My Scope of Practice: Double the Dedication

   Sandi Brunello, RN, BSN, CWOCN, is a twin - a circumstance of interest here because her "younger" twin sister brought her into the fold of wound and ostomy care. Tammi Short, RN, MSN, FNP-C, CWOCN, needed help at her hospital. Realizing the value of her "older" sister's experience in acute care and home health, Tammi became Sandi's mentor and justified an additional WOCN position. Sandi blossomed in her new job, earned her ET certification, and has since achieved distinction as a WOC nurse in her own right.

   Sandi began her nursing career as a pediatric medical surgical nurse at Children's Hospital, Austin, Tex., where she segued right from a CNA role into her first position as an RN. Later, she moved back home to Longview, Tex., and worked as a home health agency nurse. "Tammi was the WOCN at Good Shepherd Medical Center and managed the ET department," Sandi explains. "She had the opportunity to request an additional full-time WOCN position and realized that someone with my home health experience was needed. She got approval for a new position that was 80% hospital-based with the remainder of the time for home care. From September 1997 to January 1998, I worked with my sister. People assumed that because we are twins, I would know what she knew by diffusion, but she had to mentor me until I gained independence and comfort in the WOCN role. In 1998, the hospital sponsored my formal WOCN education at Emory University (Atlanta, Ga.) and in October 1998, I was certified."

   Sandi says her sister is a triple Type-A personality, so the new program embraced all aspects of practice. "I did outpatient, inpatient, and home health care, including working at the outpatient wound care center. Our practice also included urodynamics for inpatients and outpatients and spinal cord rehab. It was a wonderful opportunity to enhance my skills for the 3 years I was there, but I was always concerned I was only doing mediocre work - a jack-of-all-trades, but master of none."

   Her fears were unfounded. In 2001, she married and moved to Houston where she secured a position with MD Anderson (MDACC), the cancer facility recently rated #1 by US News and World Reports. The WOCN department at Anderson is service-based and practice-focused, so Sandi sees a select group of cancer patients with wound and ostomy problems.

  "It took me a while to get into the role," Sandi says. "I was accustomed to a more diverse patient population. Now, I see it is not so focused as it is different. My caseload includes inpatients and outpatients with gastrointestinal and endocrine cancers and melanoma and pediatric cases. Our service lines have their own surgeons who work out of the clinics. My role is to work with patients from pre-op to post-op related to ostomy teaching as well as to care for patients with wound care needs. It's nice to be able to provide a continuum of care."

   Working in pediatrics allowed Sandi to return to her first love. "Kids heal faster and adapt to the disease process better and more quickly," Sandi says. "When the disease affects the spinal cord, it affects continence, and some of my patients are so young they don't understand yet how their bodies work, adding a new dimension to my instruction. But they have a different mindset than adults - they don't get as depressed and they cope better. I recently cared for a 5-year-old with two ostomies (fecal and urinary). For adults, this would be a huge setback and there would be a grieving process. This child adapted to the change without an extended grieving process and now swims and plays despite the pouches. A lot has to do with her mom's great attitude. I find it rewarding to work with the whole family."

   Another consideration is cultural differences. MD Anderson cares for children and adults from around the world, and nurses need to be sensitive to the ways cultural diversity impacts response to illness and its treatment.

   Sandi says her responsibilities are "typical" of a WOCN, incorporating education (patient, family, and staff) with care. She instructs, precepts, and lectures to students in a primary clinical/teaching hospital. MD Anderson's WOC Nursing Education Program has clinical sites across the Houston area; the institution has the most WOCNs per capita (five full-time and two part-time WOCNs, and one per diem). As a result, students abound. "I teach and precept two or three classes a year. Almost half of my year is spent in a teaching role," Sandi says.

   Sandi is also on the product selection committee - a "big committee with big responsibilities" - a key component in product selection even when the purchases (such as infection control and safety-related items) are not directly related to the committee members' particular patient populations. She is known as an assertive patient advocate and because she has the educational background and experience, she is heard. She prides herself on her drive to stay up-to-date and her willingness to educate herself when she doesn't immediately know the answer to a question.

  The ability to help patients of all ages return to their favorite activities is one of the more gratifying aspects of Sandi's job. "I enjoy helping patients adapt their lifestyle to their body changes," she says. "They are so grateful... and sometimes, so disbelieving. A man with a colostomy recently asked me why I would want to do this type of nursing, and I replied, ‘Why not?' It's an exciting and rewarding challenge to work with all different types of people from different backgrounds and beliefs and help them get better. I love the variety. I am never bored. My common sense approach to patients with ostomies is that you can do everything you want - with a twist. Do it, just do it differently. Creativity plays into every part of the job."

   Getting buy-in from staff can be a challenge. "The challenge is the challenge," Sandi says. "Some nurses are not as receptive to your ideas because you are a nurse and no different from them. As a ‘specialist,' I appear to make their work harder. They don't always readily accept that my guidance will help their patients heal faster. Also, many of the nurses are older than I am and as the young whippersnapper, I am not always warmly greeted. And, of course, change is sometimes seen as a bad thing. My solution has been to seek and share additional information related to the care I recommend. I work like crazy with the WOCN team and the clinical nurse instructors to organize inservices. Through it all, and factoring in the nursing shortage, you must appreciate the staff nurses' perspectives. They are constantly under the gun to be more efficient and help patients prepare for hospital discharge faster."
Sandi has seen her professional responsibilities evolve from primary nurse to consultant, but she remains ever the team player, involving case management, dietitians, OTs, and PTs in the care plans she develops, all based on the patient's needs. She acknowledges that her work environment has changed through the years. "I went from working in a big facility in a big city to home health to a huge practice in a small hospital, to a big facility with a big practice," she says.

   How should a nurse decide on a specialty if she chooses to evolve her role? "Get out there and practice," says Sandi. "Seek opportunities. Precept before you commit to a program. Continually educate yourself. Listen to the voices of experience, regardless of age, including your younger siblings and the children for whom you provide care. My sister and my patients have been the best teachers in my scope of practice."

   My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.