I was chatting with another clinician recently about WOC nursing who asked me, "How did the WOC nurses end up focusing on your 3 care areas?" Her question must have struck a nerve because it led me to explore how we added wound care to ostomy care. I interviewed some of our early members and uncovered what I think is an interesting story that says quite a bit about who we are, why we are still together, and, hopefully, how we might continue to flourish in these "interesting times."

The integration of wound care into our practice coincides with the development of advanced wound care products. As a result, the stories of our specialty practice and advances in wound care products are intertwined and offer interesting parallels. I will start with a historical perspective on wound care and address WOC nursing along the same timeline.

For thousands of years, healers in many cultures recognized that when wounds occurred they needed to be covered with something. We know it was occurring among the Sumerians by 2000 BC because they were some of the earliest people to leave written records that have endured. They documented the covering of wounds with absorbent natural products as topical treatments.1

The records of nearly all civilizations since then suggest our ancestors everywhere used some form of natural products to cover wounds and absorb exudate. The early products were soft and absorbent plant materials that we would probably call "lint" today. From these historic records, we know that healers quickly figured out the need to combine absorbent products with grease or wax to prevent them from adhering as the wounds dried out.

During the Industrial Revolution in England (in the 1800s), the refinement of natural products culminated in the development of the most absorbent natural product for dressings: spun and woven cotton. By the 1950s, plastics had been added to cotton to create composite dressings like the Band-Aid(R) and abdominal pads. Throughout this timeframe, however, wound dressing development focused on protection, absorption, and minimizing the trauma of dressing changes. The underlying goal, of course, was to dry out the wound, abandon wound dressings altogether, and let nature take its course.

In the 1960s, research published in peer-reviewed journals suggested that wounds maintained in a moist state healed faster.2,3 This concept, however, was not well-received by the medical community. Additional studies were completed to challenge these findings, but they ended up reinforcing rather than disproving our current concept of moist wound healing. Today, there is a substantial body of evidence to suggest that keeping wounds moist is superior to letting them dry out because it results in faster healing, less pain, and fewer complications, such as infection. This evidence was contrary to thousands of years of experience and, thus, we did not see wound care products designed to maintain moisture for many years.

The first advanced wound care products to take advantage of this concept were not introduced until the 1970s when transparent film dressings appeared in the United States. At first, these products were not broadly adopted. Slow adoption was probably due to several factors, including awkward delivery systems that rendered the dressings difficult to apply. Ironically, film dressings are very effective at trapping moisture, but they are ineffective at managing moisture unless they are combined with an absorbent inner layer. Perhaps they were not broadly accepted at first because film dressings generally increase wound exudate when replacing gauze dressings and this was misinterpreted as a sign of infection.

By the mid-1970s, new technologies emerged for ostomy care, including the pectin-based wafer, which finally gave us a durable platform for supporting pouches that could adhere well even in moist environments. WOC nurses, known as ET nurses at that time, were having great success integrating this and other products into ostomy care. Successful WOC nurses were insightful experimenters, combining a limited set of products in new and creative ways. This was partially due to the fact that ostomy care for some patients is complex and requires creativity in combining products to meet the patient's needs. We were also becoming well-known to ostomy supply manufacturers.

Many WOC nurses also began to use these same products and skills to successfully treat chronic wounds.4 In case studies and presentations, they described filling chronic wounds with karaya powder and achieving dramatic results by covering them with pectin-based wafers. On reflection, caring for chronic wounds is a logical extension of managing skin breakdown around stomas and of dealing with the challenge of trying to maintain sealed pouches on injured peristomal skin. At this time, pressure ulcers were not yet the focus of comprehensive approaches in our facilities.

In the late 1970s experimentation flourished, with dramatic results being reporting anecdotally and in case studies and series. But it also became apparent to some WOC nurses that there was a lack of consistency in our practice. This concern helped influence the association's decision to establish a certification board and examination in 1979. During this time, some WOC nurses were beginning to feel a growing demand for wound care services. Manufacturers of the first film dressings targeted our members as emerging leaders in wound care and important influencers of buying decisions in facilities across the nation.

By the early 1980s, the second advanced dressing, the hydrocolloid wafer, arrived on the scene. Hydrocolloid wafers designed to dress wounds were similar to the pectin-based ostomy wafers familiar to experienced WOC nurses. Their use was rapidly embraced because they were much easier to use than thin film dressings, had better adhesive qualities, and were highly effective for shallow wounds and as cover dressings over other products.

Though film dressings are the original advanced wound care product, hydrocolloid wafers were the real breakthrough in advanced dressing and they were quickly established as the first-line treatment for pressure ulcers. They were easy to use and teach, and they yielded dramatic results when compared with traditional gauze dressings. Their extended wear time and superior adherence, even in moist areas such as the perineum, compensated for their higher cost compared to gauze and tape. They also acted as effective bacterial barriers and exhibited moderate absorbency, ultimately leading the way for the development of more absorbent dressings such as foams and alginates.

During this period many hospitals recognized that WOC nurses could effectively manage complex wounds. Coupled with the new products, transparent films and hydrocolloid wafers, this created a "perfect storm" and many WOC nurses found the demand for wound care increased dramatically. This led to the first great debate: Should we expand the scope of practice to include wound care? Adding fuel to the fire, Jackson and Brodwell's first ostomy text, published in 1982, included chapters on wound care.5 Today, it is hard to imagine how WOC nurses on each side of the debate were able to recognize the opportunity, compromise, and adapt to this dramatic change. What a wise group of nurses that came before us. I am reminded of a quote from Sir Isaac Newton, "If I have seen further it is by standing on the shoulders of giants."

By the late 1980s, we saw the introduction of 3 other key advanced wound care products: open-celled foams, calcium alginates, and hydrogels. Other clinicians also started to see opportunity by focusing on wound care and the first franchised multidisciplinary outpatient wound clinics emerged. This was also a time when our members saw opportunities to influence the regulation of wound and ostomy care, so we started to interact with Medicare and Capitol Hill.

In the early 1990s, wound care continued to expand and, for many members, became their primary focus. This was no doubt a factor influencing our decision to change our name and the certification board's decision to offer separate examinations for each area of focus. Product diversification and growth continued through the late 1990s. We saw the emergence of the first sustained-release antimicrobial dressings, as well as growth factor impregnated hydrogel and living skin equivalents. This was also the time of rapid expansion of outpatient wound clinics and the emergence of multidisciplinary teams who were experts in wound care. In some communities, WOC nurses were involved in this expansion from the beginning while in others, we were not. As time has passed, opportunities for our involvement in wound clinics have continued to grow.

Since 2000, product diversification has continued with the emergence of negative pressure wound therapy, combining advanced wound care products with suction. This is a technology WOC nurses frequently use for fistula management. Several manufacturers now offer versions of negative pressure wound therapy and I expect WOC nurses will have a significant impact on establishing the evidence base for selecting the right product at the right time for each patient.

Another refinement I have seen recently is the emerging role of WOC nurses as thought leaders in companies developing wound and ostomy products. These industry-based WOC nurses are quietly gaining positions of respect and influence in their organizations and we already see their impact. Nimble manufacturers of wound care products understand what will be needed, empowering consumers to manage their own conditions by refining products that foster self-care. Ironically, this is reminiscent of the evolution of ostomy care products we have seen in the recent past.

So it's back to the future!! Who knows what lies ahead but it feels like our society is losing patience with a healthcare system that is "Number 1" in costs but "Number 37" in quality.6 One of the obvious challenges we face is how poorly care is coordinated. This is especially important for people with chronic conditions and the frail elderly because poor coordination has its greatest impact on them, both socially and economically.

These are conditions that we are not going to cure. Rather, they are conditions we need to help people learn to live with and adapt to. We need to be knowledgeable about the options available and ensure we select products that allow people as much control and independence as possible. Doesn't this sound a bit like "Ostomy 101"? I believe our main challenges and opportunities over the next few years involve our pursuit of value in managing chronic conditions associated with wounds. Can we apply the principles of disease management and ostomy care to our assessment, planning, and provision of wound care? If not us, who? If not now, when?

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