My Scope of Practice: ET Nursing: Easing the Transition

  Pennsylvania Hospital was the first hospital in the United States. This 400-bed acute care facility in the heart of Philadelphia, Pa. is a recognized and distinguished obstetrical and orthopedic center that recently merged with the University of Pennsylvania Health System. For the past 17 years of its more than 225-year history, Pennsylvania Hospital has benefitted from the expertise and dedicated service of a self-described "hands-on" practitioner who attributes the good outcomes she is able to effect to her ability to teach as she treats. She takes great pride in easing the transition from pre-ostomy to post-ostomy life for her patients.

  Linda Lankenau, RN, MSN, FNP, CWOCN, an advanced practice nurse, has been working in her profession for 30 years, serving in the medical/surgical, ER, and clinical staff development arenas before becoming an ET nurse. In her current capacity as an ET nurse for Pennsylvania Hospital, Linda sees patients in various areas, including the ER, the skilled nursing facility, and physician offices. She also provides care for ALS clinic patients and interventional radiology department outpatients, as well as for critical care and medical/surgical patients throughout the hospital.

  "The hospital's ET position was created in 1984 when a physician from Hahnemann (a nearby hospital) came to Pennsylvania Hospital to start a gynecology/oncology center," Linda explains. "He performed extensive surgeries on patients who had undergone chemotherapy and pelvic radiation. Because his patients often needed ostomies and complex wound management, a request to have an ET nurse was part of his requirement for accepting the position at the hospital. Our general surgeons and urologists already were performing ostomy surgeries and also would benefit from having an ET nurse available."

  For Linda, ostomy and wound management consults are requested for patients with cancer, inflammatory bowel problems, skin breakdown, and geriatric care issues, among others. They involve skin integrity challenges, incontinence skin management, feeding tube and drain management and education, and specialty bed evaluation. The latter provides an example of how an ET nurse's knowledge and experience can have a positive impact on budget. "For specialty bed management, we have certain critical care criteria as to whom would benefit from specialty bed use, as opposed to randomly requesting equipment for patients," Linda says. "An ET nurse can help prevent excessive use of costly specialty beds." She adds that most ET nurses are decision-makers with a say in protocol and product selection in their institutions. Because they are knowledgeable and empowered, they can help make appropriate product choices, resulting in better outcomes for patients and less waste of costly supplies.

  Linda believes that the expertise of the hospital and home care CWOCN improves the quality of care for patients, facilitates the work of fellow nurses, reduces medical costs, and enables families to better manage and cope with situations that may be difficult and upsetting not only to the patients, but also to those providing care. "Part of my teaching includes finding ways to improve ostomy and wound knowledge among staff nurses to make them more comfortable when working with ostomy patients with ostomies and wounds. They then can provide better support to patients as clinicians because they have developed the skills to manage the ostomy or complex wound."

  Shorter hospital stays require more ETs to be involved in home care to help the transition from one expert to another. "In the hospital, the focus is on the wound or ostomy," Linda says. "Once the patient leaves the hospital, the focus shifts to the patient as a whole - who he is and what he likes to do. An ET nurse can help address concerns about managing an ostomy as an unseen part of every day living, offering the message, 'A person doesn't have to like an ostomy, but he or she can learn to live with it if given adequate education, support, and understanding'."

  Linda enjoys the independence she has in her practice, the relationships she develops with patients and families to make a situation less painful and more livable, and the information exchange with colleagues. "The camaraderie among CWOCNs is extraordinary," she says. "We share both the frustration and, yes, the fun of the experience of treating these special patients." She also states that as part of a large, multihospital system, she is fortunate to work with many great professional colleagues and has access to quality supplies.

  Among the more challenging aspects of her practice, Linda lists losing friends and colleagues to downsizing and the high amount of nurse turnover - investments of time and energy in training and education do not guarantee that a staff member will remain in the department or facility. She believes that because of these realities, her practice has expanded over the past 5 years and that she will continue to be responsible for helping to manage a wide range of patient care problems in her hospital complex. She admits she would like a partner to share the education and consultation, especially if the nursing shortage persists. To put it succinctly, "We need more of us. Staff nurses cannot always provide what a specialist can, but they benefit from collaborating with the clinical specialist in the care of their patients."

  Another aspect of her educational responsibilities includes precepting ET nursing students, a source of pleasure and knowledge sharing (Linda was nominated for "My Scope of Practice" by Dr. Janice Beitz, someone Linda precepted, who established the WOC ET program at LaSalle University School of Nursing, Philadelphia, Pa.). A staunch supporter of the LaSalle and Wicks ET nursing programs, Linda says many of the members of the Delaware Valley Enterostomal Therapy Association (of which she will become President in 2002) precepted at Pennsylvania Hospital. She shares with her students what she came to learn: "I came out of my ET program with only an inkling of what I would eventually come to know. Although I was well prepared by my program to start my new role, I cared for some of my most challenging patients as a new ET, with fellow ETs making special visits with me to some of my more complex patients. Each patient has added to my body of knowledge."

  One of those patients is Mr. S, an 84-year-old patient with bladder cancer who views his recent ostomy as "a new adventure." His unusual optimism elicits strong emotion from Linda. "I wish I could bottle his outlook," she says. "We need hope and humor in this specialty. We need to find the lighter, brighter side of the care we provide in our scope of practice."