My Scope of Practice: Preparing Those Next at Bat

   For 6 years in the early 1990s, Canada had no enterostomal therapy training program. Former programs in Sherbrooke, Montreal, Toronto, and Vancouver (two taught in French, two in English - one of each language hospital-based and university-based) had been closed by administration. Not wanting to see ETs - a rare species - become extinct, Diane St-Cyr, BSc, MEd, RN, ET, along with colleague Nicole Denis, approached the Canadian Association for Enterostomal Therapy (CAET) with an idea for a distance learning program - underscoring her belief that teaching and sharing are vital to preparing a new generation of practitioners that is well educated and prepared for the evolving challenges of the profession.

   A nurse since 1979, Diane earned her bachelor's degree and ET certification in 1986, her Masters in Education in 1990, and her foot care certification in 1997. A "floater" early in her career who was drawn to the ET population, she soon had wound care added to her responsibilities, as well as quality assurance. Ready for additional challenges, she responded to an invitation to become a clinical instructor at McGill University School of Nursing, where she provides wound care education to nursing students. An on-demand instructor at the University of Montreal, she also started a private practice to reach out to a patient population that previously did not have ready access to an ET and serves as a speaker for several companies. Her background in education was an impetus to do more."I love patient care," Diane says. "But I also think it's important to teach and volunteer my services in professional associations." Diane co-chaired the 1996 CAET conference held in Quebec City and for several years served on the Board as Regional Director, helping to translate documents and articles for French-speaking colleagues. She later served on the Board of the Canadian Association of Wound Care (CAWC) and was a member of the organizing committee for the 1998 and 2000 Annual CAWC conferences held in Montreal.

   The bilingual distance learning program, established through the efforts of a focus group of six dedicated ET nurses, is an accomplishment Diane finds particularly satisfying. Participants in the program, in operation since 1996, take 6 months to a year to complete the reading modules and obtain practical experience working with preceptors. In addition, Diane coordinates preceptorships with three companies (Smith and Nephew, KCI Medical Canada and 3M) to enable healthcare professionals to develop evidence-based wound care programs in their regions and to foster an interdisciplinary team approach.

   Diane does not simply disseminate existing information. She has been actively involved in developing teaching and practice tools for caregivers at a variety of caregiver levels. She co-coordinated a panel of 10 Canadian ET nurses that helped create the Canadian Ostomy Assessment Guide, an algorithm designed to facilitate selection of appropriate pouching systems by nonspecialized nurses; thus, fostering longer wear time, reducing cost, and enhancing patient quality of life. Since its development in 1999, the guide has been used by approximately 5,000 nurses who have been trained in its use in clinical practice. Not content to assume the guide would achieve its intended goals, Diane conducted a national study to assess the educational tool's impact (the results were published in Ostomy/Wound Management in August 2002). The guide was rated "extremely useful" by 67% of the nonspecialized nurses who participated in the study. The guide now also serves as a teaching tool at Canadian ET school and is used extensively by community nurses.

   Roles in three teaching programs, consultations, the nurse-run ostomy clinic, and special projects occupy 2 days of Diane's week. The other 3 days she sees ostomy and wound (pediatric through geriatric) patients at McGill University Health Center. "I go where I am needed to see wound patients to interface with the treating physicians. I see ostomy patients on my own unless there's a complication that requires physician input. I also consult weekly at the Premier Ostomy Center, Montreal, helping patients deal with management issues such as leakage and postop adjustments." This month, Diane will start to work jointly with a podiatrist (Dr. Christina Morin) in a private podiatry, wound care, and conference center. Diane says that to her knowledge, no other wound clinic in Canada is offering such comprehensive services.

   Among Diane's special projects is her involvement with the Order of Nurses of Quebec in the application of Bill 90 - a Quebec province legislation that will modify the legislated responsibilities of 11 professions. The law acknowledges a broader scope of practice for nurses and recognizes the special knowledge and autonomy of nurses in wound care. Diane was part of a focus group formed to clarify and establish boundaries between staff nurses and wound care experts and what duties each can adequately/comfortably perform. "For example, nurses - especially wound care nurses - have the right to debride," Diane explains. "The bill helps define the extent to which we can perform such duties. Because of the bill, there is - more than ever - a massive need for education in wound care for all the nurses."

   Another project would tap Diane's bilingual abilities. Aware of the discrepancies that occur when clinical assessment tools are translated into other languages, Diane wants to be involved in a proposed project that would validate the Braden scale in French.

  "My sense of satisfaction comes from two sources: helping to heal patients better, quicker, with less pain and seeing that spark of energy and enthusiasm in those I teach as they help others," Diane says. "To overcome the challenges of reimbursement, which limit what we can do as clinicians, I think we have to lobby for preventive care. For example, when treating leg ulcers, the Provincial Health Care Program will not reimburse for compression systems and for some moist healing dressings; the patient has to pay out of pocket. Plus, clinicians must do more with fewer resources, especially now with a patient population that needs higher levels of care This situation makes it crucial for us to prioritize our services (ie, who gets to be assessed first) and reinforces the need for a local wound care resource person. Shifting from traditional to more research/evidence-based practice and protocols and algorithms involving best practice should foster more efficacious care plans. It also calls for more education for nurses."

   Diane hopes to see tools such as algorithms and standard documentation instruments implemented to help staff nurses' roles evolve to handle more of the basic care while nurse specialists deal with the more complex cases. General population education, enhanced educational programs, and an increasing patient willingness to pursue what is perceived as more personalized, specialized care in the private sector, should help facilitate her vision. Meanwhile, she is sometimes frustrated because she must limit the time she spends on any one activity, particularly teaching. "It's difficult not to do a job as fully as I'd like," she says. Of her preceptor duties, Diane says it is sometimes difficult to accept that you are training these nurses only to see them leave. But she adds, "When you make a patient better, you are making a difference. I've found that if you acquire allies, acquire and share knowledge, and tap into an interdisciplinary team, nothing is impossible. With proper training and education, there is a place for everyone in this scope of practice."