Nursingmatters April 2017 • Volume 28, Number 4
INSIDE: Diagnose carefully
Patients have rights
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Celebrate nursing A special license plate will be available soon through the Wisconsin Department of Transportation — a plate for nurses, nursing staff, students, friends and family members. The specialty plate passed through legislation in 2016. It is intended to recognize the work and dedication of Wisconsin nurses as they change people’s lives. It offers a visual reminder to consider nursing as a career path because nurses make a difference every day in the lives of those they serve. Help spread the word. A person does not need to be a nurse to purchase the specialty license plate. The future of nursing will benefit because the plate creates a funding source for professional development, education and scholarships for Wisconsin nurses. The distribution of funds will be
determined by an Advisory Council of the Nurses’ Education Fund comprised of several nursing organizations. The program is made possible by the Wisconsin Organization of Nurse Executives. The organization collaborated with many nurses and nursing organizations during various phases of the legislative process. Without the group’s support the legislation would not have been approved. Nurses thank it for its support. The anticipated cost of the plate is $40; there will be a $15 issuance fee and $25 annual donation to the Wisconsin Nurses’ Education Fund. Promotional displays and materials are available now for nursing conferences or placement within an organization. Email jbauman@ dshealthcare.com for more information.
April • 2017
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EDITORIAL BOARD Vivien DeBack, RN, Ph.D., Emeritus Nurse Consultant Empowering Change, Greenfield, WI Bonnie Allbaugh, RN, MSN Madison, WI Cathy Andrews, Ph.D., RN Associate Professor (Retired) Edgewood College, Madison, WI Kristin Baird, RN, BSN, MSH President Baird Consulting, Inc., Fort Atkinson, WI Joyce Berning, BSN Mineral Point, WI Mary Greeneway, BSN, RN-BC Clinical Education Coordinator Aurora Medical Center, Manitowoc County Mary LaBelle, RN Staff Nurse Froedtert Memorial Lutheran Hospital Milwaukee, WI Cynthia Wheeler Retired NURSINGmatters Advertising Executive, Madison, WI Deanna Blanchard, MSN Nursing Education Specialist at UW Health Oregon, WI Claire Meisenheimer, RN, Ph.D. Professor, UW-Oshkosh College of Nursing Oshkosh, WI Steve Ohly, ANP Community Health Program Manager St. Lukes Madison Street Outreach Clinic Milwaukee, WI Joyce Smith, RN, CFNP Family Nurse Practitioner Marshfield Clinic, Riverview Center Eau Claire, WI Karen Witt, RN, MSN Associate Professor UW-Eau Claire School of Nursing, Eau Claire, WI © 2017 Capital Newspapers
It might be time to consider what to do about the uncertainty of a diagnosis or the moral implications of it from both a patient and practitioner perspective.
Question: To diagnose or not to diagnose Mary Ellen Wurzbach, RN, BSN, MSN, FNP, PhD John McNaughton Rosebush Professor Emerita University of Wisconsin-Oshkosh
In 1986 I wrote an article entitled “Ethical Evaluation of a Nursing Diagnosis.” This is a similar article based on the thought and experiences of the past 30 years. At the first writing I advocated promoting autonomy and doing no harm. Through the years Mary Ellen I would still advocate Wurzbach for those two principles but with more evidence of the essential nature of these two ideas. At the time of the first writing, nurse practitioners were beginning to jointly practice with physicians in Wisconsin. They were learning medical diagnosis. In nursing there was a movement toward nursing diagnosis based on the American Nurses Association Social Policy Statement definition of nursing as the diagnosis and treatment of human responses to health and illness. I was a newly-minted family nurse practitioner. There were many discussions at the meetings of preceptors, faculty and students about
whether nurses could diagnose and treat, and whether they should have the right to prescribe. This article is based on observations of the practice of diagnosis. When I was a child, diagnosis was the epitome of medical practice. The “good diagnostician” was revered. Diagnosis was the essence of medicine. With the
nurse-practitioner movement, diagnosis too became important to nurses. Given the reverence shown diagnosticians it came as a surprise to me that there was such an emphasis on prescription – and that there was a downside to both diagnosis and prescriptive authority. I was surprised that diagnoses are not as
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April • 2017
Consider diversity in healing
“Diversity in Healing Practices” will be offered this month at Viterbo University in La Crosse, Wisconsin; Nursing Research on the Green will present. The keynote speaker for the event will be Teddie Potter, PhD, RN, FAAN. Potter of the University of Teddie Potter Minnesota is currently the coordinator of the Doctor of Nursing Practice in Health Innovation and Leadership, as well as the Director of Inclusivity and Diversity in the School of Nursing. She has been a nurse educator for more than 16 years and has been an innovator in homecare; she helped to start one of the first palliative-care programs in the nation. She is also the executive editor for the Interdisciplinary
Journal of Partnership Studies. The publication is a peer-reviewed open-access online journal promoting interdisciplinary collaboration as a solution to solving society’s grand challenges. A community event to celebrate and recognize “Excellence in Nursing,” it will be held from 9 a.m. to 3 p.m. April 27. It includes the presentation of research posters along with a lunch reception. Four break-out sessions are offered in the morning. • “Home Based Primary Care – an Innovative Approach to Improve Health Care for our Veterans” by Jenna Burnstad, RN and Ann Anderson RN • “Innovation in Public Health Nursing Practice” by Jen Rombalski, MPH, RN • “Environmental Health – Should Nurses Care?” by Kathryn Lammers,
patient and practitioner perspective. As I grow older I find that many of the traditions with which I grew both personally and professionally require further consideration. On further inspection, often the ideas we take for granted and assume to be “true” may have flaws. Diagnosis is one aspect of health care that may require revision, but it’s merely an exemplar of a variety of changes that nurses could initiate. Diagnosis, prescription practices, parity in palliative care, and improvements to end-of-life care, particularly in the last five days of life. These are some of many areas for improvement in a summative evaluation of health care. Patients and practitioners alike do not always question traditional practices. Nurses are involved in many health-care situations with which they disagree. They are experiencing many aspects of the health-care system that could be changed, although change comes slowly. Even the most entrenched practices can be critiqued, and improved or changed over time. Where to go from here is not certain, but this article is a success by my own standards if even one practitioner thinks twice about a diagnosis and its implications and consequences before assigning it. I have taught ethics for more than 30 years and would still, after all of this time since my first article on this subject, advocate for promoting autonomy in our patients and doing them no harm. Harm is seldom intentional, but doing no harm requires considering and anticipating the possible consequences of any diagnosis. It’s the ethically required right that every patient has – to be unharmed by diagnosis or treatment. Promotion of one’s autonomy and “the good,” although not an ethical requirement, is the positive right for which patients hope.
continued from page 2 analytical or value-free as one always supposed. It was a surprise that there are real consequences for practitioners and patients when a diagnosis is assigned to someone. Through the years I have seen that manifested in various ways and come to several conclusions. First is the observation that diagnoses need to be accurate. Secondly, once assigned they ought to be followed by palliation of symptoms – improvement in a patient’s circumstances such as health and possibly life. It came as a revelation to me to find that some diagnoses have no treatment. They might identify a problem for which there is no solution or treatment – and how anxiety-producing and unhelpful that can be. Unfortunately our health-care system is structured around the necessity for a diagnosis of every condition known, despite the possibility that some patients might be more benefited by not being diagnosed. In some situations diagnoses change through time, as is the case with many taxonomies. One belief system or treatment regimen might accompany or follow from a diagnosis years ago, but have a different treatment or resolution today. Conversely, diagnoses may not change and, despite the fact that society has changed, become entrenched, anachronistic and at odds with current practice. As the population ages we will be confronted with more and more diagnoses. More than anything it may be time to consider whether the health-care system should be medical-diagnosis driven. It might be time to consider what to do about the uncertainty of a diagnosis or the moral implications of it from both a
PhD, RN, PHN • “Meeting Patients Where They Are: The Miracle of Animals” by Barb Haverty, RN, and Robbie Mack, MS, LPC, ICS. The first three sessions will repeat in the afternoon, along with a featured breakout with Potter, “Practicing BASE – A Design Thinking Exercise.” The event is possible by collaboration between Gundersen Health System, Gundersen Lutheran Medical Center Inc., Gundersen Medical Foundation, Logistics Health Incorporated, Mayo Clinic Health System-Franciscan Healthcare, Mayo Clinic Health System-Franciscan Healthcare Foundation, Pi Phi Chapter of Sigma Theta Tau International, Viterbo School of Nursing, Western Technical College and Winona State University.
There is no fee for the event but pre-registration is recommended due to limited seating for breakout sessions and to assist with catering. Visit www. viterbo.edu/piphi and select “Nursing Research on the Green” from the “In This Section” menu in the left column. Click on “Register Here!”
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April • 2017
Army nurse recognized for merit Col. Janis K Bauman was awarded the Legion of Merit accommodation by Maj. Gen. Donald Dunbar on her retirement from the Wisconsin Army National Guard. Bauman was recognized for exceptionally meritorious service to the Wisconsin Army National Guard. Bauman’s leadership, dedication, and commitment to the military medical community are the hallmarks of an outstanding career, according to the service. She provided a steadfast vision and guidance that led to the improvement of administrative procedures for ensuring medical readiness within the Wisconsin Army National Guard at all levels. Above all, Bauman exhibited an exceptional work ethic that will serve as the standard for all other medical leaders to emulate. Her numerous accomplishments, contributions and professionalism are in keeping with the highest traditions. They reflect great credit upon herself, the Wisconsin Army National Guard and the U.S. Army. The Legion of Merit follows strict eligibility criteria, which require evidence of significant achievement of an
Bauman exhibited an exceptional work ethic that will serve as the standard for all other medical leaders to emulate. Her numerous accomplishments, contributions and professionalism are in keeping with the highest traditions.
Col. Janis K Bauman is awarded the Legion of Merit accommodation by Maj. Gen. Donald Dunbar on her retirement from the Wisconsin Army National Guard. Bauman was recognized for exceptionally meritorious service to the Wisconsin Army National Guard.
extremely difficult duty performance in an unprecedented and clearly exceptional manner. Bauman received the recognition upon her retirement after 29-plus years with the Wisconsin Army National
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is directly responsible for planning, resourcing and executing routine medical evaluations for more than 7,400 soldiers. Her final assignment as medical officer for the 64th Troop Command Brigade, which is focused on domestic operations related to emergency preparedness. Bauman’s civilian job is chief nursing officer and vice-president of Patient Care Services for Divine Savior Healthcare in Portage, Wisconsin.
Patients have rights – positive and negative Mary Ellen Wurzbach, RN, BSN, MSN, FNP, PhD John McNaughton Rosebush Professor Emerita University of Wisconsin-Oshkosh
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Guard. She joined the Army Nurse Corp in 1987 with the 13th Evacuation Hospital in Madison, Wisconsin, and spent the next 29 years working in various positions throughout the Wisconsin Army National Guard. Her career assignments included a deployment overseas working with the 13th Evacuation Hospital, missions to Nicaragua caring for locals in various regions of the country, and volunteering to help other states on their retention boards. Prior to retirement she was commander of the Wisconsin Medical Command for three-plus years, which
One of the aspects of nursing practice that is seldom discussed is that of prescriptive authority. Since the beginning of the nurse practitioner movement, who prescribes and under what circumstances has been a cause of much controversy and concern. Today most nurse practitioners, nurse midwives and nurse anesthetists have prescriptive Mary Ellen authority with or without Wurzbach a relationship with a physician. Many have learned their prescriptive practices from their preceptors in school, in a partnership in practice, or from peers. But there are many aspects of prescriptive authority that have become traditional practice that may be detrimental to the health of our patients. Some suggestions for improving the process of prescription are offered in this article. A variety of suggestions can be made
that might improve prescriptive practices. Usually when the ethics of any practice are discussed, several principles apply. In cases of prescriptive practices the principles in conflict are beneficence – to do good – and nonmaleficence – to do no harm. Most bioethicists would say that the overriding principle is non-maleficence. Furthermore, many would say that beneficence is optional and a matter of agreement between patient and practitioner. Patients have positive and negative rights. They have the negative right to be kept safe from harm and the positive right
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April • 2017
Today most nurse practitioners, nurse midwives and nurse anesthetists have prescriptive authority with or without a relationship with a physician.
continued from page 4 to benefit from treatment. Most ethicists would say that the negative right to be safe from harm supersedes the positive right of benefit. In other words, the burdens should not outweigh the benefits. The burden or harm ought to be avoided, and considered more important to avoid than the perceived benefits of any medication. There are many ways of prescribing and benefiting patients without harming them. A variety of suggestions might guide practice. The final arbiter is the principle and admonition “do no harm.” When prescribing choose the least dangerous medication based on one’s own experience, and on the medication side-effect lists distributed by the manufacturer or pharmacy. Become familiar with the insert from the pharmacy or a small contingent of drugs that conform to the patient population one sees. Avoid medications with black-box warnings from the U.S. Food and Drug Administration. Individualize prescriptions based on a patient’s personal needs. Keep a Physicians Desk Reference or other reference material available at all times. Above all, it’s not safe to prescribe for someone who one has only just met. Consider the patient’s current medications. Perhaps a particular drug, although not new, has met the patient’s needs for
There are many ways of prescribing and benefiting patients without harming them. A variety of suggestions might guide practice. The final arbiter is the principle and admonition “do no harm.” years. It would not be prudent to suddenly switch or prescribe new medication for someone unknown to the prescriber. Phone prescriptions are particularly problematic. If for some reason a medication is prescribed for a new patient or changed for an existing one, schedule another appointment to assess the result. Provide patient education about what to do if a problem should arise. Patient education entails a description of the side effects, what to do if side effects occur, whether to discontinue the medication if it becomes problematic and an anticipation of what to do should harm present. If a dosage reduction is required, anticipate consequences. Prior to providing a prescription, examine the health history and assessment in detail – or perform the necessary actions to assess the safety of a particular medication.
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April • 2017
Book helps create healthy work INDIANAPOLIS – Employee engagement and retention can be an elusive concept to many organizational leaders, yet it is key in running a successful organization. According to Joe Tye and Bob Dent, understanding the importance of accountability for employees – and encouraging them to take ownership of their disciplines – is imperative in running a successful organization of any kind. Tye and Dent’s new book, “Building a Culture of Ownership in Healthcare: The Invisible Architecture of Core Values, Attitude, and Self-Empowerment,” was published by the Honor Society of Nursing, Sigma Theta Tau International. The book takes readers on a journey from accountability to ownership, providing a proven model along with strategies
continued from page 5 A good relationship with a pharmacy is essential. It has software programs – the practitioner should too – that list and describe interaction effects. Many websites provide similar information. Communicate with the pharmacist. Remember that every brand name and every generic from a new manufacturer may have new effects, side effects and interactions. There is safety in consistency. Ask the pharmacy not to change the manufacturer of a generic medication or from brand to generic, without discussing it with the patient. It is an unsafe practice of some pharmacies, over time, to provide the patient with multiple capsule and pill forms of the same generic drug made by different manufacturers. This negates one
Bob Dent and Joe Tye say understanding the importance of accountability for employees is critical to any organization.
and practical solutions to help improve organizational culture in the health-care setting, according to the publishers. Using construction as a metaphor, the authors make a case that an organization’s invisible architecture – a foundation of core
primary safety measure – the patient’s observation of what their medication looks like. It makes it difficult to know, when ingesting or pouring medications at home, whether the pharmacy made a mistake, whether a medication has been changed, or whether it is the same medication but a different generic made by a different manufacturer. At home a patient might assume a mistake has been made and a different drug given to them by the pharmacy. There may also be production variations between manufacturers that could affect the way the patient responds to a given dose of a medication. Another consideration when prescribing or providing patient education is “framing.” Framing is the perspective from, or context within which, one offers information. Patients will make different
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values, a superstructure of organizational culture and the interior finish of workplace attitude – is no less important than its visible architecture. They assert that culture will not change unless people change – and people will not change unless they are inspired to do so and given the right tools. Although initially written for a healthcare audience, Tye and Dent offer unique insight through their invisible architecture theory, making the book an important read for leaders in all industries, they say. Nurse leaders and business managers alike may benefit in learning how investing in both organization and people can enable a significant successful change in productivity; employee engagement, satisfaction, recruitment and retention; quality of work; client satisfaction; and financial outcomes. Visit www.nursingknowledge.org/sttibooks for more information. About the authors Joe Tye, Master of Health Administration and Master of Business Information,
is the chief executive officer and head coach of Values Coach Inc., a company he founded in 1994 following a career in health-care administration. His background Joe Tye includes stints as chief operating officer of two large community teaching hospitals. He has written 12 books on values-based life, leadership skills, and strategies to create competitive advantage by fostering a culture of ownership. Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE, is the senior vice-president, chief operating officer, and chief nursing officer at Midland Memorial Hospital. He maintains academic appointments with Texas Tech University Health Bob Dent Sciences Center School of Nursing and the University of Texas of the Permian Basin. He is president-elect of the American Organization of Nurse Executives.
April • 2017
Nursing roles expand in future Benedictine University
The nurses of the future will be involved with policy and new roles in advanced practice nursing. Allocation of nursing staff and how nursing will integrate with the full spectrum of health-care practice is likely to change during the next 10 to 20 years. Leadership roles can be a vibrant part of a nursing career so that nurses are able to add their expertise to policy decisions and better integration of services. Currently 60 percent of nurses practice in hospitals. That can change as nursing services are allocated to more locations – from homes to clinics, and public-health-policy positions to neighborhood centers. A newer position in nursing is the advanced practice nurse, who could be in a specialty such as midwifery or anesthesia. With the advanced training nurses receive, options for more specialties are possible. At Benedictine University, the online Master of Science in Nursing offers a program accredited by the Commission on Collegiate Nursing Education. The program provides the opportunity to learn tools for leadership, along with advanced nursing practices and what is required for advancement in the career. “With the multitude of specialties in nursing, I’ve been fortunate to work with diverse groups in programs for geriatric psychiatry, children’s social development, as well as project director for a National Institute of Health-funded research grant,” said Alison Ridge, assistant professor and program director. “Nursing provides great career versatility and exciting challenges.” The program begins with 18 credit hours of foundational courses that focus on collaboration among health-care professionals, ethics, research and process improvement, information processing and technologies, policy and advocacy, quality improvement and safety. Once the foundation courses are completed, students are given a choice of two concentrations – either nurse educator at 21 credit hours or nurse executive leadership at 18 credit hours. Each of the concentration curricula includes a capstone course, where coursework is used in practical applications. Career opportunities for nursing positions are numerous with a current shortage of nursing care. With the population of
continued from page 6 choices depending on how information is presented to them. Two aspects of education are essential. • First, tell patients the benefits versus the burdens, because one may have a “duty to warn” of side effects or consequences unknown to the patient.
As an integral component of Benedictine University, the Department of Nursing embraces Benedictine values, exemplified by our commitment to the value of hospitality—upholding the value of each person and open to the all people in the human family. The mission of the department is to educate men and women to deliver responsible, competent nursing care to all.
“With the multitude of specialties in nursing, I’ve been fortunate to work with diverse groups in programs for geriatric psychiatry, children’s social development, as well as project director for a National Institute of Healthfunded research grant.” Alison Ridge, assistant professor and program director BENEDICTINE UNIVERSITY
Baby Boomers reaching retirement, care needs will increase. The U.S. Bureau of Labor Statistics estimates an increase in the need for nurse educators of 35 percent by 2022, and a median wage for registered nurses of $67,490. Prospects are bright for the leadership positions. Graduates of Benedictine’s program were polled; 95 percent reported that Benedictine prepared them for their current career and, as a result of the program, they either had received or anticipated raises.
At Benedictine University, the online Master of Science in Nursing offers a program accredited by the Commission on Collegiate Nursing Education.
Graduates reported working in positions at UNC Health Care, the U.S. Army, Yale New Haven Hospital, Vanderbilt University Medical Center and Rush University Medical Center. “This is a great time to be in nursing,” said Julie Sochalski, director of the U.S. Department of Health and Human Services Division of Nursing from August 2010 to
September 2013. “It has a glorious past. It has a tremendous future, and I think anybody who is choosing this has chosen wisely.” Benedictine University is dedicated to the education of undergraduate and graduate students from diverse ethnic, racial and religious backgrounds. Visit www.ben.edu for more information.
• Secondly, conveying one’s treatment rationale allows the patient to decide if they agree or disagree with the treatment plan. An attempt to be impartial but to convey known concerns may help or hinder. There are times to be impartial but also times to try to convince patients of the “rightness” of a course of action if there is an immediate need or longterm consequence. That depends on how
severe the consequence is and how likely it is. Fear-engendering communication, however, is neither beneficial nor effective. The patient’s perspective and choice should take precedence. Safety is a primary consideration of prescriptive authority. Accepting or imitating unsafe practices of other practitioners or of the health-care system as a whole is not protective of one’s patients
or one’s professional standing. In a more essential sense acceptance or imitation may intrinsically be unethical and/ or immoral. The manner in which we practice health care can be transformative. Every example we undertake of safe, effective and cautious practice may make profound changes in health care if others follow our lead.
April • 2017
Demand exploding for wound-care nurses • By 2025, about 18 percent of Americans will be 65-plus and those 85-plus are expected to grow from the current 6 million to nearly 9 million in 2030. • The number of Americans living with chronic medical conditions like diabetes – a group particularly vulnerable to debilitating wounds – is expected to grow to 48.3 million by 2050. Though wound prevention and treatment is an interdisciplinary effort, the responsibility for those requiring day-to-day care falls squarely on the shoulders of nurses. With a mounting focus on patient safety and outcome
performance, the demand for certified wound nurses is especially high, with job opportunities in hospitals, home care, outpatient wound centers, and especially in long-term-care and skilled-nursing facilities. Among their duties are creating treatment plans, monitoring wounds to ensure infections do not develop, recommending appropriate treatments when infections do occur, cleaning wounds so they heal as quickly as possible, and teaching their patients how to care for their healing wounds. According to nursingcrossing.com the average salary for wound-care nurses ranges from $56,000 to more than $85,000 per year. Those specializing in wound care are typically more highly paid than registered nurses in other specialties. Many nurses are embracing the
growing field – not only because the rate of pay is excellent and in many cases they can set their own schedules – but the very reason why they entered the field is being satisfied. They are caring for an especially vulnerable population whose very lives might be in their hands. By successfully treating them or being instrumental in preventing such wounds from occurring, these special caregivers are clearly making a difference. Board-certified general surgeon Bardia Anvar is medical director of Skilled Wound Care, which services nursing facilities and health plans throughout the United States in treating patients with pressure wounds. He is the author of “Mastery of Skin Wound and Ostomy Care,” and a frequent speaker. In addition he is the founder of the College for Long Term Care, a certification program for those in the skilled nursing field and others who work with the elderly. Its mission is to increase public education and research of pressure ulcer injuries and promote proper treatment protocols. Visit SkilledWoundCare.com or call 866-WOUND-80 or 310-445-5999 for more information.
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An aging Baby Boomer population has spurred a growing demand for nurses trained in treating and preventing pressure injuries. According to the U.S. Department of Health and Human Services, the injuries claim the lives of 60,000 Americans each year. That number is Bardia Anvar expected to increase substantially. Take into account that, in the past decade alone, there has been a 63 percent increase in such injuries – previously known as pressure ulcer wounds or “bedsores.” Today an estimated 3 million Americans suffer from them, yet there are not enough nurses certified to treat that growing population.
According to nursingcrossing.com the average salary for wound-care nurses ranges from $56,000 to more than $85,000 per year. Those specializing in wound care are typically more highly paid than registered nurses in other specialties.
Dr. Bardia Anvar Medical Director of Skilled Wound Care
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