My Scope of Practice: Ears Wide Open

Most people do not listen with the intent to understand; they listen with the intent to reply. — Stephen R. Covey, author

  The most important lesson Vashti Livingston, MS, CNS, CWOCN, has learned over her 20 years of nursing is to really listen to the patient. No experience drove home the idea more than her interaction with an 86-year-old bladder cancer patient with a new ostomy. When the patient told her 8 months after surgery that he was finally back on track, she naturally thought he was referring to his adjustment to living with an ostomy. In actuality, he had been going to the Sexual Medicine clinic and was sharing his delight that his sexual function had returned. “By his standards, he was now finally doing well,” Vashti says. “Changing the ostomy pouch was not as relevant to his feeling of recovery. When I thought about it, I recalled that at his preoperative visit and stoma site marking, he had mentioned he was very concerned about the return of sexual function, not to mention his 52-year-old girlfriend. So, I now listen. What may be of the utmost concern to the patient is not what we clinicians always think.”   Vashti’s initial plan wasn’t always to be a nurse, let alone a wound, ostomy, and continence nurse. She studied biology at the City University of New York (New York, NY) before becoming a high school science teacher. After a couple of years in the classroom, she decided to turn the tables and once again become the student. She headed back to City University, where she earned her nursing degree in 1989 and began working for the Visiting Nurse Service of New York (VNSNY). During this time, Vashti was introduced to wound care; she developed so much interest she sought wound certification in 1997. Later, she went to Emory University and obtained certification as a CWOCN. While still working in home care, Vashti decided to return to school to obtain a Masters degree in Adult Health Nursing, opening up the possibility for her to work as a clinical nurse specialist (CNS). More than a decade after taking her first nursing job at VNSNY, Vashti left home care to work as an outpatient CWOCN CNS in Urology at Memorial Sloan-Kettering Cancer Center (MSKCC).

  Leaving home care to work in a hospital clinic was a major change in Vashti’s career, but like all great nurses she was able to adapt to her new environment and eventually shape her position into what she thought it should be. “My role in the urology clinics really evolved over the past seven-plus years,” Vashti says. “I believe in the beginning the staff — doctors and nurses — just thought I was a pouch changer. All visits were scheduled for only 15 minutes, and they could not understand why I spent so much time with my clients and why the CWOCN visit was important.”

  It didn’t take long before the physicians at MSKCC realized the value of a CWOCN. “I worked mainly with four attending doctors in the bladder group,” Vashti says. “They slowly began to realize that not only do I manage ostomies, but that I also know current wound care management (so now I get all those consults), and that I also could do an incontinence consult (so the incontinence clinic uses me as needed). The Prostate Attending doctors acknowledged I knew about catheters, skin care, containment products, teaching pelvic floor exercises, leaky tubes, and so on, so they referred clients to me if needed. Word spread to Oncology Medicine, and when they have a client with wound or skin issues that could impair the type of chemotherapy used, I may be consulted.”

  As the CWOCN for the Urology Ambulatory Clinic, Vashti enjoys working one-on-one with her patients and helping them come to terms with their new lifestyle. “I love seeing how my patients progress from being scared and anxious when I first meet them in the preoperative setting to learning to care for their ostomies,” she says. “I jokingly call it ‘graduation day’ when they come in for their regular post-cancer screening and they say to me, ‘Vashti, I do not need you today, I’ve got this’.”

  Patients aren’t the only ones benefitting from Vashti’s teaching. “I now work with a team of seven CWOCNs, and as a group we do ostomy education programs, policies and procedures, and collaborative communication between the inpatient and ambulatory divisions,” she says. “We provide educational programs for the staff nurses, the fellows, and the physician’s assistants as needed, especially to keep them aware of new products and how to use them correctly. Many of my new surgeons still love wet-to-dry dressings, or wet-to-nowhere, as one of my peers is known to comment. So after my instruction, it is interesting to hear, ‘Where is the Aquacel or Medihoney?’ Now, that’s progress! And you know you have made a difference when an Attending tells me he knows where to find my wound care supplies.”

  Providing excellent wound care, product information, and clinical direction to her patients and colleagues is vital to her responsibilities, but most of all, Vashti has proven that listening is the most valuable tool in any scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.