I am really proud of our wound clinic team and since the theme of this issue is multidisciplinary care, I interviewed them about their role in patient care and their perspective on collaborative practice. Here are the responses by our lead nurse, Debi Thompson, RN, WCC, and our hyperbaric/wound technician, Tara Stone (who is also the clinic manager).
Me: Tell me about the way you assess patients that isn’t focused on wound measurements—how you make a big picture assessment.
Debi: Believe it or not, there is valuable information in how patients get in the door—for example, whether they are using a walker, cane, or wheelchair, and if this has changed since their last visit. The best way to assess is by listening to the patients since they often like to talk about themselves. Like you often say, the wound is a symptom of something else; we have to manage the root cause.
Tara: I look for increased pain or swelling noted by the patient, or weight changes that aren’t intentional. Patients will often mention they aren’t eating because they don’t have an appetite. They tell me they sleep in a chair or even in their pickup truck, or they have to dangle their legs to control pain. I note changes in mental status or issues with family dynamics that affect patient care. It is important for wound patients to feel “heard” regarding their concerns and questions. It is also important that they understand what and why we do the treatments we do.
Me: The decision matrix for picking a wound dressing is complicated (e.g., the needs of the wound, the needs of the patient, insurance, etc.). I rely on your advice with regard to the wound treatment plan based on the assessment you perform. Tell me how you approach that.
Debi: My assessment begins when the patient walks through the door. For example: whether there is a gait problem, drainage in their shoes, whether the dressing falling off, the drainage color and amount, what type of tissue is in the wound bed, the peri-wound appearance, and who is changing the dressing (e.g., family, caregiver, or home health).
Tara: As a technician I note whether the current dressing supported the drainage, whether it sticks when it is removed or caused irritation, and whether there is an odor when the dressing is taken off. I also assess the patient and whether they are following instructions. Sometimes patients comment about the price of something being too high and they aren’t comfortable enough to tell the doctor there is a monetary barrier for fear of being seen as not being willing to do what was recommended.
Me: I always ask you to give me a brief update in the hallway before I walk in the room (often it takes less than a minute). I think it makes visits go more smoothly if know before I walk in whether major patient or wound problems await me, and I know you see things that I miss if I am in a hurry. What is your focus when you give me the “brief update”?
Debi: Because I was originally a hospital floor nurse, I think the brief update is like the shift report. I like to tell you if there are any compliance issues or new problems because that is what I would want to know as the doctor before walking in to see a patient.
Tara: As a technician I am focused on whether the wound is worse or better, or whether I see the patient declining mentally, physically or both. I ask about falls and hospitalizations. In my previous job, the doctor didn’t want an update prior to entering the room and left it up to the nurse or tech to decide what the plan would be. While doctors may feel they are empowering the nurse or technician, it is not really collaborative care because we were not working together to solve problems or create the treatment plan.
Me: What frustrates you in collaborating with doctors—me included?
Debi: My biggest frustration is being degraded in front of the patient after I have made a suggestion. Naturally you never do that! I also get frustrated being told by the doctor (in front of the patient) how to apply a dressing since I am pretty sure I know how to put on the dressings. And if there are issues about how I do something or if I need to be corrected, I think we should discuss them away from the patient.
Me: Is there something that you wish every wound care practitioner knew about working collaboratively?
Debi: Patients have told me that hearing us collaborate in the room actually makes them feel confident we are providing the best care. Perhaps not every patient feels this way, but most appreciate that we are a team and listen to each other. It can be frustrating for the nurses when the patient waits until the doctor is in the room to mention a problem or symptom because this makes it look like we weren’t thorough.
Tara: Sometimes the dressing or plan is just too complicated, and it means the staff has to do a lot of patient instruction and will likely answer phone calls requesting more explanation. We could collaborate better if everyone remembered that if possible, a simple dressing regimen is the best one.
Me: Talk about how you work with me to handle all the “loose ends” and help at least try to keep me from missing things.
Debi: It can go badly if we both forget something! There are so many little details, but they are all important. I listen as you talk to patients about the labs they need, and I try to fill out lab slips for them, and then create reminders for us to check lab results. When I hear you say the patient needs L-arginine, I start pulling the patient educational information about it and preparing to explain how to order these products. My co-workers are the best ever—everyone is very conscientious about putting comments and reminders in the chart about things to follow up on. It all comes down to excellent communication and follow-up.
Me: You all spend a lot of time on the phone returning calls. Tell me about that.
Debi: This is ongoing and can be overwhelming and frustrating, but we always work together. We do a lot of case management, handle family member questions, home health updates and “order clarifications” and pharmacy questions. Patients forget what instructions we gave them even though we provide printed instructions step by step for how to do their dressings. We have many patients with significant dementia and many who likely have early dementia but no one has admitted it yet.
Tara: We also spend a lot of time faxing and re-faxing orders to home health agencies. A big issue is the handling of the home health “485” form. The wound care practitioners do not like to sign it because the home health agency paperwork makes the wound care practitioner responsible for all the patient’s medications, etc. So, we have to send the dressing orders to the primary care provider (PCP) and let the PCP order home health and sign the form. This is time consuming.
Me: Tara, tell me about your role in helping me care for hyperbaric oxygen therapy (HBOT) patients.
Tara: As the hyperbaric technician, I have a close personal relationship with the HBOT patients because I spend so much more time with them. They often tell me things they might not share with the doctor. They complain of various symptoms over time and they want to know if it is caused by HBOT. These include new pain, increased blood pressure, changes in eating habits, new onset fatigue, changes in sleep pattern or bleeding. I am often the first to know about changes in mental status since I see them every day. I get to know their mannerisms and it is easy to notice that they are less talkative or having a hard time. In fact, HBOT patients tend to “over-share!” However, I know that they watch grandkids and are on their feet all day when they tell the doctor they are offloading their diabetic foot ulcer. I may be the first one to know they have pain that is new or worse or if they are drinking heavily. For some reason they are more likely to admit things to me.
Me: What is your role in scheduling and making the clinic run smoothly?
Debi: Scheduling can make a day difficult or run smoothly; patient acuity is key. I keep a schedule in front of me and watch the clock so I stay as close to on time as possible. I also watch if someone requires significant transfer assistance and we try to help each other with those because one nurse might not be able to manage it.
Me: Talk about your role in nutritional counseling, compression, how to do dressing changes, etc.
Debi: We do a lot of talking! We give handouts but I try to be sure the patient understands what I am talking about before sending him or her out the door with 10 pieces of paper.
Tara: We stress the importance nutrition plays in wound healing and that they need protein, vitamins and L-arginine. We stress the need to remove compression wraps if they get wet or if they cause pain. We spend a lot of time reviewing warning signs and explaining what the patient is to do if the wraps feel too tight or they get fever or chills.
Me: What do you think it means to “collaborate” in the care of a patient with wounds?
Debi: Sharing feedback and respecting the feedback given. Our doctors do a good job of handling the concerns that we come to you with regarding the patients.
Tara: Having undivided attention. None of us can collaborate well if the other person is distracted or simply not focused on the conversation. Also, we must collaborate with the patient as well as each other. We need to be direct and honest with patients if they have a poor prognosis, or if we are unable to help them fully because they are not adhering to the plan.
Me: What are some ways that I (or any doctor) could empower you to do a better job or ways that doctors actually prevent you from providing the best care?
Debi: Once the physician is finished with the visit, it actually helps me if they move on to the next patient. We can get a lot of teaching done at the end of the visit while doing the dressings but it is easier to do that when you are not in the room! We try to explain what we are doing, and it’s important to me that the patient is able to listen.
Tara: It helps if the doctor does not hover over us while we are doing the dressing, like they are trying to make sure it is done correctly, or chastise us in front of the patient. Also, while it is useful for us to discuss dressing option A (particularly when the situation is a tricky one), it’s very disempowering when the doctor either doesn’t ask our opinion or just ignores the suggestions we make.
Me: Thank you both for being so honest and thorough! I hope physicians will read this interview and take these honest comments to heart. I think my staff are the best and I posted a little video thank you on you tube that is dedicated to them here (which I created in the happy days before COVID-19 and mandatory mask wearing): https://youtu.be/_XLdR056kBc.
Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.