A healthy workplace requires professionalism, compassion, and patience. It can’t abide bullying, cliques, and passive-aggressive behavior. These articles focus on how to achieve a healthy workplace through open communication, mentoring, and leadership.
Wound care has come a long way in just a few decades. With our expanded knowledge of wound healing and recent advances in treatment, we’re now able to assess wounds more accurately, recognize wound-related problems sooner, provide better interventions, and reduce morbidity.
To bring you up to date on current evidence-based wound management, this article focuses on assessing patients with chronic wounds, optimizing wound healing with effective wound-bed preparation, and selecting an appropriate dressing.
Wound chronicity and cause
Developing an appropriate plan of care hinges on conducting a thorough, accurate evaluation of both the patient and the wound. The first step is to determine whether the wound is acute or chronic.
- A chronic wound is one that fails to heal within a reasonable time—usually 3 months.
- An acute wound heals more quickly, causing minimal functional loss in the part of the body with the wound.
Identifying the cause of the wound also is essential. If the wound etiology is unknown, explore the patient’s medical history (including medication history) for clues to possible causes. Also review the patient’s history for conditions that could impede wound healing. (See What factors hamper healing? in PDF file by clicking on Download now button.)
Other important aspects of assessment include evaluating the patient’s nutritional status, quantifying the level of pain (if present), and gauging the patient’s self-care abilities.
General physical appearance
Conduct a general head-to-toe physical examination, focusing on the patient’s height, weight, and skin characteristics.
Height, weight, and weight trend
On admission, the patient’s height and weight should be measured to ensure appropriate nutritional and pharmacologic management. After a weight gain or loss, various factors may complicate wound healing. For instance, involuntary weight loss and protein-energy malnutrition may occur in both acute-care and long-term-care patients.
Especially note trends in your patient’s weight. For a long-term-care patient, a 5% weight loss over 30 days or a 10% loss over 180 days is considered involuntary. Arrange for a nutritional consult for any patient with an involuntary weight loss, as adequate nutrition is essential for general well-being and wound healing. (See A wound on the mend in PDF file by clicking on Download now button.)
Evaluate the patient’s skin color in light of ethnic background. If you note erythema—especially on a pressure point over a bony prominence—examine this area carefully for nonblanching erythema. Keep in mind that darkly pigmented skin doesn’t show such erythema and subsequent blanching, yet the patient may still be in jeopardy. So in dark-skinned patients, check for differences in skin color, temperature, or firmness compared to adjacent tissue; these differences may signify skin compromise.
Skin texture and turgor
Generally, healthy skin feels smooth and firm and has an even surface and good turgor (elasticity). To test turgor, gently grasp and pull up a fold of skin on a site such as the anterior chest below the clavicle. Does the skin return to place almost immediately after you release it, or does it stand up (“tent”)? Tenting indicates dehydration. But keep in mind that skin loses elasticity with age, so elderly patients normally have decreased turgor.
With normal circulatory status, the skin is warm and its temperature is similar bilaterally. Areas of increased warmth or coolness suggest infection or compromised circulation. Be sure to check the temperature of skin surrounding the wound.
Proper wound assessment can significantly influence patient outcome. Measure the wound carefully and document the condition of the wound bed. Remember that accurate descriptions are essential for guiding ongoing wound care. Repeat wound measurement and wound-bed assessment at least weekly, after the wound bed has been cleaned and debrided.
Keep in mind that assessing a chronic wound can be challenging. Wounds commonly have irregular shapes that can change quickly. Also, the multiple nurses caring for the same patient may each describe the wound a bit differently.
Note the precise anatomic location of the wound, as this can influence the wound care plan. A venous ulcer on the lower leg, for instance, requires different care than an arterial ulcer in the same site or a pressure ulcer on the ischium.
Circumference and depth
Use a paper or plastic measuring device to measure wound circumference and depth in centimeters (cm) or millimeters (mm). To promote accurate assessment of healing, be sure to use the same reference points each time you measure the wound.
You can use several methods to measure circumference. For the most commonly used method, measure the wound at its greatest length, followed by the longest measurement perpendicular to the length (which determines the width). Then multiply these two measurements (greatest length x greatest width) to obtain the total wound area. Although such linear measurements are imprecise, they yield gross information relative to wound healing when repeated over time.
Classify wound depth as partial thickness or full thickness.
- Partial-thickness wounds are limited to the skin layers and don’t penetrate the dermis. They usually heal by reepithelialization, in which epidermal cells regenerate and cover the wound. Abrasions, lacerations, and blisters are examples of partial-thickness wounds.
- Full-thickness wounds involve tissue loss below the dermis.
(Note: Pressure ulcers usually are classified by a four-stage system and diabetic foot ulcers by a grading system. Both systems are beyond this article’s scope.)
Measure and record wound depth based on the deepest area of tissue loss. To measure depth, gently place an appropriate device (such as a foam-tipped applicator) vertically in the deepest (or deepest-seeming) part of the wound, and mark the applicator at the patient’s skin level. Then measure from the end of the applicator to the mark to obtain depth.
Surrounding skin and tissue
Inspect for and document any erythema, edema, or ecchymosis within 4 cm of the wound edges, and reevaluate for these signs frequently. Because compromised skin near the wound is at risk for breakdown, preventive measures may be necessary.
Appearance of wound-bed tissue
Document viable tissue in the wound bed as granulation, epithelial, muscle, or subcutaneous tissue. Granulation tissue is connective tissue containing multiple small blood vessels, which aid rapid healing of the wound bed; appearing red or pink, it commonly looks shiny and granular. Epithelial tissue consists of regenerated epidermal cells across the wound bed; it may be shiny and silvery.
Check for nonviable tissue (also called necrotic, slough, or fibrin slough tissue), which may impede wound healing. It may vary in color from black or tan to yellow, and may adhere firmly or loosely to the wound bed. (See Picturing a necrotic wound in PDF file by clicking on Download now button.)
Be sure to document the range of colors visible throughout the wound. Identify the color that covers the largest percentage of the wound bed. This color—and its significance—largely guide dressing selection.
Document the amount, color, and odor of exudate (drainage) in the wound. Exudate with high protease levels and low growth factor levels may impede healing.
If the wound is covered by an occlusive dressing, assess exudate after the wound has been cleaned. Describe the amount of exudate as none, minimal, moderate, or heavy.
Describe exudate color as serous, serosanguineous, sanguineous, or purulent. Serous exudate is clear and watery, with no debris or blood present. Serosanguineous exudate is clear, watery, and tinged pink or pale red, denoting presence of blood. Sanguineous exudate is bloody, indicating active bleeding. Purulent exudate may range from yellow to green to brown or tan.
Describe wound odor as absent, faint, moderate, or strong. Note whether the odor is present only during dressing removal, if it disappears after the dressing is discarded, or if it permeates the room.
Wound edges indicate the epithelialization trend and suggest the possible cause and chronicity of the wound. The edges should attach to the wound bed. Edges that are rolled (a condition called epibole) indicate a chronic wound, in which epithelial cells are unable to adhere to a moist, healthy wound bed and can’t migrate across and resurface the wound.
Undermining and tracts
Gently probe around the wound edges and in the wound bed to check for undermining and tracts. Undermining, which may occur around the edges, presents as a space between the intact skin and wound bed (resembling a roof over part of the wound). It commonly results from shear forces in conjunction with sustained pressure. A tract, or tunnel, is a channel extending from one part of the wound through subcutaneous tissue or muscle to another part.
Measure the depth of a tract or undermining by inserting an appropriate device into the wound as far as it will go without forcing it. Then mark the skin on the outside where you can see or feel the applicator tip. Document your findings based on a clock face, with 12 o’clock representing the patient’s head and 6 o’clock denoting the feet. For instance, you might note “2.0-cm undermining from 7:00 to 9:00 position.”
Ask the patient to quantify the level of pain caused by the wound, using the pain scale designated by your facility. Find out which pain-management techniques have relieved your patient’s pain in the past; as appropriate, incorporate these into a pain-management plan. Reevaluate the patient’s pain level regularly.
An evolving science, wound-bed preparation is crucial for minimizing or removing barriers to healing. The goal is to minimize factors that impair healing and maximize the effects of wound care. The key elements of wound-bed preparation are controlling bioburden and maintaining moisture balance. (For online resources on wound-bed preparation and other wound-care topics, see Where to get more information in PDF file by clicking on Download now button.)
Necrotic tissue and exudate harbor bacteria. A wound’s bioburden—the number of contaminating microbes—contributes to poor healing. All chronic wounds are considered contaminated or colonized, but not necessarily infected. In a colonized wound, healing is impeded as bacteria compete for nutrients; also, bacteria have harmful byproducts. To control bioburden, the wound must be cleaned and necrotic tissue must be debrided.
Cleaning the wound. Clean the wound before assessing it and applying a dressing. Use a noncytotoxic agent (typically, normal saline irrigating solution or an appropriate wound-cleaning agent). Antiseptic solutions generally aren’t recommended for wound irrigation or dressings because they’re toxic to fibroblasts and other wound-repairing cells. If you must use such a solution, make sure it’s well diluted.
To ensure gentle cleaning or irrigation, pour solution over the wound bed or gently flush the wound with solution (using a 60-mL catheter-tip syringe) until the drainage clears. Know that pressurized irrigation techniques and whirlpool therapy aren’t recommended for wound cleaning because they disturb cell proliferation in the wound bed.
Debriding the wound. Debridement removes slough and necrotic tissue. Nonselective debridement techniques remove any type of tissue within the wound bed, whereas selective methods remove only necrotic tissue. (See Wound debridement techniques in PDF file by clicking on Download now button.)
Maintaining moisture balance
To maintain moisture balance in the wound bed, you must manage exudate and keep the wound bed moist. The proper dressing (which may stay in place for days or longer) supports moist wound healing and exudate management. To minimize fluid pooling, a drain may be inserted into the wound. Negative-pressure wound therapy also may aid removal of excess exudate.
Choosing an appropriate dressing
The wound dressing plays a major role in maintaining moisture balance. Dressing selection is challenging because of the large number and variety of dressings available. Each product has specific actions, benefits, and drawbacks, so determining which dressing best suits the patient’s needs is a multifaceted process.
Dressing choice depends on such factors as wound type and appearance, exudate, presence or absence of pain, and required dressing change frequency.
For a 2-page resource on dressing options for clean and necrotic partial-thickness wounds visit the Web Exclusive content on the July 2008 issue page.
In a traditional dressing, gauze is applied in layers. The initial (contact) layer in the wound bed absorbs drainage and wicks it to the next layer; most often, this layer consists of woven cotton gauze or synthetic gauze. Remove the gauze gently, because it may be stuck to the wound or incision (especially if the gauze is cotton). For easier removal, moisten the dressing with normal saline solution to loosen it.
With a traditional dressing, the cover layer or secondary dressing is an abdominal pad with a “no-strike-through” layer next to the outside of the dressing. Be aware that wet-to-dry dressings are highly discouraged for their nonselective debriding effect and inability to provide a moist wound bed.
Reassess the patient’s wound at least weekly (after preparing the wound bed and dressing the wound) to determine healing progress. Keep in mind that wound-care management is a collaborative effort. Once you’ve assessed the patient, discuss your findings and subsequent wound management with the clinical nurse specialist, wound care nurse, and physician as appropriate.
Wound care wisdom
Getting wiser about wound care will help your patients achieve good outcomes. Poor wound healing can be frustrating to patients, family members, and healthcare providers alike. Chronic wounds may necessitate lifestyle changes and lead to severe physical consequences ranging from infection to loss of function and even death. By performing careful assessment, tailoring patients’ wound care to wound etiology, and using evidence-based protocols to manage wounds, you can promote speedier wound healing, help lower morbidity, and improve quality of life.
Collins N. Nutrition and wound healing: strategies to improve patient outcomes. Wounds. 2004;16(suppl 9):12S-18S.
Evans E. Nutritional assessment in chronic wound care. J Wound Ostomy Continence Nurs. 2005;32(5):317-320.
Kingsley A. The wound infection continuum and its application to clinical practice. Ostomy Wound Manage. 2003;49(suppl 7A):1-7.
National Pressure Ulcer Advisory Panel. Pressure ulcer stages revised by NPUAP. www.npuap.org/pr2.htm. Accessed May 28, 2008.
Nix DP. Patient assessment and evaluation of healing. In Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. St. Louis, MO: Mosby; 2007.
Nursing Educational Programs and Services. Dressing Selection Based on Stage, Exudate, and Wound Bed Appearance. Ridgeland, SC: Nursing Educational Programs and Services; 2006.
Ovington L. Hanging wet dressings out to dry. Adv Skin Wound Care. 2002;15(2):79-86.
Ramundo JM. Wound debridement. In Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. St. Louis, MO: Mosby; 2007:176-192.
Serena TE. Managing the wound microenvironment. Wounds. 2005;17(8)(suppl):7-11.
Stotts NA, Wipke-Tevis DD, Hopf HW. Cofactors in impaired wound healing. In Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Malvern, PA: HMP Communications; 2007:215-220.
van Rijswijk L, Catanzaro J. Wound assessment and documentation. In Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Malvern, PA: HMP Communications; 2007:113-126.
Patricia A. Slachta is a Clinical Nurse Specialist at The Queens Medical Center in Honolulu, Hawaii and a nursing instructor at the Technical College of the Lowcountry in Beaufort, South Carolina. The planners and author of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
On June 17, the U.S. Food and Drug Administration (FDA) recommended that medical device manufacturers and health care facilities take steps to ensure that appropriate safeguards are in place to reduce the risk of failure due to cyberattack. The FDA states it has become aware of “cybersecurity vulnerabilities and incidents that could directly impact medical devices or hospital network operations.” Read more.
The U.S. Pharmacopeial Convention has announced new standardized labeling requirements for injectable medication vials. Manufacturers can only put cautionary statements for preventing “imminent life-threatening situations” on the top of the medication vial. In other cases, the area must remain blank. Read more here.
On July 23, the U.S. Food and Drug Administration (FDA) approved Tudorza Pressair (aclidinium bromide) for the long-term maintenance treatment of bronchospasm in patients with chronic obstructive pulmonary disease. Read more.
On March 11, the U.S. Food and Drug Administration (FDA) allowed marketing of the first device as a preventative treatment for migraine headaches. This is also the first transcutaneous electrical nerve stimulation device specifically authorized for use before the onset of pain. Read more.
A patient who still has hypotension after initial fluid resuscitation most likely has which form of sepsis?
a. Systemic inflammatory response syndrome
b. Moderate sepsis
c. Severe sepsis
d. Septic shock
Answer to Quiz Time: d. Septic shock is severe sepsis accompanied by persistent hypotension after fluid resuscitation.
Learn more by reading the continuing nursing education article “Reducing sepsis deaths: A systems approach to early detection and management.”
Thank you, Dr. Cipriano, for your editorial on mindfulness practice to assist in the grief process (“Breath at the belly,” July 2010). A long-time Buddhist, I have practiced mindfulness meditation for 20+ years. Two years ago, when I suddenly lost my husband of 20 years, mindfulness practice kept me focused and in present time. I was able to fully experience grief in a way I believe is unique because of my Buddhist training. You said it well when you stated, “Grief becomes a purposeful, meaningful journey that teaches the importance of relationships and the experience of the here and now.” Being in the here and now can serve us well not just in health care, where we often deal with others’ grief, death, and dying, but in our daily lives.
Nina D’Andrea, MSN, RN
Professional judgment vs. practice guidelines
I commend Leah Curtin for pointing out that going by the book isn’t necessarily best in every situation (“Going from the gut,” July 2010.) Today, practice guidelines seem to be regarded as the Holy Grail.
I agree that guidelines are important in bringing evidence to the bedside to improve outcomes. But as an educator, I find it’s equally important to teach nursing students that nurses must use their professional judgment to interpret guidelines within the context of an individual patient situation. When a nurse follows a guideline, she does so because her professional judgment tells her it’s best to do so in that situation. When she decides not to follow a guideline, her actions likewise must be based on her professional judgment. In either case, the decision must be defensible. If the nurse can’t defend her decision, clearly she wasn’t using her professional judgment in the first place.
Mara Eisch, DNP, RN
Alphabets are good for soup, not nursing
When I talk with patients, I’m amazed at how much they must learn and comprehend about matters that affect their lives—and in so little time. So I wonder, “Why does nursing add another patient stressor by having so many degrees?” Our “alphabet” of nursing degrees is too large. Even nurses can’t name, describe, or differentiate them all. We have the AD, BSN, MN, MSN, MEd, CNL, DNP, DNS, and PhD. Do we really need this alphabet soup? Why can’t we have just one BSN, one master’s degree, and one doctorate degree? Or perhaps just a BSN and two doctorates (DNP and PhD)? Having just three nursing degrees is less likely to confuse the public and the profession.
Simplifying nursing degrees would help us communicate more effectively with patients, families, each other, and other healthcare providers. I have had this discussion with colleagues from staff nurses to deans, and have found I’m not alone in my thinking. Can we take hold of our practice discipline and get back to basics? Every degree program should have its specialties (some with subspecialties), but the degree itself should be standardized.
Cynthia Chernecky, PhD, RN, AOCN, FAAN
Disconnect between education and practice
Several articles and a letter in your May issue illustrate the disconnect between nursing education and nursing practice. In “Helping new nurses set priorities,” Joyce Nelson states that novice nurses may feel overwhelmed by the choices they must make. But why should they? After all, setting priorities in complex situations is a fundamental nursing skill. Why do our graduates feel overwhelmed by something they should already know how to do? In her letter to the editor (“Nursing academics vs. practicing nurses?”), Leslie Durr offers an explanation: Nursing education is one thing; nursing practice is quite another.
In “Understanding the DNP degree,” Matthew Patzek suggests the DNP is the solution to the problem. But is it really? And how much money should we invest in finding out? Upping the ante with regard to education leads to a more costly system. How would we know the increased investment would be worth it?
Surely there’s a simpler answer: Introduce more real practice into nursing education. The most obvious way to do this is to require students to complete a substantial clinical internship before taking the state board examination. When I was in nursing school, my classmates and I worked in a clinical setting every day during our entire course of study. While that had disadvantages, it helped ensure we were competent practitioners at graduation.
We need large numbers of nurses who are ready to practice—not a cadre of semiskilled practitioners hoping to muddle through in environments that may or may not get them on track to full competence.
Burden S. Lundgren, MPH, PhD, RN
We welcome your comments. You may submit letters to the editor electronically at www.AmericanNurseToday.com, or by mail to: Letters to the Editor, American Nurse Today, c/o HeatlhCom Media, 259 Veterans Lane, 3rd Floor, Doylestown, PA 18901. Please include your full name, credentials, city, state, and daytime phone number or e-mail address. Letters should contain no more than 250 words and will be edited for grammar, length, content, and clarity. All letters are considered American Nurse Today property and therefore unconditionally assigned to American Nurse Today.
A study in the Journal of Alzheimer’s Disease reports that mild cognitive impairment occurs significantly more often in individuals diagnosed with a lower ankle brachial index. Read more and read the study abstract.
Much has been written about leadership. But despite all the wisdom and research packed into these books and articles, a lot of practical and personal experience simply doesn’t jive with what the publications tell you. So during my travels throughout the USA, I asked the nursing leaders I met to share, in as few words as possible, at least one insight into what they’ve learned about being a leader. This wasn’t a formal study or even a representative sample. Nonetheless, I got a generous outpouring of information, inspiration, common sense, and practical tips on how to survive it all from those who’ve been there. Here’s a sampling:
“What I have learned is that you cannot learn leadership from anybody’s book!”
Bobbie Bradford, MSN, RN; former CEO, Drake Hospital, Cincinnati
“Most people don’t want to listen to you; they want you to listen to them.”
Joanne Schuster, PhD, RN; former president, Franciscan Sisters of the Poor Health System
“The most critical thing is to know your own ethical bottom line.”
Joyce Clifford, PhD, RN, FAAN; President and CEO, Institute for Nursing Healthcare Leadership
“Don’t let your assets become your liabilities. Organizations change. Rethink, retool, and refocus. Identify make-or-break outcomes and be sure you produce them.”
Gail Wolf, DNS, RN, FAAN; Professor, Acute and Tertiary Care, University of Pittsburgh School of Nursing
“The world really is run by the people who show up. It isn’t trite; it’s true!”
Mary Woody, MSN, RN, FAAN; former Dean, CNO, Charter Fellow and Living Legend of the American Academy of Nursing (AAN) (d. 2010)
“I have learned that there is no right way to do a wrong thing.”
Myrna Warnick, MS, RN; CEO, CNO, and assistant professor of nursing (d. 2009)
“The people you expect to kick you when you’re down will be the very ones who help you get back up. Trust me on this one!”
Leah Curtin, RN, ScD(h), FAAN
“It is incredibly easy to reward those who like you rather than those who contribute to the outcome. Give recognition for the right reason. Otherwise, you ensure failure.”
Josephine Flaherty, PhD, RN; former Principal Nursing Officer, Health Canada
“When someone has done you an injustice, don’t get mad and don’t waste your energy trying to get even. Time will catch up with them: Dysfunction is its own reward.”
Hildegard Peplau, PhD, RN, FAAN; Dean, Professor, former president of ANA and ICN, AAN Living Legend (d. 1999)
“Assume the best about people and the worst about situations.”
Patricia Seifert, MSN, RN, CNOR, FAAN; former president, AORN; Editor-in-Chief, AORN Journal
“Be sure the juice is worth the squeeze. Make sure the outcomes are worth the effort. This is even more important when it comes to delegation. You may abandon an underproductive project, but staff will labor on and on in an effort to do what you ask of them, whether it’s productive or not.”
Gail Wolf, DNS, RN, FAAN; Professor, Acute and Tertiary Care, University of Pittsburgh School of Nursing
“Few things are more dangerous than being a ‘true believer’ in any system or philosophy or change. Track everything, and be open to reversing course if necessary.”
Luther Christman, PhD, RN, FAAN; former dean, professor, and AAN Living Legend
“No matter how good your friends are and no matter how right you are, they may not stand behind you in a work-related confrontation, and you must forgive them for that.”
Genrose Alfano, MA, RN, FAAN; former director, Loeb Center for Nursing and Rehabilitation, Montefiore Medical Center, NY
“I have learned that nobody ever feels sorry for anybody who makes more money than they do!”
Alice R. Clarke, MSN, RN; founding publisher, Nursing Forum and Perspectives in Psychiatric Care
“Throughout your term of office, no one will care as much about the organization as you do—and no one should.”
Marianne Chulay, DNSc, RN, FAAN; submitted by Laurie McNichol, former president, Wound, Ostomy, and Continence Nurses Society
Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.
Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions or recommendations of the ANA or the staff or Editorial Advisory Board of American Nurse Today.
*With acknowledgment to Gail Wolf, DNS, RN, FAAN, who someday may write a book by this title.
May 27, 2015
Lillee Smith Gelinas, Editor-in-Chief
Cynthia Saver, HealthCom Media
American Nurse Today
Dear nursing colleagues,
This feedback I offer about the article entitled ‘Dedicated education units: An innovative model for clinical education’ (Volume 10, No. 5, pp. 46-49) seemed longer than intended for your online feedback site myamericannurse.com. Therefore, thank you for allowing me to provide information to both editorial leadership and email queries in this one letter.
Dedicated education unit (DEU) clinical teaching model warrants inclusion in your journal. As a disruptive innovative, it has changed our thinking on best practice in clinical teaching and learning and redefined academic-service partnerships. DEUs have altered the very landscape of clinical teaching and learning in the United States (US) for at least ten years.
The University of Portland School of Nursing in Portland, Oregon, has been the original and persistent translator of this Australian model into the US nursing education and service environments for those ten years. Together with our clinical partners in a Veterans Administration medical center, a private hospital system, long term care agency, and community-based organization, we have continued to sustain and further develop the potential of this model. We have hosted three international conferences and present at every opportunity to disseminate information. We continue to provide individual consultations frequently to inquiring partnerships, and have from the beginning made all our information available free on the school’s website (www.nursing.up.edu).
Among the resources on our website is an extensive DEU bibliography, including what most consider the seminal DEU article by Moscato, Miller, Logsdon, Weinberg, and Chorpenning in Nursing Outlook (2007). We published our expansion into school nursing in Braband and Vines in Communicating Nursing Research (2012) and long term care by O’Lynn in Geriatric Nursing (2013). Warner and Burton published a model that reconceptualized academic-service partnerships related to educating our nursing workforce in the Journal of Professional Nursing (2009). Two excellent articles by Nishioka, Coe, Hanita and Moscato in Nursing Education Perspectives (2014) report evaluation findings from the Robert Wood Johnson funded Evaluating Innovations in Nursing Education project. And there is more.
Why do I write? I understand the limit of five references in your peer-reviewed articles. In no way do I expect the Hunt, Milani and Wilson article to provide a comprehensive review. However, I worry that your peer reviewers or readers lack a context for this innovation, or that they would find the New Rochelle, New York experience as more novel than history might indicate.
Furthermore, why do I write? My motive is to provide a deeper historical context for a model that will continue to transform how we practice and teach. If you need peer reviewers for future DEU articles, the University of Portland School of Nursing stands ready to assist you. Thank you.
Joanne R. Warner, PhD, RN
Dean and Professor
As of May 1, manufacturers of Heparin Sodium Injection, USP and Heparin Lock Flush Solution, USP are required to use labels that reflect the total drug content. Although the change is designed to prevent medication errors, for a time, both current and revised labels may appear, heightening the risk of error. Read more.
Sarah made the transition from inpatient hospital nurse to home care (HC) nurse 6 years ago. She enjoys her practice and likes helping the patients and families whose cases she manages. Her performance evaluations have been very good.
When her HC organization posts a job opening for nurse manager, Sarah considers applying for it—but wonders to what extent her nursing skills and knowledge would transfer to the manager position.
When I first became a HC nurse manager, no one taught me what I needed (or thought I needed) to know. Based on my conversations with peers, this pattern holds true for many HC nurses who’ve transitioned to a manager position. The tips below can help HC nurses recognize and leverage the knowledge and skills they already have to become effective managers.
Effective HC nurses are multitaskers whose days often are scheduled and rescheduled based on patient, family, or organizational needs. With priorities changing frequently, flexibility is an important asset for any manager.
2. Critical thinking skills
To help patients meet agreed-upon goals, HC nurses must be able to think critically and to use their skills and perform tasks within defined time frames. This same level of energy and commitment can help them transition to the manager role, where the organization needs their enthusiasm and critical thinking skills to solve problems.
3. Technological proficiency
HC nurses need to be proficient with technology to effectively support patient-care planning, scheduling, and other operational requirements. Most HC organizations have a computer or documentation system that nurses take to the patient’s home and use to interview patients and document findings and care provided. The best systems are point-of-care and mobile; the technological skills required to use them are directly transferable for HC nurses making the change to manager.
4. In-depth understanding of the nursing process
All nurses are familiar with the steps of the nursing process—assessment, planning, implementing, and evaluation—used to provide patient care. The nursing process also is invaluable for solving problems that mangers face, including organizational ones.
5. Public health knowledge
HC nurses focus on public health—for instance, asking patients about immunizations and other wellness issues—as well as safety, outreach, education, and disease and chronic care management. Their broad-based view of health care transfers well to the manager position. Also, due to the complex regulatory environment of HC and HC nursing, nurses are accustomed to cost accounting for care and services, such as patient visits. Documentation and compliance play a large role in HC nurses’ practice. Such skills and knowledge are extremely useful for managers.
6. Effective communication and coordination skills
We continue to learn more about how effective communication can promote patient safety—and how ineffective communication can jeopardize it. HC nurses are used to communicating and coordinating with the interprofessional team, including nurse colleagues, aides, therapists, physicians, and others who may be involved in a patient’s care (such as teachers going to the patient’s home). These skills are crucial for a smooth transition to the manager role.
7. Knowledge of quality improvement
In HC, certain areas of care are identified, analyzed, and tracked or trended for improvement. Examples include infections and infection-control activities, complaints, and patient experience surveys. HC nurses who become managers can apply their knowledge of data measurement and management at a higher level.
8. Nonjudgmental attitude
The ability to be open, nonjudgmental, and sensitive to cultural, lifestyle, and other differences is crucial when caring for patients of diverse cultures in their homes. HC nurses provide care for many different types of patients and families, with many different lifestyles. This experience helps nurses in a management position to interview, build, and lead their team.
I’ve found most HC nurses can talk to nearly anyone about anything. It takes a special person to be able to walk into someone’s home as a stranger and comfortably interact on the patient’s turf immediately, assessing and providing care on that first visit. Humor, flexibility, and excellent nursing skills all come to the forefront during home visits. The HC nurse who becomes a manager transfers these interpersonal skills and applies them to such situations as meeting new peer managers, interviewing prospective new team members, and more.
9. Ability to work with team members remotely
In HC, most of your team members aren’t down the hall. They may be two or three counties away, or even across a state line. Managers must communicate and coordinate with team members who work at a distance and whom they may see only at certain times of the day or week. They must be able to screen, orient, and provide leadership, direction, and feedback for team members—often remotely.
10. Understanding that you can’t know it all—and being OK with that
To perform their jobs effectively, HC nurses need to learn continually. They must stay abreast of new products and technology, such as when a patient is discharged home from a tertiary hospital with a high-tech medical device they’ve never seen before. They must learn the new technology and become competent in using it.
When you transition to the nurse manager role, you go through a similar process, starting with a new set of skills and new terms to master. You must continue to ask questions and learn.
To help you grow into your new role, you’ll need to identify both vertical and horizontal mentors. I recommend that you read management books and anything else you can about healthcare models, innovation, and change. Realize there’s always more to know.
Model yourself after a leader you admire. When stressed, ask yourself: What would this person do? Elicit feedback from your mentors and, when possible, meet with a small group of new nurse leaders whom you can learn from and with.
New role, new responsibilities
As a nurse manager, you’ll have a new purview and a new level of responsibility. Expect team members to bring questions and problems to you; encourage them to come up with solutions and answers on their own. Identify staff who are innovative and helpful. Keep in mind that you need to develop the next nurse leaders in your organization.
Whenever possible, smile and be open. If needed, work on improving your likeability. Leaders don’t have to be stern or authoritative at all times. When it comes to the regulatory and compliance aspects of HC, there’s no room for flexibility. But to promote team building and nurture team members’ respect and trust, just be yourself.
By working with organizational leadership, possessing a clear definition of your role and responsibilities, and continually working on your management skills, you’ll be well on your way toward becoming an effective HC manager. Embrace this new opportunity to lead, inspire, influence, and spark enthusiasm in your team.
If you’re a new nurse manager in HC and have a question, please email me at email@example.com. I’m eager to hear what you brought from your practice as a HC nurse that helped in your transition to becoming an effective manager.
Tina M. Marrelli is president of Marrelli and Associates, a healthcare consulting and publishing firm in Venice, Florida. She is also on the editorial advisory board of American Nurse Today. You can reach her at firstname.lastname@example.org.
Allen NE. Survivor! 10 Practical Steps to Survey Survival. 4th ed. Jacksonville, FL: Solutions for Care, Inc.; 2014.
Marrelli T. Handbook of Home Health Standards: Quality, Documentation, and Reimbursement. 5th ed. St. Louis, MO: Mosby; 2012.
Marrelli T. The Nurse Manager’s Survival Guide: Practical Answers to Everyday Problems. 3rd ed. St. Louis, MO: Mosby: 2004.