To the Editor

SUBJECT: POINT-COUNTERPOINT ON WOC CERTIFICATION

I am not sure that patients receiving nursing care are interested in discerning the status of the "technical" versus the "professional" nurse. More likely, patients are hoping and expecting that whoever is caring for them is acting with the requisite skills and within the professional boundaries expected of all caregivers assigned to them by the governing authorities. Now that we have dispatched with this distinction, let us move on to other points.

As a nonnurse ET practitioner, I was on the front lines performing and promoting ostomy rehabilitation from the 1960s onward while nursing in general was absent from this role. I lacked any formal institutional training, let alone nursing-sponsored training, in ostomy rehabilitation. I did, however, bother to learn all I could about ostomy rehabilitation matters from the patients and the physicians and surgeons who asked me to assist their patients. I also learned from medical and surgical journals and books, even to the point of falsifying my credentials with some publishers in order to obtain subscriptions to some of them. Granted, this was not the most orthodox, efficient, or economical way to obtain a rigorous base of ostomy-focused knowledge, but it was all that was available at the time. Now, decades later and after nursing has reclaimed its role with ostomy rehabilitation, should I be wondering just how many patients, students, and colleagues (physicians, nurses, pharmacists, physical therapists, social workers, and ostomy equipment manufacturers and their sales teams) were ill served or think less highly of the information bestowed upon them by my lack of nursing credentialing? Have I failed that poorly at meeting the expectations of the varied solicitors of my services? Probably not. Incidentally, shortly before leaving hospital practice I was adding or expanding my area of patient practice to include the management of feeding tubes; again, learning directly from the physicians, surgeons, patients, manufacturers, and medical and surgical journals and books on the subject matter. A pattern of self-learning persists here. There must be a flaw in my character that drives me to self-learn from all quarters. Notice, I did not say self-educate, since I am not sure what the term educate really means in the context of learning. Granted, some would attest to the necessity of having an educator impart knowledge or facts to another, but is this really necessary in order to learn? Ask this of yourselves, not of me.

If as offered by Dr Beitz, "Licensure and credentialing give power to those who possess them" and "there is no existing research that suggests that a MSN-prepared WOC nurse promotes better patient outcomes than one with a BSN," then what are we really saying about the power? Francis Bacon's appeal to power was famously declared as "Knowledge is power." In this context one understands that knowledge is the basis of the power. And, of course, knowledge can be acquired through many differing venues. Since Dr Beitz does not tell us what the constituents of power are, beyond licensure and credentialing, is it to be assumed that power for the sake of power is desirable or useful? If so, then power is its own end game. And, what would this do for the end user of the supposed power? Does having a more powerful patient care provider ensure better patient care or outcomes? If so, how? Does being more powerful ensure more useful knowledge applicable to better patient outcomes? Or is power only useful to "avoid the slippery slope of downward substitution"? If so, are we not now alluding to the phenomenon of creating powerful entities for the sake of preserving control? Control over what or whom? Sounds to me like the classic distinction of too many officers and not enough foot soldiers deployed to perform the tasks asked or required of them. If this becomes the outcome of this appeal to power then the marketplace will readily dispatch with the excess officers in order to efficiently meet patient needs and expectations with the requisite foot soldiers.

It is my contention that health care practitioners and educators are too restrictive in their educational and practice models and act more like silos than complementary teams. Physicians and nurses have had very distinctive roles and responsibilities for decades and have done battle with each other whenever the threat of overlap has appeared. However, in fairness, it is noted that many WOC practitioners, myself included, have enjoyed a good working fellowship with their physician counterparts. In these instances the perceptions among both entities have been of complementary roles, sought after and nurtured with eagerness and high praise for one another. Or, dare I say it, the eagerness for others to defer to the WOC practitioner was motivated in large part because others did not wish to bother with the unsavory aspects of ostomy rehabilitation? However, on the broader horizon, the relationships between physicians, nurses, and patients have also taken on the appearance of a battlefield, with each camp striving to preserve its own territory and control. Is nursing, and in this particular case WOCN, impeding its own development and enrichment by limiting the pool of educational entrants to the BSN standard only? Is it not also adding to this dilemma through the higher level process of restrictive credentialing? I think so. In the broad scheme of things, the marketplace, the ultimate arbiter of rational economic and business behaviors, of which patient care is very much an integral part of the social compact, will sort out this morass and choose those models and entities which place patient needs and wishes first. Additionally, it should not be assumed so readily that the advantage will now fall to nursing entities to glean more of the patient-care market simply because of an increasing demand for services. While there are hopeful signs of this trend toward nursing-guided care emerging, what is to stop the physicians or other practitioner groups from changing their schooling and applicant criteria to permit greater numbers of practitioners to counteract this perceived nursing encroachment? Clearly, the landscape is changing and the lines of demarcation and responsibility for patient outcomes are blurring.

If I were a brand new ostomy patient now I would want those caregivers who are competent-short and sweet. Give me experience over titles. I am not interested in titles and the line(s) of letters that trail off to the right of the name on the identification tag of my caregiver. To put it more colloquially: "What's with the alphabet soup alongside the names?"

I contend that WOC practitioners should be well respected by their patients first and professional colleagues second because they are competent in their dedicated field of endeavor and not because they are committed to obtaining a BSN or master's degree before being certified. The Achilles heel in all educational and practice settings utilizing preceptorship is the presumptive quality of the educator and preceptor. Not all educational settings and preceptors are of equal quality, and yet, how does one measure the quality of them and how often? Other than anecdotal confessions, what data are readily available for us to discern this important benchmark of quality?

To suggest that the credentials of the personnel matter more than ever in litigation is presuming that credentialing is the sine qua non for asserting proficiency and competency. I will assert that it is a most convenient measure to employ, and makes it easier for lawyers to identify and target; however, it does not necessarily follow that because one is credentialed one is competent. If test-taking is the current benchmark for asserting or measuring credentialing then what of those who are adept at test-taking through the device of good short-term memory tactics but not much more versus those who are poor at test-taking but are much more competent than the testing would elicit?

Sincerely,

Mike D'Orazio (Mike ET)