, chaired by Mary Arnold, and the work in the AMC office meant that the abstracts were reviewed and included in the May issue in record time. Having the abstracts incorporated into JWOCN means that they are available for many more than conference attendees and can be a valuable source for research ideas. Next year should be equally informed. One highlight will be a Pediatric Special Issue slated for next July.

Several of the manuscripts this past year have addressed issues related to documentation of wounds. Zeleznik and colleagues, in this November issue, describe the inconsistencies among non-wound expert health care professionals regarding documentation of wounds and the terminology used to describe them. Ribu, also in this issue, reports a lack of knowledge and poor documentation amongst nurses working in home care, and Gunningberg provides similar information for nurses in acute care.1 We probably do not need to repeat the survey with nurses in the US and Canada to know that inconsistent knowledge about pressure ulcers and incomplete documentation is a significant problem.

In September, Sue Ellen Bell raised the issue of ethics and wound care documentation. She provoked a critical issue of a nursing dilemma: being torn between accurate wound documentation, which may "penalize" the patient and reduce services, and incomplete documentation, which would allow the patient to continue to receive needed services. Ayello and Meaney addressed wound content in nursing fundamentals books. The authors pointed out that, despite increasing quality and quantiy of wound content, gaps remained in the information provided in the fundamentals books, potentially placing nursing students at risk of missing critical wound assessment and treatment content. Missing critical content may deprive the new graduate of the necessary basic skills to properly document wound risk and wound assessment. At a time when litigation is all too common, such an omission may result in serious consequences.

Litigation seems to be part of the health care world. Pressure ulcers are big business, not only for the companies that make wound healing products, but also for the legal profession. A quick survey on Alta Vista found over 13,000 hits using the key words "pressure ulcer" and "litigation." This alarming number should serve as a warning to all practicing nurses about accurate descriptions of patient condition when they are admitted to care-particularly to nursing homes. The following is just one of hundreds of advertisements informing the public that: "The law requires that a nursing home must ensure that a resident does not develop bedsores (sic), unless the resident's medical condition shows that the bedsores were unavoidable. Many times, however, the development of bedsores is avoidable, and the reason for their development is the negligence of the nursing home. It is important to note that the law also requires the nursing home to prevent the progression of any bedsores the resident may have at, or during, admission to the nursing home facility."2

The reader is further encouraged to ask for a free consultation, noting: "If someone you care about has been the unfortunate victim of abuse or neglect in a nursing home, you can contact our law firm" toll-free or use the Internet for a free consultation. There is no obligation and no fee unless money ispaid.

Legal issues and the fear of being sued should never guide nursing practice; however, appropriate assessment, accurate and complete documentation, and on-going follow up according to good practice guidelines will go far to protect the nurse from legal threats.

Good clinical judgment is grounded in a concern for the health and welfare of patients. We teach our students critical thinking skills knowing that we cannot provide them with all the knowledge about every aspect of health care. The content is too great and too rapidly changing to make that a reasonable goal. Thinking cannot be limited to correctly choosing and using established routines. If it is, then necessary professional judgment is lacking to address new problems in unfamiliar contexts, such as wound assessment. Clinical judgment includes deciding on what to assess, deriving meaning from data collected, and determining actions to ensure optimal patient care.3 But clinical judgment and critical thinking are both necessary to make rigorous inquiries and decisions related to patient care.

Critical thinking involves high-level reasoning used to reach professionally informed judgments in situations where the stakes are often high, time is of the essence, and the situation is often unique.4 It allows nurses to interpret assessment data, correctly analyze problems, identify alternative actions and the implications of each, and sensibly evaluate options and rationalize choices given a particular situation. Thus, even for nurses who are non-experts in terms of wound care, one could expect that they would be able to link theory (analyze, discriminate, seek information, reason logically) to the following points of pressure ulcer prevention, reduction, and/or care:

* Identify individuals at risk of and factors predisposing an individual to developing pressure ulcers

* Assess and monitor potential pressure sites

* Assess and monitor other factors: sensation of pressure, ability to move, nutritional status, incontinence, environmental moisture, support surfaces that the patient tends to spend the most time on, amount of shear, history of other conditions (eg, diabetes, malignancy, PVD)

* Organize a consultation with a dietitican

* Describe characteristics, condition of wound bed, exudate, condition of surrounding tissue

* Intervene according to staging, conferring with experts as appropriate

* Assess patient's family's understanding of the long-term nature of wound healing of pressure ulcers

* Determine family's ability to provide wound care

* Determine family's understanding of contributing factors to ulcer development and importance of reduction of risk through or relief when an ulcer exists.1

A key point in the assessment is inclusion of the family and documenting the family involvement.

Part of our role as professionals is to mentor or preceptor undergraduate students, many of whom will not be wound care experts. Their textbooks should provide guides to care, but their judgment and critical thinking will come from creative exploration of patient needs in practice. Such skills take time to develop, to be molded, and to be applied to a particular patient situation; it is our role as mentors to ensure our students have the skills to completely and accurately document admission histories and wound risk.

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