In the Beginning
As we all know, the specialty of WOC (ET) nursing began when Dr Rupert Turnbull and Norma Gill established the first ET (ostomy specialist) position at the Cleveland Clinic in 1958.1,2 They developed the role because each of them recognized that new ostomy patients had "nowhere to go" and "no one to turn to" for education, support, and assistance with problem solving. Norma was not a nurse, but rather an ostomy patient who was skilled in ostomy care and totally committed to helping others adapt to life with an ostomy. It would not have occurred to anyone in 1958 that this should be a nursing role, since nurses had very little understanding of how to care for ostomy patients and nurses were not seen as independent practitioners!
Norma's involvement in ostomy patient management made an immediate and profound difference in patient outcomes, and Dr Turnbull began talking about his innovative approach to ostomy patient rehabilitation at surgical conferences. As a result, he and Norma were approached by surgeons who wanted to send "their" rehabilitated ostomy patients for training so that they could also become "ETs." This led to establishment of the first educational program at Cleveland Clinic in 1961.1-3 The admission requirements for the "first" ET students were very different from the requirements we have today: they had to either have an ostomy themselves or have a family member with an ostomy, because the role was based heavily on experiential learning and the empathy and skills acquired through learning to live with an ostomy. There was no textbook and very little published information on ostomy management, but the early "ET" students were nonetheless challenged to review papers that had been written, to record and analyze their observations, and to collaborate with their peers, instructors, and vendors to provide their patients with the best solutions available. Students describe the education as being intense and inspirational, involving multiple hours of clinical rounds, surgical observation, and clinical discussions, all devoted solely to ostomy care.3 Norma was so committed to the advancement of the specialty that early students actually stayed in her home (due to the absence of funding for this type of education); her daughter Sally recalls that "it was fun to have ladies from other states and countries (Canada!) come to stay with us, even though we had to get those dreaded water goblets out that later had to be washed by my sister and me!"2(p178)
The second ET Education Program was established in 1969 at Harrisburg Hospital in Pennsylvania, and 14 more programs opened during the 1970s.4 However, the 1980s brought a different trend as the emphasis on quality care was sometimes eclipsed by the emerging focus on capitated payment systems; only 1 program opened during this period, and many of the programs begun in the 1970s closed. At present, there are 5 full-scope programs in operation and 2 programs providing wound education.
Milestones
Transition to a Nursing Role
1976 was an important year for the ET nursing specialty and ET nursing education. It was in 1976 that the "ET" role became a nursing role, based on a vote by the International Association of Enterostomal Therapists to require RN licensure for admission to an ET school.1,4 This was based partially on the changing role of the nurse; during the 70s the nursing role began to expand to include patient education and patient advocacy. It was also based on the increasing complexity of health care and the recognition that a strong foundation in the health care sciences was needed for safe and effective patient care. To my mind, the "ETs" of the 70s deserve tremendous credit for their ability to see beyond themselves and their many contributions and to look ahead and make decisions that would strengthen and advance the specialty and also optimize patient care. The International Association of Enterostomal Therapists (IAET) also developed accreditation standards for ET Nursing Education Programs in 1976, another tribute to the commitment of our predecessors to excellence in education as well as in patient care.4
Board Certification
Another major advancement occurred in 1980, and that was the availability of Board Certification in ET Nursing.4 Although ET nursing was in its infancy as a nursing specialty, IAET leaders recognized the value of board certification and moved rapidly to establish the CETN (certified enterostomal therapy nurse) credential and process. This is an extremely impressive accomplishment when you consider all of the work involved in producing a certification exam!
Expanded Scope of Practice
One of the most profound changes in "ET nursing" and "ET nursing education" occurred in the early 80s, and that was an expansion in the scope of practice, to include wound care and continence.5,6 This was a controversial decision, and I remember heated discussions regarding the advantages and disadvantages of this expansion at the national conference in New York in 1982. Proponents argued that they were already involved in wound care and that this was a natural expansion of the role, while opponents argued that any expansion would divert focus and resources from the ostomy patient population, and that ostomy patient care was our primary mission. In hindsight, the expansion in scope of practice probably protected the ET (WOC) nurse role in many settings, since it is wound care that is the most marketable element of our role; at the same time, I hear from many clinicians that the volume of wound consults and the focus on wound management do sometimes reduce the amount of time available for their ostomy patients. The expansion in scope of practice had major implications for the accreditation committee and the ET Nursing Education Programs (ETNEPs); the curriculum blueprint was revised to include content related to wound care and continence, and the programs scrambled to modify their curricula, examinations, and clinical experiences. I went to "ET school" in 1980; at that time the program was 6 weeks in length and primarily focused on ostomy care. I did have one class on wound care, titled "Use of Karaya Powder for Management of Pressure Ulcers," and one class on incontinence, taught by Mikel Gray! The volume of content to be covered by the accredited programs increased rapidly following the official change in scope of practice; as a result, most ETNEPs moved to an 8-week program in the mid- to late 80s.
Admission Requirements
Another significant change occurred in 1985, and that was a change in admission requirements from RN licensure to a BSN.4 This decision was congruent with recommendations from the ANA that nursing move toward a baccalaureate degree as "entry into practice"; however, IAET made it "stick" while nursing continued with multiple entry levels into practice! This was another controversial and painful decision, in that a number of associate degree and diploma nurses who were planning to attend ET schools were now required to go back for their BSN before they could pursue their goal to become "ET nurses." Entry requirements have since been modified to be RN licensure and a baccalaureate degree, which may or may not be in nursing.
Development of Innovative Delivery Systems
During the mid- to late 80s, acute care facilities struggled to adapt to capitated payment systems, and funding for ET nursing education became less available; thus, ET nursing education programs were challenged to explore innovative delivery options. Many of the existing programs began to offer students the option to come to campus for the didactic component of the program and then to return home to complete their clinical preceptorship in their own area (split option programs), and in 1992 Albany Medical Center established the first "Distance Education" program for ET nursing.
Worldwide Education
Parallel to the development of ET Nursing Education Programs in the United States, similar programs were being developed around the world, beginning with Canada in 1968 and expanding to 21 countries by 1995.7 In 1978, the World Council of Enterostomal Therapists was established, and one of their primary goals has been development of educational programs around the world. To that end, they have established international accreditation guidelines and have fostered "twinning" programs in which a country with an established stomal therapy educational program provides support and assistance to a country seeking to develop such a program.
Today
At present, there are 5 accredited full-scope programs and 2 accredited wound care specialty programs; the number of active programs has declined significantly over the past 2 decades. However, the development of innovative delivery systems has tremendously increased the number of graduates from each program. Whereas the early programs could accommodate only 4 to 6 students per class and 3 to 4 classes per year, WOC Nursing Education Programs providing distance education options may graduate more than 100 students per year.
Criteria for admission to an accredited program include RN licensure, a baccalaureate degree, and at least 1 year of clinical experience as an RN; some programs require more. On-site programs are typically 8 to 10 weeks in length for full-scope programs, and 3 weeks for single scope. All programs are intense and packed with content, challenges in critical thinking, simulations labs, examinations, precepted clinical hours, and a number of professional practice projects. They are best described as graduate-level "short courses," and they are characterized by the same descriptors used for the early educational programs: intense, inspirational, and devoted to practice that is evidence-based, collaborative, and patient-focused.
Innovative delivery systems are now the "norm" for WOC nursing education programs. The on-site "traditional" programs are still "alive and well," but most programs also provide split option and/or distance education programs. Distance education courses are now the most popular of the delivery systems, and they are available in both synchronous ("real time") and asynchronous ("self-paced") versions; all use technology in various forms to "bring the course to the student." Most of the full-scope programs (wound, ostomy and continence) now offer students the option to take a single specialty (eg, wound only) or dual-specialty course (eg, wound and continence care). Finally, there are a number of programs that are linking WOC nursing education to graduate education. For example, the University of Virginia offers both a certificate program and a graduate program that includes WOC nursing education, and the webWOC program has partnered with Metro State University to offer graduate credit for the WOC nursing education program.
Future
So how will the WOC nursing education programs of the future differ from what we have today? My prognostication skills are limited, but it seems likely that the trend to link WOC nursing education and graduate education will continue, and that we may end up with more than 1 "level" of WOC nurse providers and education (baccalaureate-level "specialty" nurse and master's or doctoral-prepared advanced practice nurse). It is also likely that the trend toward distance education will continue and that technology will play an increasingly important role in our delivery systems. What we know for sure is this: while the educational programs of the future will look very different in terms of delivery systems and sophistication, the core values will remain exactly the same as those of the very first "ET" schools: an unrelenting commitment to advancement of care that is patient-centered, evidence-based, and collaborative!
References