Response

Thank you for the opportunity to respond to Mr D'Orazio's letter to the editor. I am glad that he has taken the time to express his views of my professional opinion on the proposed WOCNCB Certification for non-BSN nurses. I will address the points that he raises from the perspective of a WOC nurse clinician practicing in a demanding tri-specialty in the year 2007.

When I read Mr D'Orazio's letter, I found that there are some sections with which I agree wholeheartedly. I agree that patients do want those caring for them to use their requisite skills and professional acumen to provide safe care. But I cannot dismiss the issue of education of nurses so lightly. I recommend that Mr D'Orazio review the literature on patient safety. Compelling research says that the education of nurses matters!! More educated nurses are associated with better patient outcomes and greater patient safety; this statement is not merely an opinion, it is a fact based on the outcomes of multiple studies.

I agree that self-propelled learning is important, and that it is possible to learn from many venues and sources including patients, families, the literature, research, conferences, and clinical practice. In fact, lifelong learning is the sine qua non of a health care professional.

Thankfully, the "good-old, bad-old days" of early ET practice have gone and education about WOC nursing, both initial and continuing, is readily available and of high quality. Do I think that a person must have an educator teach him or her to learn? No, not necessarily. However, expert clinicians teaching others expedite the learning process. Try teaching yourself advanced statistics versus learning from a great statistics teacher and you will see what I mean.

Mr D'Orazio appears to argue that licensure and credentialing and the issue of power is problematic. Power is part of the practice of any contemporary health care practitioner. We go to school for years to gain the power of an RN license. I invite the writer to investigate the power literature and look at the types of power. I can easily think of 2 types: expert power and referential power. The former comes from recognition of rigorous educational attainment and prolonged clinical expertise. Referential power arises when people seek another's opinion and will defer to that other person's expertise. WOC nurses have both. They are recognized as expert clinicians, and they are consulted to improve patients' care. Do I want this kind of power? Yes. Using this type of power, I can save lives and make a difference. I value the power of expertise so much that it has driven me back to school to become an Adult Nurse Practitioner at the age of 53 after 21 years of being a certified Adult Clinical Nurse Specialist. I want control of my practice so I can influence patient care outcomes. I submit that a reputation of superb clinical acumen with great clinical outcomes is the most powerful way to avoid the slippery slope of downward substitution.

I too value transdisciplinary practice and have enjoyed excellent working relationships with physicians and other health disciplines over the years (in general, no battlefields in my lived experience). I believe that WOC nursing is a team sport. However, I have also noticed that my collaborative relationships have improved as my educational level went upward. I could talk the talk and walk the walk more efficiently and effectively because I knew more!! I was the one who changed.

Another issue with which I disagree is Mr D'Orazio's contention that WOC nursing is impeding its development by limiting its basic standard to the BSN/baccalaureate level. Is any other health discipline concerned with this? All health disciplines (eg, PT, OT, Nutrition) have raised their requirements substantially and no dilemma has been created. Nursing has to acknowledge that it has not kept pace and has to make some serious changes in basic nursing education requirements for the future.

One aspect of Mr D'Orazio's letter with which I disagree wholeheartedly is his contention that clinical competence and "titles" and "line(s) of letters" are mutually exclusive. When I am ill, I want a competent health professional who is well educated and well experienced in the practice of patient care. I want my neurosurgeon to be exquisitely well educated and well experienced. One is not truly competent unless one is both. Our past visionary WOC leaders figured this out decades ago. For example, diabetics are people who may have great insight into the diabetes experience but it does not prepare them to care medically for their osteomyelitic foot wounds. While I value experience, it is not all there is. When you are a person involved in a lawsuit, do you want the paralegal with 30 years of experience, or do you want a lawyer to represent you? I know who I am going to choose.

Two other issues that seem to bother the writer are preceptors and testing. I want to reassure Mr D'Orazio that quality preceptorships and clinical experiences are valued by the WOCN Society and the Directors of the WOCNEPs. In fact, we are mandated by the WOCN Accreditation Committee to assess the quality of our graduates' preceptorships. Plenty of data are available. We track issues like this to monitor educational quality and avoid having an "Achilles heel." I refer Mr D'Orazio to the WOCN Society Accreditation Manual for further reading.

The other issue that seems to trouble Mr D'Orazio is credentialing, certification, and competency. As someone whose doctoral education is heavily focused on psychometrics (test development and analysis), I strongly support the view that success at writing the WOCNCB certification exams (3 separate exams with exquisitely developed supportive psychometric validity and reliability data) is not dependent on good short-term memory tactics but solid requisite knowledge developed via rigorous educational programming. The current WOCNCB tri-specialty examination process is rigorous. Credentialing via national certification examination is not perfect, but I trust the process more than other less rigorous approaches.

I would like to thank Mr D'Orazio for sharing his views but need to remind him that the "good-old days" are gone forever and the "front line" is very different in 2007. We are now a tri-specialty (Wound, Ostomy, and Continence) and the science on which our practice is based is evolving rapidly. Visionary leaders of the past recognized that WOC practice was best based on nursing education at the baccalaureate level. Rigorous education and clinical experience make for optimal competence. I would submit that the move to required graduate level education for the tri-specialty is in sight. Education and credentials do matter.

Patient acuity and complexity are totally unlike that which existed in the 1960s and 1970s. As a person who entered nursing as a diploma graduate in the early 1970s, I can attest to the incredible acceleration of care complexity that I have witnessed in 35 years of clinical practice, and this complexity spiral has occurred across the specialties. Working in a modern operating room, for example, is a physical and mental challenge not experienced by past practitioners. There is no true comparison possible any more.

Though some persons may view my emphasis on education and credentialing as "elitist," I would point out that the American public does not. Patients want competent care from educated professionals who can skillfully navigate the phenomenally challenging landscape of modern clinical care. WOC nurses must be ready to meet that need.

Sincerely,

Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN