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Nurses and nurse practitioners continue to play an increasingly important role in wound care, and healthcare in general, as the quality-care model becomes more ingrained. This article traces the history of these practitioners and offers a perspective on their future.
Nurses are often referred to as “the backbone” of the healthcare industry. With 3.1 million registered nurses on staff in the United States, this discipline represents the nation’s largest healthcare profession.1 Based on scope of practice alone, nurses focus their care on the “whole” person, the environment of one’s care, disease prevention, optimization of health, and patient advocacy. Their responsibilities and presence within the healthcare continuum have hardly gone unnoticed. For the past 15 years, nurses have consistently ranked as the “most trusted profession.”2 As it pertains to wound care, the hierarchy of nursing with varying levels of licensure, certification, and scope of practice can be clarified to delineate leadership and reimbursement issues to meet current healthcare challenges.3 Additionally, a review of the role of nursing in wound care from a historical and evolutionary perspective helps to characterize the trend towards advanced practice nursing in the wound care specialty.3 This article will describe the origins of the wound care nurse, as well as the nurse practitioner (NP), and how these professionals fit into the current and future quality-based healthcare landscape.
History of the Modern Nurse
Nursing care of wounds in the U.S. can be traced back to the Civil War.4 The founder of professional nurses, Florence Nightingale, treated patients during the Crimean War (1853-56), and her focus was on sanitation and cleanliness (in addition to good nutrition and psychological support). These theories made their way to the U.S. and were put into practice. The ability of wartime nurses to treat the wounded was severely limited in the early part of the Civil War (1861), as only men were allowed to be nurses at that time.4 Chores such as cleaning hospitals were the early duties of nurses, and the men would cede that responsibility to the women because they were not as diligent in maintaining the high standards set by Nightingale. In addition, there were many female volunteers who had been caring for the war wounded at home, and those skills were transferred into the hospital setting. By the end of the Civil War in 1865, the wound care nurse was firmly established as a critical member of the healthcare team.
History of Specialist Wound Nurses
The current specialty certification of wound care nurses, the wound ostomy continence (WOC) nurse, began in 1958 when Norma N. Gill (herself an ostomate) was trained by Dr. Ralph G. Turnbull, a pastor, preacher, teacher, and writer, to rehabilitate ostomy patients. Internationally acknowledged as the first enterostomal therapist (ET),5 Gill founded and served as the first president of the World Council of Enterostomal Therapists, an international association for nurses involved in ostomy, wound, and continence care. In 1961, Gill and Turnbull began training ET nurses at the Cleveland Clinic in Ohio. The American Association of Enterostomal Therapists was then formed in 1968 and went through several iterations over the years. The organization’s name formally changed to the present Wound, Ostomy and Continence Nurses Society (WOCN), a professional, international nursing society of more than 5,000 healthcare professionals who are recognized as experts in the care of patients living with wound, ostomy, and incontinence,”5 in 1992. All WOC nurses are required to hold a baccalaureate degree (at a minimum) and must complete approved educational training to qualify for board examinations. The WOC nurse is involved in all aspects of education, clinical settings, and research to improve patient outcomes. WOC nurses are also recognized leaders in wound assessment and management. Although the group started as specialists in ostomy care, the scope quickly expanded into wound care, and these nurses have led wound care teams that utilize evidence-based care within hospitals and other settings for decades.
History of the NP
Similar to the ET nurse, the NP role originated in 1965 when Dr. Loretta Ford (a nurse) and Dr. Henry Silver (a physician) launched the first NP program (which specialized in pediatrics) at the University of Colorado in 1965.6 Physicians had been collaborating more often with their experienced nurse colleagues in the late 1950s and early 1960s. There was a vacuum of available primary care physicians as medical subspecialties became more prevalent in the 60s, particularly in medically underserved and rural areas. Additionally, in 1965, the formation of Medicare and Medicaid allowed for more patients to have access to healthcare. Ford and Silver recognized this and found a way to fill the void of primary care providers. The practice of the NP was founded on the tenets of health promotion, disease prevention, and the health of children and families. However, over the first 10 years of practice, NPs faced challenges due to the lack of formalized training, certification, and general opposition from physicians. That was until the 1970s, when NPs began to document outcomes data that revealed positive patient satisfaction data and proof that NPs were filling the void of primary care physicians. NPs have continued to publish scientific studies that prove their rigor and value ever since. In 1994, an article in the New England Journal of Medicine found when measures of diagnostic certainty; management competence; or comprehensiveness, quality, and cost are used, virtually every study indicates that the primary care provided by NPs is equivalent or superior to that provided by physicians.7 There was predictably great disagreement among physician colleagues; however, additional articles, including one in the Journal of the American Medical Association, again found the same conclusion.8 NPs have continued to be increasingly utilized and the overall numbers of these clinicians and graduate-level programs have grown exponentially over the past two decades. In 2017, there are more than 220,000 certified NPs in the U.S.6 Additionally, 96% of NPs possess graduate degrees (master’s or doctoral level) with the doctor of nursing practice as the terminal clinical doctorate degree. More than 85% of NPs are board certified in adult care, family practice, or geriatrics. NPs hold full practice autonomy in 23 states and Washington, DC, and are able to practice in wound care in more than 30 states without significant physician oversight of their practice.
Current State of Healthcare
Chronic wounds affect approximately 6.5 million U.S. patients9 and healthcare expenditures on wound care have exceeded $25 billion annually in the U.S. The global trend of increased obesity and diabetes is seen acutely in the wound patient. Patients are living longer with more comorbid, complex conditions, and there are not enough primary care physicians to treat them.9 Wound care is known to be extremely “siloed” with a lack of standardization within institutions and among specialists.10 Models of collaborative reorganization and integrated care have been proposed.10,11 Still, there is a great need for more highly trained, competent providers in wound care.10
NPs in Wound Care
The holistic nature of nurse training is easily applied in wound care. Patients living with chronic wounds that are complex and who have multiple comorbidities will additionally experience psychosocial challenges that impact treatment. NPs are natural wound care generalists who have the skill set to evaluate and treat wounds, as well as the overall health of the patient, and make appropriate referrals to specialists in fields such as podiatry, vascular surgery, plastic surgery, rheumatology, infectious disease, and orthopedics. In addition, NPs are licensed to perform procedures such as sharp debridement, ordering and interpreting of tests, and prescribing of medication. With wound management being a multidisciplinary area of care, a wound generalist who coordinates that care among all of the subspecialty teams is critical to quality healthcare. In 2015, the Association of American Medical Colleges released projections of a “primary care shortage of 12,500-31,100 primary care physicians and a shortfall of 28,200-63,700 non-primary care physicians,” most notably among surgical specialists, by 2025.12 NPs are already filling that gap, and it makes sense to have them provide the same function for the wound care patient. The parallel trajectories of the NP and WOC nurse roles are noteworthy. Similar to the evolution of the modern nurse during the Civil War, the NP and WOC nurse were created to fill large gaps in healthcare, and they continue to do so. Working together as part of the interdisciplinary team, the WOC nurse and NP’s expertise will continue to have a tremendous positive impact on improving patient outcomes among chronic wound patients.
Kara S. Couch is a family nurse practitioner and certified wound specialist on staff in the Wound Healing and Limb Preservation Center at George Washington (GW) University Hospital, Washington, DC. She is also adjunct clinical faculty for the department of physical therapy at GW and a board member of both the Alliance of Wound Care Stakeholders and the Association for the Advancement of Wound Care.