My Scope of Practice: Building Bridges Among Disciplines

   Bonnie Sparks-DeFriese, PT, RN, CWS, CWOCN, was attracted to wound care during her first clinical observation in 1982. She started reading and attending as many wound care educational programs as possible, eventually shaping her physical therapy practice to specialize in chronic wounds.

Although her practice settings varied (acute, outpatient, home health, long-term, and rehabilitational care), one fact remained true: gaps in wound management existed among disciplines. Nurses and therapists often did not understand nor appreciate each other's roles. To bridge those gaps in her own arenas, she pursued wound specialist certification, and later a nursing degree so she would qualify for a wound ostomy continence certification program. "Crazy, huh?" Bonnie asks, but she quickly answers, "It was worth it. As a PT/CWOCN, I am a better clinician and teacher with a better understanding of both sides."

   Bonnie cites Oscar Alvarez as a primary player in her educational scheme. She was the only PT in his Support Systems International multidisciplinary wound care program, where she says she "learned a ton" and was advised that as a wound care specialist/PT, she could make a difference. She also notes the influence of the state of affairs before and after PPS. "Before PPS, many PTs were primarily wound care therapists. Therapists had more time available to spend with patients and, therefore, were able to help nurses with complex wound care. Back then, we would assist by offering whirlpool therapy, but the rest of the treatment was left to the nursing staff. It soon made more sense to have the PT complete the treatment, including debridement, dressings, modalities, and patient education.

   "But when PPS arrived in the long-term care setting, many of us lost our wound care role and the nurses were once again overloaded. Even though the 4-year PT educational program provided the science and skill to manage patients with wounds, we weren't doing as much wound care because of reimbursement issues. As Carrie Sussman, PT, said, 'PT is an add-on service,' and the long-term care agencies did not necessarily want to pay extra for the wound care services provided by therapists. As a PT/wound care consultant, I would develop a plan, explain it to the medical provider, and then have to explain why I, as a PT, was involved. My wound care certification made me more credible, but it wasn't until I earned my nursing degree and my CWOCN that I achieved the respect of my new (nursing) peers."

   As the Skin/Wound Specialist at Maricopa Medical Center, a 541-bed hospital that is part of the Maricopa Health System, Phoenix, Ariz., Bonnie's duties included consulting for patients with wounds, ostomies, fistulas, and skin care problems. She was also responsible for program development, including policies, procedures, and protocols. Bonnie served as Co-chair of the Multidisciplinary Product Committee and was a member of the oncology multidisciplinary team. In these capacities, she honed her decision-making skills and influenced patient care regimens, often by offering guidance on wound and skin care products (purchasing and use) and care plans for nonhealing wounds. She also was involved in different modalities, such as electrical stimulation and negative pressure therapy.

   "What I like most is teaching patients and staff, especially the interns and residents - they seem to most eager to learn and are open to suggestions," says Bonnie. "Nevertheless, patient care always has been my focus: making decisions about care, performing the care, and teaching both the patient and family. In order to be an effective teacher, you first must be an effective clinician. Every time I see a new patient, I see a new opportunity to learn and re-learn about the condition, the tissues, the treatment, and so on. No two patients are alike. That's what keeps my job challenging and stimulating."

   And then there are the obstacles: paperwork, working within the hospital contracts over which she has no influence, difficulties obtaining supplies, and working around the politics and red tape inherent in any health system. "It takes so long to get things done," says Bonnie. "I bristle at the time it takes to complete projects. Recently, we decided to upgrade documentation that included wound care and risk assessment. In addition to this, I wanted to upgrade some of our wound care products and support systems. I was amazed at the number of meetings one must attend and the people whose approval was needed in order to change something within this system. You have to jump through a lot of hoops and secure numerous 'OKs', and I'm nurturing the patience necessary to work within the system concept."

   Of great concern is the fact that many of Maricopa's patients do not have insurance and they don't have the money to pay for products or appropriate care. "They cannot stay in our acute care facility until the wound is closed," Bonnie says. "Hospital length of stay is often 3 days or less for many patients. That was hard for me to accept, coming from outpatient/long-term care settings." In addition, Bonnie had to compromise, using products that will not damage tissue, even though they might not have been the best product for the wound. "As a teaching hospital, many different services will want to see a wound at different times during the day, making it likely that the dressing will be removed more than once a day. As such, it makes little sense to use a dressing that is too costly or adherent."

   This dedicated, busy clinician found the time in 1994 to be part of a humanitarian mission to South Viet Nam. The American Voluntary Medical Team included physicians, nurses, and nonmedical personnel who handled everything from pediatrics, OB-GYN, and family practice, to dentistry. In the 2 weeks she was there, Bonnie says the team saw more than 2,000 patients. "At that time, I was a PT with a love for wound management with no medical experience outside of the US. In rural Viet Nam, we had to wash and re-use gauze, and I was able to provide treatments I never would be allowed to perform in the US due to our professional practice acts, such as I&Ds. I even pulled a tooth!"

   Bonnie's desire to eventually teach in a university system that utilizes a team approach has been realized. Recently, Bonnie was recruited to join the Emory University Wound Ostomy Continence Education program as a nurse clinician and instructor, where she says she can, "keep my hand in patient care and learn from my previous teacher and new boss, Dorothy Doughty."

   Bonnie says wound management is like a drama… it keeps you involved from beginning to end. "It is a wonderful field. I could not have asked for a better educational and career combination - PT and ET/WOCN. When someone asks me if I feel more like a PT or an RN, I say 'Neither'. I am a wound specialist in my scope of practice."

   My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.