Most of the wounds in the 154,644 patients were diabetic foot ulcers, venous leg ulcers, and pressure ulcers. The study authors note that debridement is a “key process” in wound bed preparation and starting the healing process.
The findings are congruent with previous studies and are based on an analysis of the largest wound data set to date. (more…)
Why is it that the people who are the most caring toward others neglect their own needs? Have you noticed this?
I’ve seen it time and time again. The healthcare worker who’s always the last to leave work, who always volunteers to work those extra shifts so patient care won’t be compromised, who never says “No” when it comes to something a friend needs. These same compassionate and devoted clinicians seem to always worry about others and not themselves. (more…)
Pressure ulcers take a hefty toll in both human and economic terms. They can lengthen patient stays, cause pain and suffering, and increase care costs. The average estimated cost of treating a pressure ulcer is $50,000; this amount may include specialty beds, wound care supplies, nutritional support, and increased staff time to care for wounds. What’s more, national patient safety organizations and insurance payers have deemed pressure ulcers avoidable medical errors and no longer reimburse the cost of caring for pressure ulcers that develop during hospitalization.
Frequent debridement improves wound healing A study in JAMA Dermatology reports that frequent debridements speed wound healing. “The more frequent the debridement, the better the healing outcome,” concludes “Frequency of debridements and time to heal: A retrospective cohort study of 312 744 wounds.” The median number of debridements was two. Most of the wounds in the 154,644 patients were diabetic foot…
Here are some resources of value to your practice. National Guideline Clearinghouse The National Guideline Clearinghouse, supported by the Agency for Healthcare Research and Quality, summarizes many guidelines of interest to wound care, ostomy, and lymphedema clinicians. Here are some examples: Guideline for management of wounds in patients with lower-extremity neuropathic disease Pressure ulcer prevention and treatment protocol Lower limb…
By Gail Hebert, RN, MS, CWCN, WCC, DWC, LNHA, OMS; and Rosalyn Jordan, BSN, RN, MSc, CWOCN, WCC, OMS Imagine your physician has just told you that your rectal pain and bleeding are caused by invasive colon cancer and you need prompt surgery. She then informs you that surgery will reroute your feces to an opening on your abdominal wall.…
By Rose O. Sherman, EdD, RN, NEA-BC, FAAN Unfortunately, most clinicians can’t avoid having to work with difficult people. However we can learn how to be more effective in these situations, keeping in mind that learning to work with difficult people is both an art and a science. How difficult people differ from the rest of us We can all…
By Tamera L. Brown, MS, RN, ACNS-BC, CWON, and Jessica Kitterman, BSN, RN, CWOCN Pressure ulcers take a hefty toll in both human and economic terms. They can lengthen patient stays, cause pain and suffering, and increase care costs. The average estimated cost of treating a pressure ulcer is $50,000; this amount may include specialty beds, wound care supplies, nutritional…
By Gregory S. Kopp, RN, MN, MHA A new job can be stimulating, but it can also be stressful. Not only will you have new responsibilities, but you’ll also have a new setting, new leaders, and new colleagues. And the quicker you can figure out who’s who and what’s what—without stepping on anyone’s toes—the better off you’ll be. But establishing…
By Ronnel Alumia, BSN, RN, WCC, CWCN, OMS Achieving excellent wound care outcomes can be challenging, given the growing number of high-risk patients admitted to healthcare facilities today. Many of these patients have comorbidities, such as obesity, diabetes, renal disease, smoking, chronic obstructive pulmonary disease, and poor nutritional status. These conditions reduce wound-healing ability.
By Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP Quality patient education is essential for comprehensive health care and will become reimbursable under healthcare reform in 2014. However, it’s difficult to provide effective education when time for patient interactions is limited. You can enhance your instruction time—and make your teaching more memorable—by using the techniques of analogy and metaphor.
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN The first 24 hours after a patient’s admission are critical in preventing pressure ulcer development or preventing an existing ulcer from worsening. A skin inspection, risk assessment, and temporary care plan should all be implemented during this time frame. Essentially, it’s the burden of the care setting to prove to insurers, regulators,…
By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Why is it that the people who are the most caring toward others neglect their own needs? Have you noticed this? I’ve seen it time and time again. The healthcare worker who’s always the last to leave work, who always volunteers to work those extra shifts so patient care won’t be…
As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber might not follow your recommendation and offers solutions. It focuses on physicians, because I’ve had the most experience with them. (more…)
Navigating through the thousands of wound care products can be overwhelming and confusing. I suspect that if you checked your supply rooms and treatment carts today, you would find stacks of unused products. You also would probably find that many products were past their expiration dates and that you have duplicate products in the same category, but with different brand names. Many clinicians order a product by brand name, not realizing that plenty of the product is already in stock under a different brand name. (more…)
Colleen Jackson recently was promoted to a manager position on her unit. At first, she was thrilled with the opportunity to advance her leadership skills, but now she’s having second thoughts. She doesn’t feel confident in her new role and worries how her team views her. She confesses to her manager, “I keep thinking someone will figure out how much I really don’t know and question whether I should’ve been given the position. Sometimes I feel like an imposter. When I mention this to my friends, they tell me to ‘fake it until you make it.’ But I’m not so sure about that!”
Colleen isn’t alone in feeling like an imposter. In imposter syndrome, a person doesn’t feel good enough, is unsure of what she’s doing, and feels she can’t live up to others’ expectations. She may be afraid she’ll be found out as an imposter at any moment. The syndrome is most common among women leaders who feel they don’t deserve the success they’ve achieved despite external evidence of their competence. It’s more likely in perfectionists who constantly compare themselves to others.
Certain situations, such as taking on a new role, can lead to imposter syndrome. For instance, Colleen may think that because she was seen as qualified for her new role, others expect her to immediately have expert knowledge. If, like Colleen, you feel you don’t deserve the career success you’ve had, you may experience deep feelings of inauthenticity and fear you’ll be found out as a fake. (See Inside the imposter syndrome.)
In small doses, feelings of inadequacy may not be a bad thing, because they remind us to work on building our competency. But people with imposter syndrome feel a level of self-doubt that can lead to overwork and a paralyzing fear of failure. The fear of being unmasked causes incredible stress. Colleen and others like her may have unrealistic expectations of themselves in a new role—expectations that can compromise their success.
Overcoming imposter syndrome
For people with imposter syndrome, the response to their success may rest too heavily on others’ approval, recognition, and opinions. A wise mentor once told me we can easily overestimate how much time others spend thinking about us and our behaviors. Most people, she observed, are self-absorbed. This is important to consider, because the idea that Colleen is an imposter probably has never crossed her team members’ minds.
Imposter syndrome can create performance anxiety and lead to perfectionism, burnout, and depression. So learning how to manage these feelings is important. Cathy Robinson-Walker, MBA, MCC, who coaches nurse leaders, provides advice to help cope with imposter syndrome. Her recommendations include the six actions steps below.
Discuss your feelings with a trusted mentor.
Sharing your insecurities with someone you trust and respect can help you separate what’s real from your perceptions of insecurity. A trusted mentor might inform Colleen she’s making good progress as a beginning leader and that no one expects her to be an expert at this point. The mentor can provide guidance about specific areas where Colleen might need additional growth and how to best go about this.
Pay attention to your own self-talk and consider whether your thoughts are empowering or disabling.
Do you often say to yourself, “I achieved this only because I work harder than anyone else, not because I’m more competent”? Valerie Young, author of The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It, makes a strong case that your internal script is a well-rehearsed pattern that serves as a key to feelings of being an imposter. She cautions that individuals with imposter syndrome may sabotage themselves as a way of holding back, due to feelings of being a fraud.
Instead, choose a different script and talk yourself down during times of self-doubt. Instead of thinking, “I’m the wrong person for this job,” retrain yourself to say, “I have a lot to offer in this position.”
Make of list your strengths.
Take the time to make a written list your strengths and what you contribute. Ask others for input, and refer to the list in times of self-doubt. If you’re in a new role, remember that you were chosen for a reason. In Colleen’s case, her supervisor saw her leadership potential. Also realize that most people overestimate their abilities; people with imposter syndrome underestimate theirs.
Accept that perfection is unrealistic and costly.
Trying to be perfect and feeling you need to “know it all” is unrealistic and can be costly on a personal level. Perfectionists typically believe anything short of a flawless performance all the time is unacceptable. But none of us can live a mistake-free life; we all make errors. Those with imposter syndrome hold themselves to impossibly high standards and feel shame, insecurity, and low self-esteem when they don’t meet their own expectations. But progress, not perfection, is what really matters.
Know you’ll need to develop your competencies at certain times in your career.
Throughout your career, you’ll go through periods when you’re on a steep learning curve and will need to further develop your competencies. You may feel like a novice and have to work hard to build new competencies.
Be honest about what you know and don’t know, and seek advice from experts on your unit or in your organization. The simple act of saying, “This is new for me, and I’m working hard to learn this role” can be empowering. Colleen, for instance, might be surprised at others’ reactions to hearing this from her. They might perceive her as a more authentic leader.
Be willing to be uncomfortable and move through your fear.
In Fear of Flying, author Erica Jong urges readers engaging in new experiences to feel the fear and do it anyway. Fear is a useful emotion, as long as it doesn’t escalate to the level of paralyzing behaviors. Practice and preparation can help ease new leaders’ fears. The fear of new challenges will never truly go away, but it can be managed.
Building competence leads to competency
People with imposter syndrome generally are intelligent, thoughtful, and capable but lack self-confidence. Over time, clinicians like Colleen will grow out of feeling like an imposter as they build their competency and become more comfortable in their roles. Eleanor Roosevelt said, “I believe that anyone can conquer fear by doing the things he fears to do, provided he keeps doing them until he gets a record of successful experience behind him.” If you feel like an imposter, this is good advice to ponder.
Selected references
Clance PR, Imes S. The imposter phenomenon in high achieving women: dynamics and therapeutic intervention. Psycho Theor, Res and Prac.1978;15(3):241-7.
Jong E. Fear of Flying. Austin, TX: Holt, Reinhart & Winston; 1973.
Robinson-Walker C. The imposter syndrome. Nurs Leader. 2011;9(4):12-13.
Young V. The Secret Thoughts of Successful Women: Why Capable People Suffer from the Impostor Syndrome and How to Thrive in Spite of It. New York: Crown Business; 2011.
Rose O. Sherman is an associate professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton. You can read her blog at www.emergingrnleader.com.
Critical limb ischemia may not increase mortality risk in patients with diabetes
Diabetic patients with critical limb ischemia (CLI) who are assessed quickly and treated aggressively do not have an increased risk of long-term cardiac mortality, according to a study in Diabetes Care.(more…)
Knowledge is exploding online, making it essential that you’re comfortable using the Internet. You can also go online to save time and find a job, among other tasks. (See Online value.)
However, you also need to keep in mind that anyone can put information on the Internet. As the caption of a cartoon by Peter Steiner, published in The New Yorker says, “On the Internet, nobody knows you’re a dog.” (more…)
What an honor it is to be the wound care “superhero”—the guru, the healer, the go-to person. Unfortunately, this honor may be accompanied by wound care overload—too much to do in too little time.
Once someone is crowned the superhero specialist, others may try to transfer every aspect of wound and skin care to that person—all treatment plans, assessments, documentation, prevention, education, and accountability. Superheroes don’t cry, so they don’t complain about the workload. Yet, the overload must be controlled. (more…)
About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders.
A stoma has no sensory nerve endings and is insensitive to pain. Yet several complications can affect it, making accurate assessment crucial. These complications may occur during the immediate postoperative period, within 30 days after surgery, or later. Lifelong assessment by a healthcare provider with knowledge of ostomy surgeries and complications is important.
Critical limb ischemia may not increase mortality risk in patients with diabetes Diabetic patients with critical limb ischemia (CLI) who are assessed quickly and treated aggressively do not have an increased risk of long-term cardiac mortality, according to a study in Diabetes Care.
By Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis…
By T. Michael Britton, RN, NHA, WCC, DWC As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber…
by Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS What an honor it is to be the wound care “superhero”—the guru, the healer, the go-to person. Unfortunately, this honor may be accompanied by wound care overload—too much to do in too little time. Once someone is crowned the superhero specialist, others may try to transfer every aspect of wound and…
By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders. A stoma has no sensory nerve endings and…
By Robyn Bjork, MPT, CWS, WCC, CLT-LANA The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of…
By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Knowledge is exploding online, making it essential that you’re comfortable using the Internet. You can also go online to save time and find a job, among other tasks. (See Online value.) However, you also need to keep in mind that anyone can put information on the Internet. As the caption of…
By Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA
An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis and other tissue and skin changes. (more…)
The Affordable Care Act of 2010 requires nursing homes to have an acceptable Quality Assurance and Performance Improvement (QAPI) plan within a year after the start of the QAPI regulation. While the implementation of this regulation may be a year out, now is the time to start applying its principles. Reducing pressure ulcer rates is a great program to target for a QAPI plan.
A team approach
If you decide to use pressure ulcers as your QAPI project, don’t take on your entire program at once. Break the program down into system subsets (for example, admission process, prevention program, and weekly rounds). Determining the status of your program in each subset—completed, needs improvement, or not completed—can help you prioritize which areas to target. It’s important you have support from leadership for your efforts.
I’ll use the example of the admission phase (ensuring that within the first 24 hours, skin and risk concerns are identified and a temporary plan of care is implemented) to illustrate a QAPI project. To address this area, a team was created, including representation from staff members involved with the admission process. The team then used the problem-solving model Plan-Do-Study-Act (PDSA) to examine the process.
The first step in the PDSA cycle is to Plan. During this step, you:
• evaluate and analyze the current process to determine baseline data, which are used to measure progress
• identify system performance gaps
• determine the root cause of the performance gaps
• develop an action plan that identifies the goals, steps, responsible staff, and target dates.
In our example, the team determined that within the first 24 hours, skin inspections were being completed only 10% of the time. The root-cause analysis revealed that the admission nurses didn’t feel competent to document identified pressure ulcers or skin concerns, so they deferred it until the wound nurse was available. The team’s action plan included the following:
• Develop and educate all the facility nurses on how to complete and accurately document a skin inspection.
• Develop and implement a competency evaluation to assess the nurse’s ability to apply the knowledge at the bedside.
• Develop an ongoing plan to ensure all nurses receive this education during orientation and yearly thereafter.
The team also set the following goal:
By the end of the next quarter, 100% of admitted patients will have an accurate skin inspection completed within 24 hours of admission.
The second step of the PDSA cycle is Do. During this step, you implement and execute the plan, while documenting your observations and recording data.
In our example, the “Do” was to:
• develop and provide the skin inspection education and bedside competency evaluations
• develop an evaluation and tracking
system
• add the education to the orientation program
• add the education to the staff development calendar to be offered yearly.
The third step of the PDSA cycle is to Study: In this phase, you:
• reevaluate and analyze the system
• compare the results with the baseline data and predictions
• summarize what was learned and accomplished and what needs to be improved
• determine if another PDSA cycle is
necessary to continue to improve the system.
Once all staff had been properly educated and competency testing completed, an analysis of the rate and accuracy of the admission skin inspections done within 24 hours of admission was completed. It was found that 100% of the patients admitted had a complete skin inspection done within 24 hours. However, not all the nurses could accurately stage pressure ulcers, so it was determined that the system needed improvement to ensure accurate assessments.
The last step of the PDSA cycle is to Act. In this step, you:
• determine what changes need to be made
• modify the plan to continue to improve the system
• repeat the PDSA cycle as necessary.
In our example, the team determined the nurses needed more guidance and education on staging of pressure ulcers. Therefore, a new PDSA cycle was set to ensure the nurses are competent in this area.
Benefits for staff and patients
It may be difficult to start the QAPI project and at times the process may be stressful, but keep in mind that a successful pressure ulcer QAPI project can improve not only the quality of life and care of your patients but also morale and team building for your staff. n
Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has beenspecializing in wound prevention and management since 1990.
