My Scope of Practice: A Day in the Life of an ET Nurse
You would remember meeting Nancy Faller, RN, MSN, PhD, ET Nurse Clinical Specialist. Soft spoken (if emphatic), compassionate (if no-nonsense), her small stature and ponytails belie the wisdom and power inherent to and nurtured by her many years as a nurse. One can easily imagine her not taking any guff from either her superiors or her patients when she served in the US Army, whether during her first year as a staff nurse at the station hospital on Fort Knox, Ky, or her second year in Vietnam, where she received the Bronze Star for Achievement.
While serving at the 67th Evacuation Hospital in Qui Nhon, Nancy held a number of positions including staff nurse, assistant head nurse, head nurse, and relief night supervisor, an awesome responsibility for a young professional less than 2 years out of college (Nancy only wishes her ET Nursing Education could have predated this experience, where povidone iodine and wet-to-dry dressings were used liberally). Her more recent former mentee at Rutland Regional Medical Center in Vermont still sings her praises for helping develop a busy full-scope ET Nursing practice (inpatient, long-term, home, clinic, and consultative care).
When you ask Nancy to provide an evidence-based practice algorithm for restoring and maintaining skin integrity, you get a comprehensive chart, complete with photos of buttocks exhibiting various types of altered skin integrity called, “No IFs, ANDs, or BUTTs — Cut the CRAP and Cure the Skin.” (Perhaps it would be best to clarify the Critical Review of Abstract Presentations [CRAP] is a recognized instrument used to appraise podium, paper, or poster information. Nancy used the same acronym for her tool.) Her evidence base often is her own extensive experience, something she rarely touts other than to proudly refer to herself as “Nancy Nurse.” Her days — indeed, her life — leave little room for much beside providing care, yet she makes the time to serve as a forthright and outspoken member of the OWM Editorial Advisory Board and she is a member of the national and international ET Nursing associations. She currently serves on the Editorial Review Board, the Norma Gill Foundation, and the Education Committee of the international association. Additionally she has volunteered as Treasurer-Membership Coordinator for American members since 1983.
Nancy occasionally will take the soapbox when issues arise (see “Can We Talk?” in this issue). This “My Scope of Practice” is based on an article she prepared for a urologic journal that is no longer published and offers insights into a “composite” day of ET Nursing practice. OWM is proud to salute one of its own.
What is an ET Nurse (ETN)?
ET Nurses provide acute and rehabilitative care for people with stomas, fistulas, tubes and drains, wounds, and incontinence. Some cover the full scope, while others have narrowed their practice to just one area. ET Nurses are found in many settings: hospitals, private practice, industry, education, extended care facilities, home health agencies, and clinics. Some work for one institution and provide consultative services to others. Basically, ETNs are subject to supply-and-demand, where usually demand far exceeds supply.
How does a composite day evolve?
An ET Nurse, especially one working in different care settings, carefully orchestrates her schedule to fit a variety of activities. A typical day starts in a nursing home, evaluating the progress of a patient with a venous leg ulcer and reassessing the charge nurse’s competency in applying the compression system. While at the facility, the Director of Nursing asks for help in setting up a research-based trial of disposable undergarments.
They make an appointment to discuss products to be evaluated, patients to be included, protocols to be used, and procedures to be followed.
The next stop is the hospital. A clinic patient presents before a percutaneous endoscopic gastrostomy for swallowing dysfunction related to head and neck radiation therapy. After providing instruction and addressing concerns, the patient’s abdomen is examined and a site is selected for the stoma. Before the patient and her husband leave, the ETN coordinates the procedure date with the GI nurses, the tube feedings with the dietitian, the follow-up care with the home nursing coordinator, and the equipment needs with the local supplier.
Up on the floors, the ETN sees an old friend/patient who has had an ileostomy for 30 years — in the course of an emergency admission for a kidney stone, she forgot to bring her equipment to the hospital. The problem is easily resolved with a quick trip back to the crisis cache in the ETN’s office. Next, a 90-year-old gentleman with a pancreatic drainage tube is desperate to get home for his 60th wedding anniversary. Plans are quickly put in place for home nursing care to monitor tube placement and to change dressings, as well as follow-up with his surgeon.
The next stop is a home visit out in the hinterlands. It necessitates a drive into the neighboring state to access the only road onto the old farmstead. A young woman, post stroke, has developed a pressure ulcer on her right ischium. The ETN and home care nurse appraise the situation and determine that the wound care plan is appropriate but a chair cushion is needed to improve pressure relief, as well as an occupational therapy consult for feeding suggestions. In addition, a program of timed voiding is established.
Next, the ETN returns to the hospital for a meeting with the purchasing agent. They are finally stocking a stretch, non-woven, polyester tape, justified by a clinical study demonstrating a reduction in tension blisters after hip surgery. The product selected allows use to be tailored to individual patients. The product should be in place in 1 month, a fact that necessitates a call to the company’s sales representative to schedule a staff inservice (before the product arrives on all the nursing units).
The ETN must make time to field phone calls from the State Health Department, where she is on contract to Children with Special Health Needs. Jen, a young girl with spina bifida, is leaking in between clean intermittent catheterizations (CIC). She is not infected, so the options are monitor fluids, increase frequency, or add medication. The ETN starts with the simplest solution. The child, with supervision from her mother and her teacher, will keep a special pediatric flow sheet of all intake and output, including incontinent episodes, for 2 weeks. At that time, the ETN will review whether intake is high or low and determine if the leakage is related to fluid volume. Additionally, the ETN will meet with the school nurse to review the procedure for CIC, the catheter size at school, as well as the place catheterization is being performed to verify that no environmental factors are interfering with the catheterization regimen.
Roger, a teenager with cerebral palsy, has had increasingly soft stools as well as bowel accidents during the night for a week. His fluids had been increased previously to a satisfactory level and he had been able to maintain this rise. His cellulose fiber supplement needs to be boosted to increase water absorption.
The ETN is asked whether she is available to lecture on the artificial urinary sphincter in 3 weeks. She sets aside time before the next scheduled monthly children’s clinic. The ETN is asked to call Gary at Medicaid — she routinely provides testimony on equipment needs and there are questions regarding a young man who suffered a traumatic brain injury in a multiple vehicle accident.
Hospital rounds must be finished. Three inpatients (a mother of four with vesico-colic fistulae secondary to ovarian cancer, a nun with a fungating breast lesion, and a newlywed with an emergency colostomy for a perforated diverticulitis) must be seen before the ETN can leave work and attend a retirement party for the Director of Social Service, the go-to person for facilitating transitions out of the hospital. Support services are critical for ET nursing patients.
Once she finally arrives home, the ETN will review publications and regulatory/reimbursement materials relevant to her field. For example, she may study incontinence code revisions from Medicaid Services. She also may begin a manuscript for publication or provide editorial comments on a manuscript already submitted. Old-fashioned and thorough, when Nancy is the ETN, the review may include not only clinical content critique, but also organizational suggestions, addressed in outline format. Reviews always include a stick-figure nurse, complete with cap and smile.
By evening, the ETN would like to put up her feet and relax but it is time to think about attending an educational conference — perhaps to the 2007 Symposium on Advanced Wound Care in Tampa, Fla. That sounds like a great place to start a vacation.
In the end, it is clear: the ETN does CARE — in a clinical role, providing direct and consultative patient services; in an administrative role managing and promoting the ET Nursing Department; in a research role, knowing, using, and initiating research activities; and in an educational role, providing teaching for patients and colleagues alike. Nancy certainly cares…as evidenced by her scope of practice.
My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ.
This article was not subject to the Ostomy Wound Management peer-review process.
