Summary of certifications available for wound care
The American Academy of Wound Management (AAWM) offers three certification levels for wound care professionals. Certification is based entirely on portfolio review by members of the AAWM’s board of advisors. The levels are:
• Diplomate status.
This can be awarded to physicians, nurses, physical therapists, and other health care providers who have been granted a doctorate degree from an accredited university and who have two years of clinical research experience in wound care.
• Fellow status.
This can be granted to individuals who are trained at the master’s level in related health care disciplines with two years of approved clinical or research experience in wound care.
• Clinical associate status.
Clinical associate status is available to registered nurses, certified physician assistants, individuals with a baccalaureate degree, or other health care providers with extensive training and background in wound care. Additionally, individuals must have five years of documented clinical or research experience in the field of wound care.
Certified individuals are permitted by the AAWM to use the credentials "CWS" after their names. Applicants who, after portfolio review, do not meet the eligibility requirements for certification are relegated to a membership classification.
Professionals certified by the AAWM are eligible for the following:
- a listing in and copy of the National Registry of Board Certified Wound Specialists;
- a subscription to the quarterly publication of the AAWM;
- reduced fees for continuing medical education programs sponsored or cosponsored by the academy.
AAWM fees are as follows:
• certification: $400;
• certification renewal: $150;
• annual US membership: $75;
• annual international membership: $95.
The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) has revamped its certification process. As of Jan. 1, 1998, the long-standing CETN credential will be changed to CWOCN certified wound, ostomy and continence nurse. The WOCNCB notes that CWOCNs and those who previously earned a CETN still will be able to call themselves enterostomal nurses.
The testing procedure also will change. The current system involves four separate examinations, one each in wound care, ostomy care, and continence care, and a full-scope examination that encompassed all three specialty areas of practice. Beginning in 1998, there will be just one certification examination divided into three sections. Candidates will sit for the section or sections that correspond to the specialty area(s) in which they desire to become certified.
For example, a candidate who wishes to earn the credential certified wound care nurse (CWCN) would take one section; a nurse who desired to earn the credential certified ostomy care nurse (COCN) would take a different section. Passing both sections earns both credentials. Passing the entire test earns a candidate the new CWOCN credential (the equivalent of the CETN). Also offered is the certified continence care nurse (CCCN).
Some or all of the test can be retaken
Candidates who take the entire test but successfully pass only one or two sections will earn the credentials for the section or sections they passed. They can retake portions of the test or the entire test at a future sitting.
The eligibility requirements for taking the WOCNCB certification exams as of the New Year are as follows:
1. Currently licensed as a registered nurse. Beginning in 2000, new candidates also must have a baccalaureate degree. However, individuals renewing certification will not be required to have a baccalaureate degree as long as certification status is continuously maintained.
2. Any one of the following:
- completion of an enterostomal therapy nursing program education program accredited by the WOCNCB;
- completion of a graduate program in nursing with documentation of course work related to wound, ostomy, and/or continence;
- 2000 hours (one year full time) experience in wound, ostomy, and/or continence practice.
3. Completion and filing of an application for desired specialty certification examination(s).
4. Payment of required fees(s).
The WOCNCB certification fees are as follows:
- certification in all three specialties (CWOCN): $300;
- certification in two specialties: $275;
- certification in one specialty: $225;
- Recertification by professional growth program: $400. n
Nutritional assessments help home care agency improve its results
Streamlined form pays dividends
Treating wounds can be an amazingly complex area of care, but there are times it can be helpful to emphasize a simpler approach involving early nutritional assessments and improved nutrition.
In most cases, doing a thorough nutritional assessment during an initial visit and urging patients to eat properly or drink nutritional supplements can prevent wounds from worsening or not healing properly. Samaritan Home Care in Oklahoma City, OK, discovered that an earlier nutritional assessment would increase the chances of its wound care patients healing normally. "We felt our patients with wounds weren’t healing, particularly the elderly patients who lacked [adequate] nutrition or who don’t like to eat alone, and that does affect the healing process," says Glenna Herren, RN, BSN, quality manager for the freestanding agency, which conducts between 4,500 and 5,000 visits per year.
Focusing on nutrition
Samaritan now uses a wound care flow sheet (see sample, p. 137) and is developing a critical pathway to document its care of wound patients, Herren says. Requiring nutritional assessments of wound care patients or even involving a nutritionist in a patient’s care can be the key to speeding recovery and ensuring quality, according to veterans of those techniques. Betsy Raiford, RN, CETN, a wound care nurse in the home care division of St. Vincent’s Medical Center in Jacksonville, FL, has found in practice that wound healing is greatly dependent on nutrition.
In fact, "what you put on a wound may play a small part in wound repair," adds Rita A. Frantz, PhD, RN, FAAN, associate professor of nursing at the University of Iowa in Iowa City. "My belief is that you could maximize external treatment of the wound, and if you had somebody who simply doesn’t have a solid nutritional base, the wound won’t heal."
St. Vincent’s home care division began emphasizing nutrition in wound care three years ago, after Raiford attended a wound care/ostomy program at Emory University in Atlanta. There, she recounts, nutrition was strongly promoted as a wound care therapy, something that had not been done when she attended nursing school years before. Raiford says she uses a standard nutritional assessment tool with wound care patients to determine whether they need supplements. She sometimes does a prealbumin test, which has a three-day half-life, to measure current nutritional status.
Raiford uses the nutritional assessment tool developed by the Rockville, MD-based federal Agency for Health Care Policy and Research (AHCPR). The assessment is part of AHCPR’s clinical practice guidelines, titled Pressure Ulcers in Adults: Prediction & Prevention, published in 1992.
Updated program appeals to physicians
Samaritan implemented a new wound care program to identify patients at risk of developing wound care problems, Herren says. "We set up the program to assure our physicians that once their patient was referred to us, they wouldn’t be bothered by our nurses with as many questions," she explains.
As a result, Samaritan’s wound care flow sheet was streamlined from two pages to one and incorporates the use of documentation by exception rather than narrative. The original wound care flow sheet was used to track and document up to six simultaneously occurring wounds. The new form, however, is used for one wound only to eliminate confusion among the caregivers.
"We originally had a narrative documentation form, but we changed it because some nurses were too wordy while others didn’t document enough," Herren says. "The new sheet tracks a wound on a daily basis over a seven-day period and gives the quality manager information on how the wound is progressing or digressing. Documentation is done through checks and circling yes or no questions, so the caregiver doesn’t run the risk of being ambiguous or confusing.
In addition, a nutritional assessment was added to determine if the patient needs additional education or consultation regarding proper nutrition. Samaritan also updated its wound care policy to reflect the changes in its documentation process. Wounds are reassessed and documented every 62 days or more frequently if there is a significant change, Herren says. A pathway development committee at Samaritan introduced a critical pathway to assist in tracking the care and treatment of wound patients.
Even with all the necessary data, improving a patient’s nutritional status can be difficult for a number of reasons. With the mostly elderly patients at Five Hospitals Homebound Elderly Program in Chicago, one problem is getting "physician buy-in," says Nancy Southern, BSN, director of patient services.
"We sometimes recommend tube feeding for the extra calories these patients are not receiving. Physicians are not too willing to do that, especially if the patients are old and dying," Southern explains. In some cases, she notes, "the wound is looking worse," but there is nothing her nurses can do. To help avoid the situation, Southern says her program now uses a wound care critical path to identify nutrition deficiencies in the earliest stages and plans to involve a nutritionist more in wound care.
Michelle Webb, RN, case manager at Sumner Home Health in Gallatin, TN, says she also has run into some problems with wound care nutrition with her often poverty-stricken clientele. "On some of the more difficult cases, we’ve brought [nutritionists] in from local hospitals. It’s kind of a Catch-22," she explains. "A lot of people can’t afford some of the recommended supplements."
To remedy the situation, she asked her vendors for contributions. "I’ve had pretty good luck with the [durable medical equipment suppliers] giving patients nutritional supplements."
Diabetes presents a harder challenge
Nutrition becomes more complicated in patients who suffer from certain diseases. Raiford cites diabetics, who commonly suffer with nonhealing wounds, as one example. "If the sugar intake is too high, the white blood cell count is too high," she says. Those patients "seem to be the most challenging to take care of. It is a two-fold issue." Keeping the disease under control can hasten wound healing, she adds.
One problem for quality improvement, notes Frantz, is a lack of research specific to nutrition and wound healing. "It has not been as extensive as research on healing of surgical incisions," she explains. "We are left with a state of knowledge in which we must transfer what we know about surgical wounds or incisions to chronic wound care."
Another problem is the difficulty of changing the mind-set of some caregivers. "When people are taking care of patients, we’ll take care of hygiene and dressing wounds, but nutrition is the last thing that gets addressed," she adds.
In the next few years, Raiford predicts, home care quality managers will dramatically increase their concern about nutrition because both the Joint Commission on Accreditation of Healthcare Organizations and Medicare are beginning to focus on the issue.
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