WCET NNG ETN Book 2020 PDF

Enterostomal Therapy Nursing
Growth & Evolution of a

Nursing Specialty Worldwide
A Festschrift for
Norma N. Gill-Thompson, ET
2020 Commemorative Edition
Commemorating the 100th Birthday of

our Founder Norma N. Gill and the
Year of the Nurse and Midwife
Edited by Paula Erwin-Toth

and Diane L. Krasner
1920-1998
Norma N. Gill-Thompson, the world’s first Enterostomal Therapist (ET), was an extraordinary person. Despite
being afflicted with a life-threatening and incapacitating illness, she found the strength to look beyond her
own situation to recognise the needs of others in similar circumstances. Norma N. Gill was a leader with vision,
creativity, and innovation. Along with her surgeon, Dr RB. Turnbull, Jr, and other pioneers, they forged a path of
education for people who required ostomy surgery, their families and health care professionals throughout the
world.
As the founder and first president of the World Council of Enterostomal Therapists® (WCET®), she is internationally
acknowledged as the first Enterostomal Therapist in the world. From teaching throughout the world to creating
the ET School at the Cleveland Clinic in Cleveland Ohio, USA, Norma realised the importance that proper
knowledge as well as having the right equipment would have for persons with a stoma. Starting in 1978 with the
first Congress in Milan, the WCET® Biennial Congress has provided a forum for the world’s ostomy, wound and
continence care nurses, industry partners and others interested in this tri-specialty to share the evidence, new
knowledge and learn together. Norma greatly believed in the dissemination of knowledge, evidence, and practice
innovations to improve care.
Norma served as the first editor of the WCET® Journal so 2020 is a doubly celebratory year for WCET® as the
journal is celebrating its 40 th Anniversary. Over time, the WCET® Journal has grown not just in size from 12 to
48 pages but in depth and breath of scope to include wound, incontinence/continence and ostomy content.
Through the strategic sustaining partnership with Calmoseptine®, Coloplast, Dansac, Hollister and Welland
Medical, the WCET® Journal remains a free member benefit. Consistent with Norma’s outreach around the globe,
the WCET® Journal is the official journal of both the WCET® and the International Interprofessional Wound Care
Group (IIWCG). Each WCET® Journal issue is published in five languages - English, Chinese, French, Portuguese and
Spanish. Congratulations and thank you to our publisher Greg Paull and his staff at Cambridge Media in Perth,
Australia as well as the persons who have diligently served as WCET® Editors - Norma N. Gill Thompson, Patricia
Blackley, Mary Jo Kroeber, Donna Bull, Susan MC Russell, Julia Thompson, Elizabeth A. Ayello, Karen Zulkowski and
Jennifer A Prentice.
WCET Journal WCET 杂志 Journal du WCET Revista do WCET

®
Revista del WCET
® ® ® ®
years Volume 40 Number 3 September 2020 years 2020年6月第40卷，第2期 years Volume 40 Numéro 2 Juin 2020 years Volume 40 Número 2 Junho 2020 years Volumen 40 Número 2 Junio de 2020
Official Journal of The World Council of Enterostomal Therapists® 世界造口治疗师委员会和 Journal officiel du Conseil mondial des stomathérapeutes (World Council of Official Journal of The World Council of Enterostomal Therapists® Revista oficial del The World Council of Enterostomal Therapists®
and International Inter-professional Wound Care Group 国际跨专业伤口护理组官方杂志 Enterostomal Therapists®) et du Groupe international interprofessionnel pour and International Inter-professional Wound Care Group y del Grupo Internacional Interprofesional de Cuidados de Heridas
le soin des plaies (International Inter-professional Wound Care Group)
Éditorial
Editorial 非同寻常的COVID-19 COVID-19 : Relativité aux soins des plaies, de la peau et des Edição Especial COVID-19 COVID-19 especial
Nurses and nursing - endurance and initiative stomies
News and views 编者按 Éditorial de collaboration spéciale Editorial Editorial

Around the WCET® world COVID-19：与伤口皮肤和造口术护理的相关性 Lésions de pression liées aux dispositifs médicaux chez les COVID-19: Relatividade aos cuidados com feridas COVID-19: relación con respecto a la piel de las heridas y el
professionnels de la santé en période de pandémie da pele e estomias cuidado de las ostomías
Original article 特邀社论
Preventing facial pressure injury for healthcare providers 疫情期间专业医护人员的医疗器械相关压力性损伤 Actualités et opinions Editorial convidado Editorial especial
adhering to COVID-19 personal protective equipment Dans le monde du WCET® Lesão por pressão relacionada a dispositivo médico nos Lesiones por presión relacionadas con dispositivos de uso
requirements 新闻与观点 profissionais de saúde em época de pandemia médico en profesionales de la salud en tiempos de pandemia
WCET®的相关内容 Papier blanc
Case study Manifestations cutanées avec la COVID-19 : il est possible Notícias e Opiniões Noticias y opiniones
白皮书 Por volta do mundo WCET® El mundo del WCET®
Successful treatment of an ileal conduit fistula with negative que la peau et les orteils violacés que vous voyez ne soient
COVID-19的皮肤表现：肉眼可见的紫色皮肤和脚趾可能不
pressure: report of a case pas des lésions de pression des tissus profonds
是深部组织压力性损伤 Informativo Informe oficial
Original article 综述 Revue Manifestações cutâneas com a COVID-19: a pele e dedos Manifestaciones de la piel con COVID-19: la piel y los dedos de
Introduction of pressure injury preventive measures and 局部镇痛药和局部麻醉药用于治疗慢性下肢溃疡 Analgésiques topiques et agents anesthésiques locaux pour arroxeados que você vê podem não ser uma lesão por pressão los pies de color púrpura que ustedes ven puede no deberse a
improvement initiatives for patients undergoing prolonged 相关性疼痛：一项系统综述 la douleur associée aux ulcères chroniques de la jambe : tissular profunda lesiones por presión del tejido profundo
surgery at a government hospital in the United Arab Emirates 原著 Une revue systématique
Revisão Revisión
患者治疗教育；一种多面性医疗保健方法
Original article Article original Agentes analgésicos e anestésicos locais tópicos Agentes analgésicos tópicos y anestésicos locales
Development of an incontinence-associated dermatitis L’éducation thérapeutique du patient, une approche para dor associada às úlceras crônicas de perna: para el dolor asociado con las úlceras crónicas en
prevention bundle using an evidence-based framework soignante aux multiples enjeux uma revisão sistemática la pierna: una revisión sistemática
Original article Artigo original Artículo original

ET/WOC nursing – leadership lessons learned from the Educação terapêutica do paciente; Uma abordagem Educación terapéutica del paciente: abordaje multifacético
COVID-19 pandemic: an opinion multifacetada da saúde para la asistencia sanitaria
Un monde de professionnels experts spécialisés dans les soins infirmiers aux

为在造口、伤口或失禁护理方面有需求的人们提供专家级专业护理 personnes stomisées, porteurs de plaies ou ayant des trouble de la continence Un mundo de conocimientos de cuidados de enfermería profesional para
A world of expert professional nursing care for people with ostomy, wound or continence needs A world of expert professional nursing care for people with ostomy, wound or continence needs
personas que tienen ostomía, heridas o necesidades para incontinencia
Congratulations to the WCET® Journal on Achieving this 40 th anniversary milestone.
years
Enterostomal Therapy Nursing
Growth & Evolution of a
Nursing Specialty Worldwide
A 2020 commemorative update to the

second edition of the Festschrift for
Edited by
Paula Erwin-Toth MSN, RN, CNS
and Diane L. Krasner PhD, RN, FAAN
© Paula Erwin-Toth and Diane Krasner 2010
All rights reserved
First published 1996
Second edition 2012
Commemorative edition 2020
Library of Congress Cataloging-in-Publication Data

Enterostomal therapy nursing: growth & evolution of a nursing
specialty worldwide: a festschrift for Norma N. Gill-Thompson/edited
by Paula Erwin-Toth, Diane Krasner
p. cm.
ISBN 0-9613805-9-4
1. Enterostomy — Nursing. I. Gill-Thompson, Norma N
II. Erwin-Toth Paula, 1955- III. Krasner, Diane.
[DNLM: 1. Enterostomy — nursing — personal narratives.
2. Specialties, Nursing — personal narratives.
3. History of Nursing — personal narratives.
WY 156.5 E61 1996]
RD540.E56 19%
617.5"54 — dc20
DNLM/DLC 96-14923
for Library of Congress CIP
This commemorative edition published by
on behalf of the World Council of Enterostomal Therapists

with the kind permission of Paula Erwin-Toth and Diane Krasner.
Editors’ foreword to the
commemorative edition
Paula Erwin-Toth & Diane L. Krasner
As we celebrate the 100th anniversary of the birth of the first Enterostomal Therapist, Norma
N. Gill, it is somehow fitting that 2020 has proven to be a year of enormous threats to health.
Throughout her life Norma faced physical, personal and professional challenges that would have
broken the spirit of a lesser mortal. The Star Trek science fiction television series had several plots
that took place on alternate timelines and demonstrated how one pivotal event or person can
alter the future. Our world, and those of Norma’s patients and students (and of course Norma’s
family), would have been drastically different without Norma’s knowledge, skills, dedication and
caring.
If the ground-breaking Cleveland Clinic team of Dr Rupert Turnbull and patient Norma N. Gill
had not existed, the outcomes for many of their patients would have been far less satisfactory.
For example, after undergoing urostomy surgery at the age of 10, Paula and her family would
have been left on their own to figure out how to manage it. Even with Norma’s help it was still
a challenge with the limited equipment available in 1965. Norma used her influence, putting
pressure on medical device companies, to improve the quality, selection and availability of
ostomy products and accessories. Norma’s drive to share her knowledge and experience led her
and Dr Turnbull to open the first School of Enterostomal Therapy. And the rest, as the saying goes,
is history.
From the very beginning, the Enterostomal Therapist role was patient-centered and
interprofessional. Having been a patient, Norma understood the importance of patient-centered
care and literally represented the concept. Many of the first ETs were either ostomy patients
themselves or family members of patients with ostomies. Dr Turnbull, and the many others
who participated in the early days of Enterostomal Therapy, all impacted the development and
evolution of the ET specialty. You will read their amazing stories in this book. Their vision of
patients having access to appropriated trained specialty nurses is their lasting legacy.
As the specialty has grown and evolved – from Enterostomal Therapist – to ET Nursing (WCET®)
– to Wound Ostomy Continence Nursing in the US (WOC Nurse) – and most recently to Nurses
Specialised in Wound, Ostomy and Continence Canada (NSWOCC) and in other countries - Stoma
Care Nurse, Tissue Viability Nurse etc to identify nurses in our specialty, the commitment to
patient-centered care and interprofessional practice remains strong.
Dear Norma, our friend, role model, mentor - we salute you, your vision and your legacy. This
commemorative edition marking the 100th anniversary of your birth recounts the beginnings,
growth and evolution into a worldwide nursing specialty, committed to the care of people with
wounds, ostomies and continence problems. It is our honour to carry on your mission and make
you proud!
3
WCET® commemorative message
Elizabeth A. Ayello (WCET® President 2018-2022)
Laurent O. Chabal (WCET® Vice President 2018-2020, WCET® President Elect 2020-2022)
To recognise the 100th year anniversary of the birth of Norma N. Gill-Thompson - founder,
first president and first journal editor - WCET® is delighted to mark this occasion with this
commemorative edition of the Festschrift. The original Festschrift was written to celebrate
Norma’s 75th birthday. WCET® deeply appreciates that co-editors Paula Erwin-Toth and Diane L.
Krasner have graciously given permission to use their book to mark this occasion.
Forest E. Witcraft famously said, “A hundred years from now it will not matter what my bank
account was, the sort of house I live in, or the kind of car I drove… but the world may be different
because I was important in the life of a child.” The world is different because of Norma. In the
foreword, you learned how Norma made a difference in the life of one child - Paula Erwin-Toth.
Rest assured, there are countless children and adults throughout the world whose lives were
enhanced by her relentless efforts to provide education so they could live a full and productive
life. Their names and stories are known to the nurses throughout the world who benefited from
the specialised education that Norma along with her interprofessional team of both patients and
professionals created through this tri-specialty of ostomy, wound and continence care. There can
be no greater tribute to a person than to know that through their efforts, that more than one
person’s life has been changed for the better. Norma made a difference!
Within these pages you can revisit the amazing history of the more than 40-year journey that
forged this specialty. By reading and rereading the stories as told by those who lived them,
today’s stoma, wound and continence care nurse may get a new understanding of change and
appreciation for decision makers that can help shape the future.
WCET® has continued to evolve. Each journal issue, as well as educational resources such as our
pocket guides, are now published in multiple languages. Other educational resources have been
developed such as the Wound Education Toolkit and the International Ostomy Guideline. Even
in this year of physical distancing, by harnessing the power of technology, WCET® can connect
electronically with its members and those alike to provide educational webinars. Through WCET®
NNG twinning projects, outreach continues to areas of the world where educational programs
in our specialty are still needed. Named in Norma’s honour, Norma N. Gill Foundation® (NNGF®)
scholarships continue to remove financial barriers that prevent nurses from attending educational
programs. With founding roots at the Milan 1978 Congress, the WCET® Biennial Congress remains
one of the oldest and most important global education events for nurses in our specialty.
We applaud all you have achieved Norma. May you continue to inspire us to do the most good.
So as 2020 commemorates the dual celebration of Norma’s birth and the 40th anniversary of the
WCET® Journal, join WCET® in our continuing efforts to improve the care of patients with stomas,
wounds or continence care needs. Let us provide expert care for patients, educate patients and
colleagues, publish our research and/or use the best available evidence as a basis for our practice
and mentor the next generation. Norma made a difference and so can you. Join us in our mission
and let us be inspired by Norma, following her vision and building together the future of our
tri-specialty.
4
Contributors to the
Second Edition
Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN

Faculty, Excelsior College, School of Nursing, Albany, New York
Senior Adviser, The John A. Hartford Institute for Geriatric Nursing
President, Ayello, Harris & Associates, Inc, Copake, New York
Clinical Editor, Advances in Skin and Wound Care
Executive Editor, World Council of Enterostomal Therapists Journal
New York, New York, USA
Paula Erwin-Toth, MSN, RN, CWOCN, CNS

CEO, PETprojects
Director Emerita, WOCN Nursing Education, Cleveland Clinic
Cleveland, Ohio, USA
Louise Forest-Lalande, RN, M.Ed. ET

WCET President 2010-2012
Montreal, Quebec, Canada
Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN

Professor and Nurse Practitioner
Department of Urology, University of Virginia
Charlottesville, Virginia, USA
Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN

Wound and Skin Care Consultant
York, Pennsylvania, USA
Sally J. Gill-Thompson, ET
Manager, Klein’s Orthopedic and Medical Equipment
Cuyahoga Falls, Ohio, USA
5
Contents
Preface to the Second Edition 8
Paula Erwin-Toth, MSN, RN, CWOCN, CNS
Diane L. Krasner, PhD, RN, CWCN, CWS, MAPCA, FAAN
Acknowledgements 9
Foreword to Second Edition 10
Into the 21th Century – The World Council of Enterostomal

Therapists (1996-2012) 12
Louise Forest-Lalande, WCET President 2010-2012
The WCET Journal in the 21st century* - “So far … so good” 16

Elizabeth A. Ayello, Executive Editor, WCET Journal (1994 till present)
History of the Journal of WOCN 25

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN
Product Innovations: An Industry Update by our Sponsors 32

Coloplast, ConvaTec, Hollister
Preface (to the First Edition) 46

Paula Erwin-Toth, MSN, RN, CETN
Diane Krasner, MS, RN, CETN
Future Trends in ET Nursing Internationally 47

Patricia Blackley, GD (HE), RN, ET, FRCNA
History of the World Council of Enterostomal Therapists Journal 55

Mary Jo Kroeber, MSc (Hlth Sc), Grad Dip Admin, BA SocSc, B App Sc (Nsg),
RN, RM, FRCNA, ET, AFCHSE
Care of the Adolescent with an Ostomy 60

Bonnie Bolinger, RN, CETN
The Evolution of the Urinary Diversion 67

Todd D. Cohen, MD
Andrew C. Novick, MD
Development of Enterostomal Therapy as an International Nursing Specialty 75

Priscilla J. d’E Stevens, SRN, ET
6
History of Ostomy Products Manufacturers 82
William Davidson
Joseph Fischer
Childhood Ostomy Surgery: A Developmental View 95

ET Nursing Education: A Global Perspective 103

Nancy A. Faller, RN, MSN, CETN
Current Trends in Ostomy Surgery 110

Victor Fazio, MD, FRACS
Reminiscence 117
Leonard Fenton
History of the Journal of WOCN 119

Mikel Gray, PhD, CUNP, CCCN, FAAN
ET Nursing and Continence Care: History and Perspective 124

Katherine F. Jeter, EdD, ET
ET Nursing and Wound Care: Embracing the Challenge 132

Manufacturers’ Role in the Development of the W.C.E.T. 138

Alfred R. Priest
The Student Experience: Living the Legacy 140

Bonnie Sue Rolstad, RN, BA, CETN
Enterocutaneous Fistulas 146

Marilyn Spencer, RN, BSPA, CETN
Fran Anderson-Ciambor, RN, ET
Living with a Legend 151

Sally J. Thompson, ET
Enterostomal Therapy: the Personification of a Philosophy of Care 161

Robert W. Turnbull, BA, MS
Gwen B. Turnbull, RN, BS, CETN
Norma Keeps Going and Going and Going … 169

Cheryl Van Horn, BSMT, CETN
Pioneer Years 171

Frank L. Weakley, M.D.
7
Preface to the Second Edition
M
uch has changed in the 16 years since the first edition of this book
was published to honor our friend and mentor Norma Gill-Thompson,
ET. Norma’s passing in 1998 made working on this second edition
especially poignant. Improvements in adhesive and pouching technology coupled
with expanded professional and community resources available for people with
ostomies are impressive.
The need to improve access to these resources by people with ostomies continues
to be a global challenge. For that reason, we have decided to have the proceeds
from this second edition of this book go to the WCET Norma N Gill Foundation
(NNGF). WCET’s NNGF provides scholarships which support in part the development
of specialty programs in emerging countries and provide financial assistance for
individual nurses to obtain specialized training in wound, ostomy and continence
care. We believe this is a perfect match of goals — to honor our dear Norma while
continuing her legacy of educating nurses worldwide so all patients can be cared
for by nurses who have been appropriately trained in our specialty practice.
Norma’s spirit lives on in the collective efforts of clinicians, industry and support
organizations to improve the lives of people with ostomies around the world. We
are pleased to donate our book, this Festschrift to that cause and thank you for
your support of the important work of the WCET to keep Norma’s vision alive.
Paula Erwin-Toth, Deerfield, Ohio, USA
Diane L. Krasner, York, Pennsylvania, USA
8
Acknowledgements
O
ur deepest appreciation to Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON,
ETN, MAPWCA, FAAN, Executive Editor of the WCET Journal for making
this second edition a reality. Dr. Ayello’s dedication to wound, ostomy and
continence/ET nursing, research, and nursing education keeps Norma Gill’s legacy
alive around the world.
We also thank the leaders of Coloplast, ConvaTec and Hollister for their generous
financial support which made this second edition possible.
A special thank you to Cambridge Publishing for their super design and consultation
services in the publishing of this edition of the Festschrift.
Sincerely,
Paula and Diane
9
Foreword to Second Edition
R
eflecting on the year 1995 when Mom
received a call from Diane Krasner,
Diane and Paula Erwin-Toth had an
epiphany that in the year that Mom would
turn 75, a Festschrift in her honor should
be born. A meeting was set up with Diane
to discuss the book and to plan its contents
during Diane’s visit to Cleveland. What a
thrill and an honor it was for Mom! In true
“Norma fashion” she quickly began assisting
to “suggest” authors for each Chapter!
While most of Mom’s visions for Enterostomal
Therapy came to fruition as made evident
in the Festschrift, there was one that never
became reality. She felt it to be extremely
Picture 1 important as ET evolved into a nursing
specialty that there be “tiers” of ET Nursing.
Those with higher nursing degrees would be administrators and serve in
supervisory capacities and diploma nurses and licensed practical nurses and those
already ETs without a nursing degree would work at the bedside with the patients.
Interestingly enough, WOCN recently announced a similar program in their Wound
Treatment Associate Education Program for wound care.
As this updated Festschrift comes to fruition and we see the immense strides that
have been made in ostomy surgeries, care and products, we need to take a look at
what “holes” still exist. As I enter into my 41st year as an Enterostomal Therapist, I
see every day the needs of the ostomy patients in the community that are not being
met. I see those ostomates who have had their stomas for many years now with age
becoming unable to continue caring for their stomas independently. I see these
same ostomates as well as new ostomy patients entering Extended Care Facilities
that have no idea how to care for a stoma. I see Home Care Nursing Agencies with
no one specialized in ostomy care, each nurse giving their own rendition to the
ostomy patient on how to care for their stoma. I see little availability of outpatient
clinics where an established ostomy patient can get help without having to be a
“patient” of the facility. And I wonder, would the “tiers” of Enterostomal Therapy
that Mom so long ago saw the need for embrace these current needs?
10
It has been a pleasure to witness another of Mom’s visions, the World Council of
Enterostomal Therapists (WCET), grow and continue to find funds through the
Norma Gill Foundation to train international nurses. Throughout her international
travels in the early years, Mom envisioned the need for a TRUE international
organization. She called the WCET “her baby” and was proud of and active in WCET
until the time of her death.
It is therefore extremely fitting that the WCET has assumed the project of updating
and republishing this Festschrift. I know she is watching from above and is not only
pleased but humbled.
Picture 2
Picture 1. Norma N Gill-Thompson with daughter Sally.

Picture 2. Enlargement of the ET symbol on Norma’s grave.
Photos courtesy of Sally J. Gill-Thompson. © WCET 2012, used with permission
11
Louise Forest-Lalande
Into the 21th Century – The

World Council of Enterostomal
Therapists (1996-2012)
Louise Forest-Lalande, WCET President 2010-2012
S
ixteen years have passed since the publication of the book Enterostomal
Therapy Nursing, Growth & Evolution of a Nursing Specialty Worldwide. This is a
Festschrift for Norma N Gill-Thompson, the founder of Enterostomal Therapy
Nursing. Things have evolved and changed over time, but the World Council
of Enterostomal Therapists (WCET) still adheres to Norma’s values and vision
of specialized ostomy, wound and continence care for all patients worldwide
including emerging countries.
The WCET membership has continued to grow with almost 1400 members from
57 countries. The membership, through their International Delegates (ID), at the
biennial General Meeting elect a Board of Directors who are charged with achieving
the WCET goals and mission. WCET board positions include the President, Vice
President, Secretary, Treasurer, Executive Editor of the Journal, Congress Liaison,
and Chairpersons of the following standing committees — Education, Norma N
Gill Foundation and Publications and Communications. The WCET board truly
represents a global community of ET nurses. Members are encouraged to join in as
active participants on these standing committees. This small group of volunteers
works diligently to achieve Norma’s goals.
In 2010, it became obvious that, in order to pursue expanding the WCET and
meet the needs of the membership, a business background was mandatory. With
the membership’s approval, a Director of Operations was hired to help with the
daily activities and responsibilities and assist with an increasing and demanding
administrative workload. It is important to understand that this organisation is led
by volunteers, most of whom still hold full-time positions in ET nursing.
One of the first objectives has been to develop a Business Plan to ensure the
continuous success of the WCET in the future. The preparation of the Business
Plan led to the development of strategic initiatives from which major goals and
objectives for the coming years were extracted. The strategic initiatives developed
are the following:
1: Provide Professional Support on Clinical issues to support ET Nursing
2: Develop a Stronger Business Approach for WCET
12
Into the 21th Century – The World Council of Enterostomal Therapists (1996-2012)
3: Strengthen Existing Services

4: Create Systems to Ensure Better Volunteer Management
5: Focus on Membership Development and Long-Term Sustained Growth
ET NURSING EDUCATION
Over the years, Enterostomal Therapy Nursing practice has evolved to include wound
and continence care. Guidelines for developing a program have been updated and
a checklist is now available for those wanting to develop a new program in their
country. Until 2004, nurses were required to complete an Enterostomal Therapy
Nursing Education Program (ETNEP) to become an ET nurse. However, in some
countries and for various reasons, it was sometimes difficult or impossible for
nurses to complete a full program. Therefore, in 2004, changes were made making
it possible to complete part of the training in Stoma care only, Stoma and Wound
care, or Stoma and Continence care. This format is referred to as the “Recognised
Education Program (REP)”. Nurses completing a REP do not received a certificate
of ET nursing, but, according to the program they have completed, receive a
Stoma Care, Stoma and Wound Care or Stoma and Continence Care certificate. The
WCET Education Committee has adjusted the guidelines and checklists content to
accommodate the REPs. Both the ETNEPs and the REPs receive WCET recognition if
they meet the WCET standards and criteria.
Another development in the recognition process is the establishment of site
visits. Previously ETNEPs and REPs were recognized according to the written
documentation sent by the Program Director. Since 2011, a site visit is organized
for each program to ensure that the required criteria coordinates with the
documentation submitted. At the same time, in addition to the certificate of
recognition awarded by the WCET Education Committee to the Program Directors,
each student receives a personalized certificate to be included in their portfolio.
Ongoing educational activities are provided to the membership through the
WCET Biennial Congress and the WCET Journal (see the updated chapter on the
WCET Journal in the 21st century for more details about the journal). Both provide
great opportunities to health care professionals involved in stoma, wound and
continence care to share their knowledge and expertise, learn from each other
and to network. Thanks to modern technology, it is now much easier to keep
contact with colleagues all over the world. The WCET held its first joint meeting in
2010 with the Wound, Ostomy and Continence Nurses Society (WOCN), an allied
organization. This initiative has been a revelation for many and an excellent way to
raise the profile of ET Nursing around the world.
COMMUNICATION
Communication with the membership is primordial for an organization such as
the WCET. The WCET Journal is a scientific journal which publishes clinical and
13
Louise Forest-Lalande
scientific articles. The BullETin is a newsletter which provides information about ET

Nursing all around the world. Members are welcome to announce any upcoming
educational events and report on projects and activities that could be of value for
ET nurses or their patients. Both the WCET Journal and the BullETin contain other
than English language documents.
The International Delegates (ID) are key people for communication with the
members of their country. They are the link between the WCET Executive Board
and their country members that they represent. Each country elects an ID for a
period of two years. The ID can serve for an additional two years.
Since the WCET strives to be a member driven organization, a membership survey
is conducted periodically to get the opinion, comments and suggestions of the
members. The survey provides extremely valuable information to the Executive
Board and helps to direct any future initiatives.
The WCET website was revamped in 2010 to make it more user-friendly and to
facilitate the communication between the members. It is an ongoing project to
keep the website updated and dynamic. Our aim is to introduce online voting by
the end of 2012 and to provide online educational activities such as webinars.
Links are provided where allied organisations, such as the WCET UK, may share a
place on the WCET website.
NNGF
Since 1996, additional NNGF Scholarships categories were created. They are as follow:
1. ETNEP/REP Scholarship: assists nurses to attend a WCET recognised ETNEP/REP
program
2. Congress Travel Scholarship: enables nurses from emerging or developed
countries to attend the Biennial WCET Congress
3. Educational Material Scholarship: provides assistance to obtain teaching
materials for ET training
4. General Scholarship: provides assistance to educators for on-site training in
emerging countries
5. Membership Scholarship: provides registered nurses with a one year WCET
membership
TWINNING PROJECTS
As stated on the WCET website (www.wcetn.org), “The NNGF Twinning Projects
were established in 1999 to increase awareness of the differences between
developed and emerging countries. By establishing and fostering links between
Enterostomal Therapy Nurses in developed countries and registered nurses in
emerging countries, the goal of the NNGF Twinning Projects is to promote and
develop the specialty of Enterostomal Therapy Nursing. “
14
Into the 21th Century – The World Council of Enterostomal Therapists (1996-2012)
A relevant example of a successful Twinning Project is between Hong Kong and

China. In 2000, there were only two ET nurses in Hong Kong. As a direct result
of the Hong Kong-China Twinning Project, six ET Nursing programs have been
developed with additional programs soon to obtain WCET recognition. As of 2012,
there are more than 400 trained ET nurses. The commitment and dedication of
the teachers and tutors who shared their knowledge and experience deserve our
respect and gratitude. Many other Twinning Projects are ongoing.
COLLABORATION WITH OTHER ORGANISATIONS AND INDUSTRY

It is essential that the WCET works in synergy with allied organisations in order
to pursue its mission. The WCET needs to work closely with national associations
such as the European Council of Enterostomal Therapy (ECET), the Wound,
Continence, Ostomy Nurses Society (WOCN) and the Canadian Association of
Enterostomal Therapists (CAET), ostomates associations such as the International
Ostomy Association (IOA) and Friends of Ostomates Worldwide (FOW), and
regional interest groups such as the Asian Pacific Enterostomal Therapists Nurses
Association (APETNA). These organizations share the same goal of improving the
quality of life of people with stoma, wound or continence needs. The respect and
comprehension of each and every one of these entities is crucial. Industry also
shares this same goal and has given tremendous help and support to the WCET to
accomplish our mission. The challenge is therefore to nurture good relationships
and develop successful partnerships both with related organisations and industry.
NEXT STEPS: MOVING FORWARD!

Promoting the specialty of ET nursing remains a challenge, especially hindered
by the global financial crisis we are experiencing. In 2012, WCET has received an
educational grant from an industry partner to develop international ostomy best
practice guidelines.
Some ETNEPs and REPs are now available online. However, the WCET endeavors to
develop an international multilingual online program. With the advancement of
technology it should hopefully become a reality within the next few years.
Another challenge for the WCET is to develop tools to support ET nurses for
demonstrating to their employers how they can not only improve the quality of
life of patients with ostomy, wound or continence needs, but also be cost-effective
for health care systems.
An organisation such as the WCET can make a difference worldwide both for the
patients and the community of Enterostomal Therapy Nurses. This was Norma’s
vision! This is what the WCET is committed to pursue! This is what WCET has
accomplished!
15
Elizabeth A Ayello
The WCET Journal in the 21st

century* - “So far … so good”
Elizabeth A. Ayello, Executive Editor, WCET Journal (1994 till present)
I
t is my honor as the current executive editor to continue the story about the
WCET Journal from 1996 (which is the date of the publication of the original
Festschrift) till now.
THE JOURNAL PUBLISHER

While the pioneers who created the WCET Journal were interested in fostering
communication among WCET members, it was also with great foresight that these
founders insisted that the WCET Journal be an association owned journal. This is
important because WCET controls the content of what is published in the journal,
owns the copyright on the articles published, and benefits financially from any
profits realized after production and mailing costs. The WCET Journal is a stable
publication as it has had the same publisher for over twenty years. Beginning in 1991
with Volume 11, Number 4, Ink Press International became the journal’s publisher.
They changed their name to Cambridge Publishing with Volume 20, Number 3
July/September 2000 and the WCET Journal enjoys an outstanding relationship
with Greg Paull, the publisher, Sandra Carbone, Production Coordinator, Sarah
Horton, Graphic Designer, and the rest of the staff. Greg Paull is working to try
to get our journal on Medline. This is not easy to achieve, but it is a good goal
that we are aiming to accomplish. This will greatly expand non-WCET members
to capture articles published in the WCET Journal when doing literature searches
beyond CINAHL. WCET values and is grateful to Cambridge Publishing for its loyal
support of the journal.
INDUSTRY PARTNERS AND THE WCET JOURNAL

Industry partners have long played an important role in the creation and
sustainability of the journal The support of industry in helping to produce the
journal have been described in detail in the chapter by Patricia Blackley and Mary
Jo Kroeber. Industry ads make it possible for WCET members to receive the journal
without any additional cost. Industry has also sponsored two supplements since
2008 and ordered reprints of articles for posting on website links. Most recently, an
initiative, entitled journal sustaining partners has benefited both the journal and
industry members who have been loyal supporters of the WCET Journal.
16
The WCET Journal in the 21st century* - “So far … so good”
JOURNAL EDITORS
We all know that Norma N Gill, ET, was the first editor of the WCET Journal. Her
first editorial can be found in Box 1. Her words are just as inspiring now as when
she first published them in 1982.1 The original journal was 12 cream-colored,
unbound pages including the front and back covers. As written in my editorial
in 2010, “It included two short, one page articles. One was on assessing behavior
for patient teaching by an ET nurse from Australia and the other was about stoma
rehabilitation in Japan. The rest of the contents included announcements about
activities around the WCET world, a sample of a conventional ileostomy card for
patients to carry, and information about various committees and conferences.
The list of International Delegates (ID) contained the names of 28 IDs from the
following locations: Australia, Belgium, Brazil, Canada, Denmark, Egypt, France,
Finland, Holland, India, Ireland, Israel, Italy, Japan, Mexico, New Zealand, Norway,
Puerto Rico, Singapore, South Africa, Sweden, Switzerland, United Kingdom, United
States, West Germany, Yugoslavia and Zimbabwe. The application for membership
listed the ‘dues’ as ten pounds sterling or twenty dollars US, with lapsed members
having a reinstatement fee of £20 which thirty years later is basically what most
of our WCET members pay for membership excluding any additional country
associated fees.“2 You can read more details about the creation and formative
years of the WCET Journal in the original chapter by Patricia Blackley and Mary Jo
Kroeber who are both former editors of the journal, entitled “History of the World
Council of Enterostomal Therapists Journal” as published in the 1996 first edition
of the Festschrift.
Since the publication of the Festschrift in 1996, the WCET Journal has been fortunate
to have several other editors. The year 1996 began with Donna Bull continuing her
role as journal editor and ended with Susan MC Russell from Canada who assumed
the role after that year’s biennial congress.
1998 — A PIVOTAL YEAR FOR THE WCET JOURNAL

October 1998 would prove to be a month of great change for WCET. The last
issue of 1998, volume 18, number 4 October/December, announced that Julia
Thompson, RN, ET, PhD, FCN (NSW), FRCNA from Sydney Australia would be the
new editor. Not only does an editor’s role require reading and editing manuscripts
and informing readers about important issues, but it also includes putting into
context and interpreting events that have significance for the association. Imagine
taking over as editor of a major association’s journal and your first editorial is to
report and reflect on the passing of Norma N Gill-Thompson, founder of ET nursing,
first WCET President and first WCET Journal Editor. That indeed was what Dr. Julia
Thompson had to address in her first editorial.3 Julia’s compassion to help comfort a
grieving WCET association while guiding readers to continue the work are evident
17
Elizabeth A Ayello
in her words, “like all true leaders, Norma recognized the job that had to be done,
saw a way of doing it and set about empowering others to continue in her stead.
Therefore, this issue includes reports on newly established and developing stomal
therapy education programs and services in a range of different places around
the world … evidence that the enormous task Norma started is ongoing, despite
her passing.” 3 Of course there was also a recounting of Norma’s life4 (see Box 2),
a copy of the eulogy given by Paul Erwin-Toth at the funeral5 (see Box 3), and a
remembrance of Norma by Prilli Stevens6 (see Box 4). It was particularly touching
that Nancy Faller’s President’s message, was translated into 17 other languages-
Afrikaans, Chinese, Danish, Dutch, French, German, Hebrew, Irish, Italian, Japanese,
Lithuanian, Portuguese, Romanian, Spanish, Swedish, Ukrainian and Xhosa7 (see
Box 5). What better way to honor the woman who globalized ET nursing than to
demonstrate the WCET Journal’s commitment to content in languages other than
English not just in the President’s message but in the item of interest by Amer
Odobašić, MD from Bosnia and Herzegovina.8,9
Editors need manuscripts to edit! To stimulate more manuscripts, the journal had
a writer’s award. Not all manuscripts were refereed but Julia and her international
editorial board worked hard to continuously increase the quality and diversity
of articles in the WCET Journal. The number of research articles increased. Julia
Thompson was also an innovator when in volume 21 number 4, October December
2001, she introduced the very popular “Stories from the Bedside”10,11 which
continues today to be one of the most popular features in the WCET Journal.
2004 TILL NOW

By early 2004, I was asked to assume the role of Executive Editor of the WCET Journal.
I will forever be grateful to Julia Thompson for the smooth transition in editorial
leadership. 12 I remember how much time and effort Julia took to make sure when
we met in Brazil that I was well informed about the journal and its workings. As
some other editors before her have also done, she continued to contribute to the
journal by remaining on the editorial board. Besides being a peer reviewer and
author of manuscripts, most recently she has authored a series of features entitled
“Ethical ET”.
Back home in New York City, reality set in. It was very daunting to live up to Norma’s
words and the accomplishments of the preceding editors. My computer kept
changing the spelling from Australian English to American English and at times it
was frustrating. That was just one of the many challenges that editing this global
publication presents! It soon became clear that given the volume of manuscripts,
more volunteers were needed to peer review manuscript submissions and to
assist with the logistics of the review process. Karen Zulkowski has been serving
as Assistant Editor for the wound section and Judith Weller for the ostomy section.
18
Beginning in 2012, Kevin Woo and Sarah Lebovits will assume responsibility for the
ostomy section.
Since that time, I have tried to continue to build on the strength of all the previous
editors and help the journal grow in the early part of the 21st century. When
members remarked how they missed the flags on the cover of the Journal and in
the opening ceremony of the biennial congress, our editorial team put the flags on
the International Delegates page in front of each of their names.
As the specialty of ET nursing has continued to expand, and evidence-based
practice has come into the forefront, we have tried to further increase the number
of research articles. Realizing that we all could use more information about how to
interpret research findings including statistics, I sought out a nursing expert in this
field, Rona Levin PhD, who has graciously been writing our “Translating Research
Evidence for WCET Practice”. Drs Vera Lucia Santos, Deborah Rastinehad, and now
Karen Zulkowski have all coordinated the reporting of abstracts from the WCET
biennial congress in the journal.
We have introduced other new features including “Ask a WCET Nurse” coordinated
by the two Barbaras, Barbara Delmore and Barbara Suggs, and WCET Wound
Rounds coordinated by Daniel O’Neill, MD. Of course, we still have “Stories from
the bedside”. Eva Carlsson, RN, PhD continues to do the annual index of yearly
articles. Starting in 2012, Jo Sica will be coordinating a column that will provide
information from our WCET-UK colleagues. Other new features premiering in 2012
include “The Bottom Line”, coordinated by R. Gary Sibbald, MD, Kevin Woo, PhD,
RN and Laurie Goodman, RN, MS. Kevin Woo and Sarah Lebovitz, MS, RN are also
spearheading the new feature “WCET Ostomy Rounds”.
Staying true to the WCET commitment of publishing in languages other than English
(LOTE) every issue has had at least one article published in a language other than
English. Since WCET does not provide translations, this can only be accomplished
when authors submit their manuscript in dual languages. All our manuscripts are
peer reviewed by members of the editorial board. These volunteers represent
every continent of the world except Antarctica! Since many of our authors are new
to writing and English may be their second language, the peer review and editing
process takes a long time.
Technology has helped change the world of publishing. One of the good ways
is that authors can now submit their manuscripts online through the electronic
editorial manager systems. The not so good news is that for many publications,
print journals are too costly and are being replaced by electronic online versions
of journals. We know from the surveys of WCET members that the WCET is highly
valued as a membership benefit and that you still want to continue to receive
a print copy of the journal. The WCET Board of Directors has heard you and the
19
Elizabeth A Ayello
print journal continues to be mailed to all current members who are financial.
Others want electronic access to the journal, and to accommodate those needs,
back issues that are electronically formatted beginning with volume 22, number
4 October/December 2002 can be found in the library under the members only
section of the WCET website (www.wcetn.org).
The future looks bright for the WCET Journal. Thanks to the vision of our WCET
leaders, the journal celebrated its 30th anniversary in 2010. As I wrote in that
issue’s editorial “I cannot imagine the courage and work that the board and journal
staff had to have to forge this journal.” 13 “It is not easy as volunteers to make the
journal a reality.” 13 “When I think back to the origins of the journal, I wonder how
they did it? No computers, just a typewriter, no fax, no email. It must have been
difficult. Most importantly I would like to pay tribute to all the past editors of the
WCET who besides Norma Gill, include Patricia Blackley, Mary Jo Kroeber, Donna
Bull, Susan Russell, and Julia Thompson.”13
“In closing, I wonder what those pioneers of the journal would think about the
journal now? I hope we have been good stewards of their vision. As I look forward,
(most editors are future focused), I wonder what the journal will look like thirty
years from now? Will it still be a print journal, or will it be in some format that
technology has not even invented yet? I hope I’ll be watching from wherever I am
living in my retirement years eagerly awaiting the next edition of the WCET Journal.
Congratulations to us and here’s to the next thirty.“13 Rest assured dear Norma, we
will listen to our members and continue to share our experiences in this wonderful
specialty and journal that you created.
* Parts of this chapter are based on an editorial from the 30th anniversary editorial.
Permission is granted for its use while WCET Journal retains copyright on that material.
REFERENCES
1 Gill, NN. Editorial. WCET Journal 1982; 1(1):2.
2 Ayello, EA. Thirty. WCET Journal 2010; 30(4):6-7.
3 Thompson, J. Continuing their work. WCET Journal 1999; 19(1):6.
4 Vale Norma N Gill-Thompson 26.6.1920-25.10.1998. WCET Journal 1999; 19(1):7.
5 Erwin-Toth, P. Eulogy delivered at Norma’s Funeral - 29 October 1998. WCET Journal 1999;
19(1):9.
6 Stevens, P. In memory of Norma N Gill-Thompson. WCET Journal 1999; 19(1):9.
7 Faller, N. President’s message- Letter of farewell to Norma N Gill; 20 June 1920-25
October 1998. Requiescat in pace! Rest in peace! WCET Journal 1999; 19(1):2-4.
8 Odobašić, A. Item of Interest- Početak enterostomalne terapije u Bosnie I Hercegovini.
WCET Journal 1999; 19(1):35.
20
9 Odobašić, A. The beginnings of Enterostomal therapy in Bosnia and Herzegovina. WCET

Journal 1999; 19(1):36.
10 Rudoni C, Davenport. Story from the bedside: Neosphincter reconstruction for
imperforate anus: a chance to achieve continence. WCET Journal 2001; 21(4):29-30.
11 Blackley, P. Story from the bedside: independence the key to life. WCET Journal 2001;
21(4):31-34.
12 Thompson, J. Editorial. WCET Journal 2004; 24(2):6.
13 Ayello, EA. Thirty. WCET Journal 2010; 30(4):6-7.
Box 1- First WCET Journal Editorial
Editorial
Norma N Gill, C.E.T.
It is rather scary to suddenly be the Editor of a Journal when this isn’t something
that you have done before. My reason for accepting this position was two-fold.
It is a challenge. The other part is more serious AND important. It is to try to
prod and push all of you to help make it your “mouthpiece” to exchange and
gain information.
Each of you can be a reporter in his own right. Feel free to write an article, an
idea, a problem and solution, or even a “Letter to the Editor” saying what you
like and dislike about the Journal. Also, ask the other medical personnel you
know to submit an article of interest.
With the help of Evonne Fowler, Chairman of my Committee, and her committee
from different countries, Nortrud Loy and the officers of the organization, we
are going to make the W.C.E.T. Journal the best in content so that when the
next editor is appointed, he or she will know what you want in your journal.
©WCET 1982, reprinted with permission
21
Elizabeth A Ayello
Box 2 — The WCET announcement of the passing of Norma N Gill-Thompson
Vale Norma N Gill-Thompson 26.6.1920 — 25.10.1998

WCET members worldwide will be saddened to learn that Norma Gill-
Thompson passed away on Sunday, 25 October 1998 at the Cleveland Clinic
hospital, following a short illness.
Norma was born on 26 June 1920 in Akron Ohio, the only child of Richard
Nottingham and Esther Mullennax Day. In 1958 she embarked on a career path
that would transform her own life, as well as those of countless others. Together
with Dr. Rupert B. Turnbull at the Cleveland Clinic, Ohio, she implemented the
specialty which was to come known throughout the world as Enterostomal
therapy.
Norma dedicated her life to improving the care and quality of life of people, like
herself, who had undergone ostomy surgery. Other health-care professionals
and patients were quick to recognize the valuable contribution she was making
to the physical and psychological rehabilitation of people with ostomies. In
1961 the world’s first school of Enterostomal therapy opened, with Norma as
its director. Nurses and physicians from across the globe sought specialized
training from Norma, and gained from her amazing expertise, as well as her
warmth, generosity and insight.
As her reputation soared, Norma’s unwavering goal remained that of
broadening the support, resources and care available to people undergoing
ostomy surgery worldwide. She was instrumental in the formation of many
community and professional organizations, including the United Ostomy
Association, The Wound, Ostomy and Continence Nurses Society and the
World Council of Enterostomal Therapists.
Norma was the recipient of numerous awards, and was much sought after as
a speaker on a local, regional, national and international basis. Even after her
retirement, she continued to be a valued faculty member of the RB Turnbull
Jr School of Enterostomal Therapy at the Cleveland Clinic, she generously
continued to share her expertise with staff and students until as recently as
August of this year. She was also founder and owner of the Worldwide Home
Health Centre in Akron, Ohio.
Norma was preceded in death by her first husband Edward ‘Ted’ Gill in 1974,
and is survived by husband Herb Thompson, son David Gill and his wife
Barbara, two daughters — Sally Thompson and Marilyn Gill, three stepsons —
Herb, Lynn and Hank Thompson — and seven grandchildren.
22
Box 3 — Eulogy from Norma’s Funeral
Eulogy delivered at Norma’s Funeral — 29 October 1998
Paula Erwin-Toth, RN, ET, United States of America
It is an honour to have the opportunity to say a few words on behalf of Norma’s

‘other’ family — her friends, colleagues and patients, especially the paediatric
patients, whom Norma always referred to as her ‘kids’. At the age of 10, I
proudly and gratefully became one of those ‘kids’ and, somehow, it has always
been a comfort to remain so, even after I turned 40.
Norma shared enduring bonds of love and respect with thousands around the
world — her work has touched millions of lives and will touch millions more.
Innumerable adjectives — and, by Norma’s own admission, a few expletives
— have been used to describe her. She once told me that she should have her
name changed legally to ‘That damn Norma’. Then she roared with laughter
and added, “Ain’t I a stinker!” Everyone in this room has a Norma story to share.
She inspired us, encouraged us, challenged us and sometimes even nagged
us; she never stopped caring and never stopped learning — her thirst for
knowledge was unquenchable. She never failed to listen and offer advice,
vision, direction and support.
My heart aches for her family, who, in their personal grief and pain, have
found the strength to extend their love and understanding to all who loved
Norma. This type of public grief and mourning is usually reserved for royalty,
celebrities and heads of state. In our world, the world Norma helped create,
she was all of these.
I felt privileged to be involved in Norma’s care during her final illness. It was
a reaffirmation of my own faith and my dedication to Enterostomal therapy
as both a vocation and avocation. Most importantly, it was a treasured
opportunity to say goodbye to a woman who was like a second mother to me.
During the past few weeks, as her condition deteriorated, I said to myself and
others, “I cannot imagine a world without Norma.”
As I grieve, reflect and look upon the loving faces of her family and friends, I
have come to the realization that the fire that was in Norma may have died but
the light that is Norma Gill-Thompson can never be extinguished — not in this
world or in the next.
23
Elizabeth A Ayello
Box 4 — Memorial message from Priscilla J d’E Stevens
In memory of Norma N Gill-Thompson

Priscilla J d’E Stevens, RN, ET, South Africa
The stomal therapy and ostomy world waited anxiously for news of our
beloved and dynamic founder and leaders as she struggled on in yet another
battle against illness and surgery earlier this year.
Alas, her indomitable spirit eventually succumbed to the inevitable and she
slipped away peacefully on 25 October. It is perhaps fitting that her final
journey ended where in many ways it had all begun, back in Cleveland Clinic
in Ohio.
Norma was an amazing human being — a person who, following her own
experience of inflammatory bowel disease and having had a grandmother
with a colostomy, discovered in herself an evangelical zeal, a wish to dedicate
her life to others. Those ‘others’ were all the people around the world who have
required and undergone ostomy surgery, and Norma’s goal was to improve
knowledge and rehabilitative services for all of them.
On a personal note, I consider myself so fortunate to have encountered Norma
early in my nursing career, when she travelled across the Atlantic to address an
audience of British nurses at the Royal College of Nursing back in 1964. This in
itself was an awe-inspiring task FOR THE AVERAGE HUMAN BEING, BUT Norma
took it in her stride. And the rest, as they say, is history. Suffice for me to say
that the legacy of her influence on the whole spectrum of stomal surgery and
rehabilitation is such as to be unsurpassed in this century.
©1999 WCET, reprinted with permission
Box 5 — President’s message from WCET Journal addressing the passing of Norma N Gill
President’s message- Letter of farewell to Norma N Gill-Thompson:

20 June 1920-25 October 1998. Requiescat in pace! Rest in peace!
Nancy Faller, RN, ET, United States of America
This very short ‘Letter to Norma” was written while I was in the funeral parlour.
It has been translated into multiple languages as a homage to that great lady
and pioneer of Enterostomal therapy around the world.
Dear Norma,
I am here today to say goodbye on behalf of all your pupils … from Austria to
Zimbabwe … with kilts or kimonos … in hospitals or homes … Aliza to Zoe.
You are gone but not forgotten. We thank you for sharing the vision which
unifies us today. We love you. We miss you. Go in peace. Walk with God.
Nancy
©1999 WCET, reprinted with permission
24
History of the Journal of WOCN

Mikel Gray, PhD, FNP, PHP, CUNP, CCCN, FAANP, FAAN
T
he history of the Journal of Wound, Ostomy and Continence Nursing closely
reflects the growth and development of enterostomal therapy, and the
WOCN Society. In her Notes on Nursing1, Florence Nightingale began the
search for the knowledge and evidence base that support the practice of nursing,
and admonished nurses to write down their observations lest they be lost in
the daily struggle to provide care. Her admonition remains true today, but it has
evolved far beyond personal observations into a rich literature of peer reviewed
journals, textbooks and an explosion of online resources that comprise the written
record of nursing science.
From its inception, Norma Gill-Thompson and her colleagues realized the need
for a journal reporting the collected experience of enterostomal therapy. The
first issue of this ongoing document was titled the ET Journal. It was published
in the summer of 1974 under the direction of Editor Kathleen Burns, RN, ET. The
ET Journal began as a quarterly newsletter published for members of the North
American Association of Enterostomal Therapy and it evolved into a mixture of
clinical and professional practice articles that served as the official publication
of the International Association of Enterostomal Therapy (IAET). Kathleen Burns’
first editorial outlined the mission of this new publication.2 She stated that the
Journal should provide a resource for education, a forum for the evolving role
of the enterostomal therapist, a medium for the announcement of professional
association activities, and a publication defining enterostomal therapy to related
health care professionals. She characterized the ET Journal as a “source of current
information on the total care and rehabilitation of persons with fecal or urinary
ostomies or other situations of uncontrolled drainage (page 1).” This visionary
statement is remarkably consistent with the Journal’s current mission to provide
the source for full scope WOC nursing practice, including the care of patients with
ostomies, and uncontrolled drainage from chronic wounds, tubes, and urinary and
fecal incontinence.
The first issues of the ET Journal primarily reproduced articles from other professional
publications. Soon, however, reprints were replaced by original articles authored
by enterostomal therapists and ET nurses. Although largely unacknowledged at
the time, this change represented an important transition as ETs began to generate
the knowledge base that comprises wound, ostomy and continence nursing. The
25
Mikel Gray
clinical practices advocated by these early authors were based largely on clinical
experience, case studies, and intuitive observation. Nonetheless, their experiences
and insights remain a rich part of our current body of knowledge, and many of
their insights have been supported by objective research.
Over the ensuing years, the Journal lost the presentation of a “newsletter” and
gained the appearance, as well as the infrastructure, of a peer reviewed professional
publication. In 1982, the renamed Journal of Enterostomal Therapy contracted
with its first professional publishing company, C.V. Mosby. During this important
period of growth, the Journal was edited by Frances J. Anderson-Ciambor, RN, ET,
followed by Victor Alterescu, RN, MBA, MPH, ET, Patricia Kynes, RN, BSN, ET and
Joan Halperin-Landry, RN, MS, CETN. Each of these Editors brought her or his
own unique perspective and skills to the Journal, while sharing certain essential
characteristics including a dedication to quality. All of the Journal’s captains have
acted as developmental editors, assisting novice authors to publish what was often
their first peer reviewed article or first research report.3,4 This tradition of the editor
as a mentor to novice authors continues with the Journal today, which publishes
cutting edge, original research reports as well as systematic and comprehensive
review articles summarizing best evidence for wound, ostomy and continence
nursing practice.
Like the Journal, the IAET grew and gained in sophistication during this period. In
his final Editorial in 1984, Victor Alterescu reflected on the evolution of the field of
enterostomal therapy and its professional association.5 His editorial captured not
only the “state of the association”, it demonstrated the group’s growing identity as
creators of change rather than simply reacting to changes imposed by others. This
growth in the vision of the association and its journal also can be seen in a 1985
editorial by Patricia Kynes6 who presented a solid plan for ET nurses to respond
to the latest trend in health care financing (the diagnosis related group) using
resources written and distributed by the IAET.
In 1991, the title Journal of Enterostomal Therapy was modified to the Journal of ET
Nursing. In this first issue with a redesigned cover and a new name, Journal Editor
Dot Smith reflected on the profound changes that had occurred in the field of
enterostomal therapy nursing and in the Journal.7 She noted several controversial
issues in particular, including the development of an accreditation process for
ET Nurse Education Programs, the introduction of a certification process for
ET nurses, monitoring of national leadership’s relationships with industry, the
addition of skin and incontinence care to the professional practice scope of the ET
nurse, and the possibility of a name change for the organization. As an ET nurse
with a distinguished history as a member of the IAET, Dot stated that many of
her colleagues could recall “personal memories” as well as “battle scars” from each
26
of these “painful dilemmas” (page 79). Dot went on to comment on the change
in name from the Journal of Enterostomal Nursing to the Journal of ET Nursing.7
She wrote that the change in the Journal’s name reflected the evolution of this
specialty practice in nursing. She observed that the Journal was a symbol of ET
nursing. She defined the Journal as representing the scope and depth of ET nursing
practice, both to its practitioners and to the physicians, health care administrators,
allied health care professionals and basic and applied scientists who worked in
collaboration with its constituents. She accurately predicted that change in the
Journal was only one of many changes ET nurses would face in the coming years.
However, she also observed that these changes were not to be feared or despised.
Instead, Dot noted that “if we stop growing, stop learning, stop taking risks, we will
fold” (page 79).
In 1992, the Journal of ET Nursing published a guest editorial by Margaret
Heitkemper, RN, PhD, Professor of Physiologic Nursing at the University of
Washington in Seattle.8 In this historic document, Heitkemper noted that research
had been identified as one of the three priority areas for the IAET, and that ET
nurses who were not directly involved in ETNEPs were less likely to be involved
in clinical investigations, either as primary investigator or data collector. She
noted that over the past 5 years (1986-1991), the IAET had increased its efforts
to support research activities, by finding specific studies, through presentations
at the national conference, and through the inclusion of research production and
utilization in ETNEPs.
Heitkemper’s guest editorial is significant because it reflects a significant step
in the evolution of wound ostomy and continence nursing, and the Journal. The
addition of original research reports to the Journal’s contents is an essential
component of the growth of our specialty practice. Less than 20 years prior, the
first issue of the Journal contained a single clinically based article for ETs, reprinted
from a medical journal. In contrast, the September/October 1992 issue of the
Journal contained articles on a research based risk assessment tool for a pressure
ulcer prevention program9 and an original research report of a clinical trial of the
Braden Scale on an acute care hospital ward.10 Although the Journal still comprised
primarily integrative review articles, case studies, or articles summarizing clinical
experience, the crucial element of original research had grown from an idea to a
regular feature within the Journal.
By 1993, Dot Smith’s foreshadowing of a possible name change for the IAET had
become a reality, and the IAET became the Wound, Ostomy and Continence
Nurses’ Society.11 Volume 20, issue 3 of the Journal celebrated the pioneers of ET
nursing, and provided a “Hall of Fame” of professional significant to the growth and
development of enterostomal therapy and ET nursing, including past presidents of
27
Mikel Gray
the organizations and past and current editors of the Journal. In a special feature
titled “Moment in Time”12 she compared stoma care in the 1950s to ostomy care in
the 1990s. She further reminded readers of the development of the WOCN, from
its inception as a 33 member organization called the North American Association
of Enterostomal Therapy to the IAET, to the WOCN Society. Her article focused on
one of the principal pioneers of ET and ET nursing, Norma Gill-Thompson. Dot
observed that after 43 years of living with the impact of an ostomy, Norma had
helped to found the WOCN and the World Council of Enterostomal Therapists, had
founded the first ET education program, and continued to teach the foundations
of enterostomal therapy, having recently completed a tour of China.
Editor Dot Smith also informed readers that the Journal would be unveiling a new
title and design, which would be announced at the organization’s 25th National
Conference held in San Antonio, Texas, and in 1994 our current title, the Journal
of Wound, Ostomy and Continence Nursing, became official. This change in title
was accompanied by a change in editors, and I began my tenure as editor of this
remarkable Journal.
The Journal of Wound, Ostomy and Continence Nursing (JWOCN) continues to serve
as a symbol for ET nursing, as well as the resource for wound care, ostomy and
incontinence specialty track nurses. Published six times annually, the Journal is
divided into three sections: wound care, ostomy care, and continence care. Each
section is overseen by a Section Editor with particular clinical expertise in that
aspect of WOC nursing practice. The Journal also contains a variety of regular
features. Clinical Challenges provides novice and experienced authors a chance
to illustrate critical thinking skills and share clinical experience and expertise in
areas where clinical evidence is sparse or undeveloped. Research Spotlight reviews
a variety of topics essential when designing, completing and reporting original
research. Though designed for the clinical practicing WOC nurse, this feature is
increasingly used by graduate nursing faculty and students. The Wound, Ostomy
and Continence Nursing Certification Board now provides a regular feature, Getting
Ready for Certification, that provides practice questions and tips on preparing for
initial or renewal of certification in the areas of wound, ostomy, continence and
foot and nail care.
The Journal of Wound, Ostomy and Continence Nursing continues to reflect the
rapid growth in the field of ET/WOC nursing. It is the official publication for peer
reviewed articles for the WOCN Society® and the premiere publication for a global
community of authors and clinicians who provide care for wounds, ostomies,
continence and foot and nail problems. The Journal remains the primary source
for the cutting edge knowledge and evidence that defines our practice in the early
21st century. The Journal is an ongoing monument to the remarkable vision and
28
perseverance of the pioneers of ET nursing including Norma Gill-Thompson, as

well as the newest practitioners of its skills. Dot Smith was absolutely correct when
she once described the Journal as a symbol.7 It is an ongoing record of the history,
current trends and future growth of our practice. It is the living record of the laws,
hypotheses, theories, and innovations that underpin our clinical practice, and the
opinions and insights that describe our history and predict our future.
In 2000 I stepped down from my first tour of duty as the Journal’s editor and
Katherine Moore, PhD, RN, CCCN became the Journal’s Editor-in-Chief. Dr. Moore’s
appointment set a precedent as the first editor of the Journal living outside the
United States. Dr. Moore also served as Professor and Associate Dean for Graduate
Studies with the Nursing Faculty with the University of Alberta. Dr. Moore’s
tenure at the Journal was marked by multiple accomplishments such as leading
the editorial board through its move to Lippincott-Williams & Wilkins Publishers.
This move was significant for the Journal because it gave us access to Lippincott’s
Nursing Center, the world’s largest repository for online continuing education
materials. Dr. Moore’s crowning achievement was acquisition of an Impact Factor
for the Journal, placing JWOCN among the top nursing journals in the world.
In 2006 I again assumed responsibilities as Editor-in-Chief of the Journal, along
with a growing Editorial Board that includes Dorothy Doughty, the Journal’s
first Deputy Editor, and stellar group of Section Editors, and a global cohort of
Consulting Editors who are focused on maintaining the highest editorial and
scholarly standards for all published materials, coupled with the kind of mentoring
and developmental editing characteristics of the Journal since its inception. This
ongoing commitment to the Journal as a repository for clinical evidence and
research-based knowledge pertinent to ET/ wound, ostomy and continence nursing
is supported not only by the increasing proportion of articles published by authors
from across the globe, it is also reflected in the Journal’s formal affiliation with the
Canadian Association for Enterostomal Therapy (CAET). Through this relationship,
the Journal is now an affiliate publication of the CAET. Kathryn Kozell is the first
feature editor representing the CAET, and every member of the Association now
receives the Journal as a member benefit. We look forward to expanding this type
of relationship to select professional associations who share this long-standing
commitment to a peer-reviewed journal dedicated to the care of patients with
wounds, ostomies and continence disorders.
Comparing the 21st century Journal of Wound, Ostomy and Continence Nursing to
the publication I first interacted with as author and editorial board member under
Dot Smith’s tenure reveals the massive progress and changes that characterize
professional publications, the role of professional associations such as the WOCN
Society®, and nursing practice in the field of enterostomal therapy in general. While
29
Mikel Gray
the historic Journal consisted of reprints from medical journals, case studies and
anecdotal observations, the current Journal primarily consists of original reports
of research designed for and by ET/WOC nurses. Similarly, while the historic journal
was mostly limited to authors primarily based in the North America, the current
Journal reaches a global audience, and its author pool includes a world-wide
group of ET nurses, along with a growing cohort of physicians, surgeons and basic
researchers seeking to publish in the Journal. While the historic Journal was limited
to a printed document that was indexed in written guides such as Index Medicus
and the Cumulative Index of Nursing and Allied Health Literature, the current
Journal exists as both a printed and electronic document indexed in the largest
electronic databases for nursing journals available, such as MEDLINE and CINAHL.
In addition to its online presence, Journal content can also be accessed via its
web page (http://journals.lww.com/jwocnonline/pages/default.aspx). Under the
leadership of our first Web Page Section Editor, Lee Ann Krapfl, the Journal’s web
page is more than an electronic version of the table of contents and pdf versions
of print articles. Instead, it combines these features with a great deal of unique
content including supplemental digital content designed to augment materials
appearing in the printed journal, editorial content from our Web Page Editor or
guest editors, an image of the month, quick polls, and a blog called Getting the
SKINny. The online web page is also unique because it provides a central repository
that enables us to publish articles as electronic documents, prior to their inclusion
in the printed Journal. As of 2012 the Journal is also available via a third cutting
edge electronic format, as an application for use with the iPad tablet computer.
This unique version of the Journal will combine shared editorial content with even
more unique materials including short educational or demonstration videos and
links to other pertinent resources.
From its historical role as a printed document combining clinical and professional
practice issues if interest to ET nurses, to its current role as a multimedia resource
for the latest evidence-based knowledge for wound, ostomy and continence care,
the Journal remains the most significant and constant record of our historical
record, our current wisdom, and the evolving knowledge that will underpin our
practice as we progress into the 21st century.
REFERENCES
1. Nightingale F: Notes on Nursing. Philadelphia: Lippincott, 1992.
2. Burns K: Quarterly takes new name, editor. IET Journal 1974; 1(1):1.
3. Alterescu V: On writing. Journal of Enterostomal Therapy 1983; 9(4):121-2.
4. Halpern-Landry J: Editorial perspectives. Journal of Enterostomal Therapy 1988; 14(1):3.
5. Alterescu V: Diablerie. Journal of Enterostomal Therapy 1984; 10(6):207-8.
30
6. Kynes P: On surviving diagnosis related groups. Journal of Enterostomal Therapy 1985;

11(1):3-4.
7. Smith D: Toward the future of ET nursing. Journal of ET Nursing 1991; 18(3):79-80.
8. Heitkemper M: Research and the ET nurse. Journal of ET Nursing 1992; 19(3):82-3.
9. Fournier L, Kemp M, Farley K, McMyn R, Paulford N: A research-0based risk assessment
tool as the cornerstone of a pressure ulcer prevention program. Journal of ET Nursing
1992; 19(5):155-59.
10. Salvadalena GD, Snyder ML, Brogdon KE: Clinical trial of the Braden Scale on an acute
medical unit. Journal of ET Nursing 1992; 19(5):160-65.
11. Smith D: A silver celebration. Journal of ET Nursing 1993; 20(3):91.
12. Smith D: A moment in time. Journal of ET Nursing 1993; 20(3):101.
31
Coloplast, ConvaTec and Hollister
Product Innovations:
An Industry Update
by our Sponsors
COLOPLAST
Working Together on the Best Solutions
SenSura® Mio, Coloplast’s latest ostomy pouch with an elastic adhesive is now
making life easier for thousands of people. The pouch would never have been a
reality without the passionate collaboration between users, skilled nurses and
other professionals within the field. Together we believe we can do even better!
There are 1.5 million people with a stoma in the West alone. Each of them has
their own story. We listen carefully to improve solutions, because people with
stomas need to feel at ease in their everyday lives, no matter where they are or
what they’re doing.
No Body is the Same
SenSura® Mio is our newest colostomy appliance. It features an innovative, new,
elastic adhesive that is formulated to provide enhanced fit to the body. Because
no two people are the same, SenSura® Mio is pliable to individual body contours
and maintains a secure fit with every movement. Able to withstand prolonged
contact with feces and urine, our products are extremely secure. Because they are
in constant contact with the skin, our ostomy pouches use skin-friendly adhesives
that create a perfect seal, but are still easy to remove without causing pain or
irritation to the skin. And we tailor our pouches to the body’s anatomy, so they
won’t restrict movement.
It’s been a long journey to get that far, and we’ve not done yet. Let’s go 60 years
back in time and see how it all started.
The World’s First Ostomy Bag!
The founder of Coloplast, Elise Sørensen, was a Danish nurse. She went to sick
people’s homes and cared for them. She got very close to her patients and she
learned a lot about the specific trouble patients were dealing with in silence.
There are aspects of illness that patients rarely discuss with the nurses and doctors
because they are too embarrassed.
32
Product Innovations: An Industry Update by our Sponsors
Then in 1954 her sister Thora was diagnosed with cancer of the colon. Thora was
lucky to have a successful surgery, but the decline in her life condition after the
recovery was devastating! She was a young woman, just 32 years of age. She could
no longer go to the theater, go bicycling or go travelling. In 1954, devices were more
or less cotton wool and bandages. Her social life fell apart. Elise was heartbroken
but came up with an idea: a bag! A disposable bag that will stick to your body and
that you yourself can replace in privacy. A hygienic device that would make her feel
free, clean and attractive again. This bag would prevent leakage and significantly
reduce smell from the stoma.
Elise went to see Aage Louis Hansen at Danish Plastic Emballage. He refused, “Too
specific! I can’t sell that.” But luckily his wife Johanne happened to be an educated
nurse and she could see the potential. So Aage Louis Hansen gave in and agreed to
manufacture one thousand samples — by hand! Elise’s ground-breaking idea led to
the production of the world’s first adhesive, single-use ostomy bag. Elise Sørensen
distributed them to all the hospitals in the country and put an advertisement in
the most important medical pamphlet. And shortly after Danish Plastic Emballage
could not stop making anything else — but pouches!
The ostomy pouches were an instant success, the orders piled up — and in 1957,
Coloplast was born.
Coloplast today includes Ostomy Care, Urology and Continence Care, and Wound
and Skin Care. We operate globally, employing more than 7,400 people in 40
countries worldwide. For more than 50 years, we have developed and marketed
innovative products that make life easier for people with medical conditions of a
private nature.
Constantly Looking for Better Ways
To lead the market within intimate healthcare, we focus heavily on innovation. For
us, innovation is all about translating challenges into solutions that make life easier.
Our innovations build on closeness to customers, radical thinking and ambitious
goals. This approach brings new solutions fast to the people that need them.
Even though we lead the market within intimate healthcare — we are not satisfied
yet. People in need of our products and healthcare professionals still face significant
challenges every day. To solve the challenges that still remain, we need to get even
closer to customers and look for new ways to stimulate our innovation processes.
Compare today’s ostomy pouch with that patented in 1954 and the differences are
actually not that significant. Despite vast improvements, users can still experience
leakage or skin irritation. So, even though these products have been a business
success, there’s still room for improvement. It’s time for the industry to dream
up radical solutions and wild ideas that can deliver new value to both users and
healthcare professionals.
33
Looking Beyond our Boundaries

Jakob Øelund, an engineer working in global R&D, is excited about looking beyond
Coloplast’s usual sources for fresh ideas.
We’ve found inspiration by visiting companies such as Coca Cola, BMW and Adidas.
They are all good at being first with new concepts. These visits have inspired us to
be more daring with our ideas — and to process them in new ways. After reviewing
BMW’s work with concept cars for the future, we asked ourselves: “How might we
address end-user needs in 2020?” This inspired us to think out of the box, forcing
us to imagine the solutions first, and then how we could tackle any barriers to
realizing them.
Of course, we continue to work closely with end users, healthcare professionals,
universities and other partners in the innovation process. We also try out new ways
to stimulate our creativity by, for example, setting particularly tight deadlines.
This has had an effect: we’ve been able to cut development times by half for new
products — which is good news for the people in need of better solutions.
Closer to the Users: Face-to-face and Online
Our R&D department aims to get even closer. For example, all of our R&D employees
have visited users in their homes. It helps us to understand and translate their
needs into solutions and not just think about technicalities.
We are also trying to connect people with stomas around the world. The new
online community www.Innnovationbyyou.com (IBY) for people with ostomy
and continence issues aims to turn users of healthcare products into co-
creators of tomorrow’s medical devices. With the website, Coloplast takes user-
driven innovation to a new level: we have always involved users in our product
development, but technology now allows us to get even more direct input from
users — who are the real experts. IBY is not a temporary project, but a committed
innovation model, which will feed our innovation and product development
processes for many years to come. All forthcoming (or future) products will be
made using input from users, nurses and other members from around the world.
Closer to Nurses: Coloplast Ostomy Forum (COF)
COF is a number of national, professional networks facilitated by Coloplast,
designed for stoma care nurses to exchange experiences and influence product
development at physical, biannual sessions. To be exact, 22 countries, 400+ nurses,
44 annual meetings!
The forum started 17 years ago and encouraged nurses to play a bigger role in
product innovation. The COF members used their knowledge and experience to
develop products which are now part of everyday life across the globe. COF is
a unique opportunity for both the user and for the nurse participating. For the
34
nurses to meet, share knowledge and work with peers from around the world to
develop better products and services — and to gain knowledge that can make
their work even more interesting and fulfilling, and even help improve the stoma
care.
Most importantly: by working together we can make a real difference and set a
new standard for stoma care.
Learn more and contact us: www.coloplast.com
CONVATEC
Leading Innovation in Ostomy Care
ConvaTec is a leading manufacturer of ostomy products that supplies approximately
one-third of the worldwide ostomy care market.1 ConvaTec may be best known as
a pioneer in the creation of modern ostomy devices, including ground-breaking
ostomy systems and adhesives for skin barriers (see Figure 1). More than three
decades ago, ConvaTec introduced the world’s first two-piece pouching system for
ostomy patients, as well as a revolutionary adhesive that was able to stick to moist
environments, called the Stomahesive™ skin barrier. This breakthrough adhesive
was able to secure the pouch to the body. A full overview of ConvaTec ostomy
products is available at www.convatec.com under the Ostomy tab.
Innovative Ostomy Products
ConvaTec Moldable Technology™ Skin Barriers utilize a unique, tri-laminate
adhesive to protect the skin around the stoma. This proprietary innovation uses
Rebounding Memory Technology™, which provides a “smart” adhesive that actively
adjusts to gently hug the stoma, effectively sealing it from the peristomal skin. The
“hug” results in demonstrated improvement in skin protection. ConvaTec Moldable
Technology™ Skin Barriers are also easier to use than other ostomy systems because
no scissors or pastes are required.2-4 In addition to providing additional security
and skin protection, this technology is also easy to use.3
Vitala™ Continence Control Device (CCD) is a new paradigm in ostomy
management for end colostomies, featuring a device that can be worn up to 12
hours per day. It rests gently against the stoma to effectively create a tight seal to
prevent waste from escaping. Rather than relying on an external pouch to store
waste, patients only expel waste when they need to, based on body cues. The
result: reduced odor and noise, and nothing to get in the way of everyday life for
the user.
Stomahesive™ and Durahesive™ Skin Barriers are a gold standard for attaching
pouching systems to the body. Developed and introduced by ConvaTec, these
revolutionary hydrocolloid skin barriers are designed to adhere to moist
35
environments and provide a secure seal against leakage. Hydrocolloid skin barriers
are the basis of virtually all other commercial skin barriers used today.
Natura™ and Esteem synergy™ Two-Piece Pouching Systems feature the pouch
and skin barrier as two separate pieces that join together with different coupling
mechanisms. Natura™ Ostomy System is the high-performance system that is
durable under challenging conditions and provides an audible click to indicate
when the system is secure. Esteem synergy™ Ostomy System provides the skin-
friendliness and versatility of a two-piece product with the low profile and flexibility
of a one-piece product, while using an innovative Adhesive Coupling Technology™
that seals the pouch to the barrier without the need for locking plastic rings. Both
systems allow the user more flexibility in pouch changes while maintaining the
secure barrier seal during changes.
Esteem™ One-Piece Pouching System combines the pouch and skin barrier into
a single unit. Esteem™ Ostomy System has an extremely low profile and offers
features similar to those found in two-piece devices, including the InvisiClose™
Clipless Closure. Designed for ease of use, the user can replace the complete
system when needed.
Little Ones™ Pouches and Skin Barriers are specially designed to comfortably
fit a child’s unique body contours. Parents love them because they let kids be
kids.
The SACS™ Instrument is an evidence-based tool for the objective assessment

and classification of peristomal skin lesions, an important issue for patients and
ostomy care nurses. It was developed by a group of Italian ostomy care nurse
experts with support from ConvaTec to help establish a standard language to
describe and classify the condition of the skin surrounding the stoma.5 Prior
to the SACS™ Instrument there was no universal system to objectively classify
peristomal lesions, which posed problems for healthcare professionals.6 The SACS™
Instrument was based on a prospective, observational, multicenter study involving
339 patients.5 It was face-validated in Italy and subsequently content-validated in
the United States.5,7 Training on the use of the SACS™ Instrument is available on
ConvaTec websites, and an iPad™ app is available in English and Italian.
Figure 1. ConvaTec has a long history of product innovation and growth.

Year Milestone
1972 Stomahesive™ Skin Barrier launched commercially in Britain
1978 SUR-FIT™ Ostomy System with Hydrocolloid Skin Adhesive, a hydrocolloid-
based, two-piece, disposable pouching system
36
1981 Stomahesive™ Paste, a hydrocolloid paste for improved sealing and skin
protection
1985 Durahesive™ Protective Skin Barrier launched
1988 Little Ones™ Pediatric Ostomy System launched
1989 DuoDERM™ CFG™ and DuoDERM™ Extra Thin Dressing launched
1992 Durahesive™ Skin Barrier with CONVEX-IT™ Technology launched
1999 ESTEEM™ One piece Ostomy System: Extremely low profile and flexible ostomy
system
2000 ISO 9001 certification
2002 Esteem synergy™ Ostomy System launched
2003 ConvaTec Moldable Technology™ launched in both Natura™ and Esteem
synergy™ Ostomy Systems
2006 Natura™ Ostomy System with ConvaTec Moldable Technology™, the first flat
wafer with Rebounding Memory Technology™
2008 • SUR-FIT Natura™ low pressure adapter launched
• The SACS™ Instrument
2010 Vitala™ Continence Control Device, temporarily restores continence for end
colostomies up to 12 hours each day
2011 Launch of new line of pouches: Natura™, Esteem™, and Esteem synergy™
Ostomy Systems
Innovative Alliances and Outreach Programs

In addition to developing innovative products, ConvaTec has pioneered new and
effective ways of supporting and encouraging healthcare professionals who care
for people who have had ostomy surgery, as well as the patients themselves.
ConvaTec Connects™ was established in early 2008, as the company embarked
on a concerted, worldwide effort to partner with the healthcare community to
ensure that ConvaTec ostomy products and services are guided by a commitment
to continuous improvement. To meet this need, ConvaTec Connects™ inaugurated
its own regional Ostomy Advisory Boards, comprising distinguished ostomy care
leaders from around the world. In 2012, there were 16 regional advisory boards
representing 23 countries, with nearly 200 participating ostomy care experts.
Nursing Associations provide vital backing for their members and ConvaTec has
a long-standing history of support for various national, regional and international
ostomy nursing associations including: the Wound, Ostomy and Continence Nurses
Society (WOCN) (www.wocn.org), the European Council of Enterostomal Therapy
(ECET) (http://www.ecet-stomacare.org), the World Council of Enterostomal
Therapists (WCET) (http://www.wcetn.org), and contributions to the Norma Gill
Foundation.
37
The Great Comebacks™ Program was founded, with the support of ConvaTec,
in 1984 under the leadership of Rolf Benirschke, a former place kicker with the
San Diego Chargers (a US football team) who underwent ileostomy surgery.
The program was designed to raise awareness of quality of life issues for people
living with Crohn’s disease, ulcerative colitis, colorectal cancer or other diseases
that can lead to ostomy surgery. Today the Great Comebacks™ community raises
awareness around the globe through inspirational individuals who have chosen to
share their stories and offer hope to others facing these diseases and transitioning
to life after surgery. Great Comebacks™ now has a dedicated YouTube Channel
to help with our mission of inspiration and education. To find out more, visit
www.greatcomebacks.com and www.youtube.com/greatcomebacks.
ConTact™ Magazine was created specifically for ostomy patients by ConvaTec in
2008 and has been circulated in up to 15 countries around the world. Each issue
contains information on new products, nutrition, patient stories and advice for
patients who have had ostomy surgery.
Inspire.com is an independent, internet-based social network and ostomy
support community developed and sustained with funding from ConvaTec. People
who join Inspire.com can connect with others living with an ostomy, get ostomy
information and resources, and discuss their health concerns in a safe, private and
protected environment.
Customer Interaction Centers (CIC) were developed to provide patients and
healthcare professionals with ongoing toll-free telephone support. In the United
States, the phone centers are staffed by Certified Wound Ostomy Continence
Nurses who answer 500 to 600 calls each day from people living with an ostomy,
their families, and health care professionals. Around the world, the CICs offer
information on living with an ostomy, how to measure the stoma, skin care, new
product trials, starter kits, and retailer referrals.
Patient Associations are essential to developing and delivering support and
information to people who have had an ostomy. ConvaTec continuously supports
associations such as the International Ostomy Association (IOA) and successor
organizations at local, regional and global levels to help the IOA reach out in
new and effective ways. Additional information is available at the IOA website:
www.ostomyinternational.org.
Summary
Innovation has been the heart and soul of ConvaTec for more than three decades,
beginning with Stomahesive™ skin barrier in 1972, continuing to the present
era of advanced pouching systems that use ConvaTec Moldable Technology™.
The driving force is steadfast commitment to improving the lives of people after
38
ostomy surgery, made possible through a continuous dialog with patients and the
people who care for them.
References
1. ConvaTec Inc. Data on file, 2012.
2. Scott V, Raasch D, Kennedy G & Heise C. Prospective assessment and classification of
stoma related skin disorders. Poster presented at the 41st Annual Wound Ostomy and
Continence Nurses Society Conference, Orlando, Florida, June 2009.
3. Hoeflok J, Guy D, Allen S & St-Cry D. A prospective multicenter evaluation of a moldable
stoma skin barrier. Ostomy Wound Management 2009; 55(5):62–69.
4. Chaumier D, Beghdadi N, Le Gal Lambec M, Ligier MC, Espirac B & Edmond D. OSMOSE
Study An evaluation of the peristomal skin condition in patients using ConvaTec Moldable
Technology™ Skin Barriers — Preliminary Results. Poster presented at the 11th ECET
Conference, Bologna, Italy, June 2011.
5. Bosio G, Pisani F, Lucibello L et al. A proposal for classifying peristomal skin disorders:
results of a multicenter observational study. Ostomy Wound Management 2007; 53(9):38–
43.
6. Salvadalena G. Incidence of complications of the stoma and peristomal skin among
individuals with colostomy, ileostomy, and urostomy: A systematic review. Journal of
Wound Ostomy and Continence Nursing 2008; 35(6):596–607.
7. Beitz J, Gerlach M, Ginsburg P, Ho M, McCann E, Schafer V et al. Content Validation of a
Standardized Algorithm for Ostomy Care. Ostomy Wound Management 2010; 56(10):22–
38.
™ indicates trademarks of ConvaTec Inc, except for iPad, which is a trademark of
Apple Inc.
AP-012308-MM
©2012 ConvaTec Inc.
HOLLISTER
Since the last Festschrift publication, Hollister has been very active worldwide.
With a presence now in over 90 countries, Hollister continues to deliver products
of the highest quality. Our core focus is and will always be on the person with an
ostomy — to help ensure they lead more rewarding and dignified lives.
One cornerstone of product development is to incorporate our deep understanding
of skin barriers. Hollister offers a range of differing skin barriers to suit different
skin types, stoma types and wear time needs. This includes SoftFlex®, FlexWear®,
Flextend®, Flextend M™ and FormaFlex™ skin barriers. A range of skin-friendly
barriers ensures that our customers have more options to meet their needs.
With skin barriers established as a solid foundation, we focus on key product
details that matter to a person with an ostomy. Some details, while seemingly
small, can be significant. Product details that improve comfort and convenience,
39
yet provide value-for-money when economic issues are becoming significant, are
all considered during our product development.
In 1997 Hollister introduced a new range of pediatric products called Pouchkins™
Pouching Systems to address the needs of newborn and preemie infants. While
these infants represent a small population of people with ostomies, there was a
distinct need. That same year also saw the introduction of a new one-piece product
line — The Moderma Flex™ Ostomy Pouches. Due to its popularity, this product line
has been continuously expanding over the years and now includes a full range of
pouches with differing skin barriers, that include flat or convex options.
In 1998 Hollister introduced a new two-piece, low-profile ostomy system. The New
Image™ and Conform 2™ two-piece ostomy systems incorporate four different
skin barrier formulations for use with a full range of pouches. Each skin barrier
incorporates the well-regarded Hollister floating flange. This allows for the pouch
to be attached to the flange without putting pressure on the abdomen. Since the
flange is not attached directly to the skin barrier, but is instead ‘floating’ over the
skin barrier, it provides flexibility during movement. This creates a comfortable
two-piece barrier as opposed to a rigid fixed flange. Convex skin barriers were
introduced in 2000 and 2001.
In 2002, the Adapt accessory line was introduced with Adapt® paste and convex
barrier rings, and strips. Other accessory items were subsequently rebranded into
the Adapt portfolio. A new flat skin barrier ring was introduced in 2006. This ring
offered an advantage over other rings as it was easy to shape and mold without
flaking or breaking. Its high absorption and pH buffering capabilities provides
customers with excellent skin protection.
The AF300™ ostomy filter was developed in 2006 and provides a unique filter
construction. The combination of advanced materials and leading-edge
technological design in the AF300 filter meets the needs of customers by creating a
product with enhanced air flow, superior gas deodorizing capabilities, and internal
and external liquid protection.
QuietWear™ Pouch Material was introduced in 2007. This innovative pouch material
fuses the plastic film of the pouch to the non-woven portion, resulting in a pouch
that feels more like fabric than a traditional pouch. The benefit is reduced noise for
the wearer and increased comfort — similar to wearing clothing.
The new FormaFlex™ shape-to-fit skin barrier was introduced in 2010. This new
skin barrier provides a simplified application process of shaping the barrier to suit
the stoma, without scissors.
The launch of the highly successful, new, integrated closure — the Lock ‘n’ Roll
microseal closure on drainable pouches in 2003, provided users with a closure
which was easy to use and easy to teach for clinicians.
40
Product development continues with new concepts ready to be introduced in

2012 and beyond.
Dansac A/S
At Dansac, we are dedicated to providing innovative and outstanding solutions
for people with stomas, clinicians and their caregivers worldwide. Our focus is to
create unique stoma care products that enhance and improve the quality of life
of people living with a stoma. We do this not only by developing and improving
stoma care products, but through educational materials, supportive services and
practical information guides.
By listening to and understanding our customers, Dansac leads the way in
designing modern, reliable products and educational services that support people
living with a stoma to overcome physical, social and psychological implications
and enables them to live life the way they want to live.
Always evolving and striving for the best possible solution for the people we serve,
Dansac has continually introduced new products and made enhancements based
on their feedback.
In 1997, Dansac introduced the first drainable pouch with an integrated filter. This
pouch was called InVent®. Prior to this, integrated pouch filters were only available
on closed pouches. At last, people with a more liquid output stoma could benefit
from a reliable filtered pouch.
In 1999, to continue to make life easier for people using drainable pouches, we
introduced our first integrated closure product called FoldUp™. This novel, easy-
to-manage and intuitive opening soon became the preferred choice for people
with an ileostomy.
In 2003 through 2005, a complete one-piece pouching system called Nova 1 and
two-piece pouching system called Nova 2 were introduced. These fully featured
product lines provided new levels of comfort, security and discretion for people
with all types of stomas. The skin barriers are made with a tapered design to
ensure flexibility and improved security at the edges without the need for
securing with tape. The pouch cover utilized a water-repellant material that
improved user comfort. A new product concept of soft convexity was introduced
on the Nova ranges in 2004. Traditional firm convexity, while useful, did not meet
the needs of users who needed more than a flat skin barrier, but something less
than firm convexity. Soft convexity X3 and 5mm solutions successfully addressed
this gap.
A breakthrough innovation was made in 2006 with the introduction of the
NovaLife® flushable pouch. This two-piece closed pouch system incorporates a
unique filter and pre-filter system into the flange assembly. The flushability of the
41
pouch provides the wearer with a feeling of a ‘return to normal’. With this concept,
a discreet and convenient method of stoma management was achieved.
In 2011, a new range of one-piece and two-piece products was introduced. With
the introduction of the NovaLife 1 one-piece pouching system, and the Novalife
2 two-piece pouching system, we believe that we have created our best ostomy
product line to date. The design and functionality of the NovaLife pouches are
based on QOL studies, real-life testimonials and clinical evidence. The needs and
requirements of our customers have influenced its development. Designed for life,
the features incorporated into these two systems, better address today’s needs of
lifestyle, comfort and convenience. The lower headspace makes the pouch more
discreet and the off-centre starter hole means the skin barrier can be positioned
lower on the abdomen. By minimizing the whole upper area, we have reduced
slouching and made it easier to hide the pouch. The new NovaLife filter effectively
vents deodorized gas to avoid problematic ballooning of the pouch.
In 2012, Dansac launched a new seal with an innovative design and material. Since
skin surfaces differ around the stoma, this new shape allows the seal to be oriented
wherever more material is needed to ensure a leak-proof seal.
One of our cornerstones has always been to listen to the needs of our customers
and those who care for them, and translate what we hear into unique products and
services. We will continue to evolve and dedicate ourselves to what we do best:
stoma care.
42
First Edition of the Festschrift
In Gratitude
Publication of the first edition was made
possible by generous grants from:
Coloplast Sween
ConvaTec®, A Bristol-Myers Squibb Company
Hollister Incorporated
Marlen Manufacturing and Development Co., Inc.
Smith & Nephew United, Incorporated
43
Contributors to the
First Edition (as they were in 1996)

President, Anderson Consulting, Yardley, Pennsylvania, USA
Clinical Nurse Specialist, Royal Adelaide Hospital & WCET Editorial Board,
Auburn, South Australia, Australia
ET/Wound Specialty Program Manager Columbia/Largo Regional Medical Center,
Home Health Division, Tampa, Florida, USA
Todd D. Cohen, MD
Fellow in Urology, Duke University Medical Center, Durham, North Carolina, USA
Clinical Nurse Specialist Stomal Therapist, Chief Professional Nurse-Stomal
Therapy Unit Groote Schuur Hospital, Capetown, South Africa
William J. Davidson, BS
Retired Vice President Marketing & Business Development, ConvaTec,®
A Bristol-Myers Squibb Company, West Trenton, New Jersey, USA
Manager, Enterostomal Therapy Nursing Director, Enterostomal Therapy
Education Cleveland Clinic Foundation, Cleveland, Ohio
ET Nurse Clinical Specialist, Mendon, Vermont, USA
Chairman, Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Leonard Fenton *
Founding President, Marlen Manufacturing and Development Company, Inc.,
Bedford, Ohio, USA
Joseph Fischer
Regional Director, Extended Care KCI® Therapeutic Services, Elmhurst, Illinois, USA
44
Associate Professor of Nursing, Nurse Practitioner, Department of Urology,
University of Virgina, Charlottesville, Virginia, USA
Founder and Retired Executive Director, Help for Incontinent People,
Spartanburg, South Carolina, USA
ET Nurse Consultant & Executive Director, Association for the Advancement of
Wound Care Baltimore, Maryland
Mary Jo Kroeber, MSc (Hlth Sc), Grad Dip Admin, BA Soc Sc, B App Sc (Nsg),
RN, RM, FRCNA, ET, AFCHSE
Director Nursing Services, Lower North Metropolitan Health Services,
Perth, Western Australia, Australia
Chairman, Department of Urology, Cleveland Clinic Foundation,
Alfred R. Priest, BS
President, Fisheries, Enhancement Foundation, Inc., Belleair, Florida, USA
ET Nurse Consultants, PA St. Paul, Minnesota, USA
ET Nurse Consultant, Euclid, Ohio
President, Worldwide Home Health Center, Inc., Akron, Ohio, USA
Consultant, Yardley, Pennsylvania, USA
ConvaTec,® A Bristol-Myers Squibb Company, Yardley, Pennsylvania, USA
Retired, Enterostomal Therapy, Education, Cleveland Clinic Foundation,
Columbia Station, Ohio, USA
Frank L. Weakley, MD
Retired, Department of Colorectal Surgery, Cleveland Clinic Foundation,
45
Preface (to the First Edition)
V
ery few patients who are afflicted with life-threatening, energy-sapping
illnesses have the strength to look beyond their own situations to the
needs of others who suffer. Very few among us have the determination
and dedication to champion a cause for humanity — worldwide — for a lifetime.
Such has been the exceptional role of Norma N Gill-Thompson, the world’s first
Enterostomal Therapist (ET). If there were more Normas in this world, it would
certainly be a better place.
The twenty chapters in this book highlight Norma’s life story and her interests from
different points of view. You will hear from her caregivers, from her Cleveland Clinic
colleagues and their children, from her students, from the people she inspired in
industry, from one very special patient, and from those who carry on her legacy —
ETs from around the world, including her own daughter, Sally Thompson, ET.
Norma’s story is inspirational. Her mission of care for patients with ostomies and
enterocutaneous fistulas, patients whom others had forgotten, is unique. At age
seventy-five she is still inspiring us, crisscrossing the globe to open ET schools, to
lecture, to guide, to build community.
We hope that this tribute to Norma N Gill-Thompson, ET will document for future
generations her special role as the Mother of Enterostomal Therapy. We hope that
this Festschrift for the first ET will start a tradition of honorary volumes for other
ETs. ET nursing is a specialty that can be so very proud of its founders and those
who try to follow in their footsteps. ET and wound, ostomy and continence nurses
should embrace the past while looking to the future. We hope that you will enjoy
reading the contributions and the stories in this Festschrift and that you will take a
moment to reflect on the very special life of the first Enterostomal Therapist.

Cleveland, Ohio

Baltimore, Maryland
1996
46
Future Trends in ET Nursing Internationally
Future Trends in ET
Nursing Internationally
A
nyone who has had contact with enterostomal therapy nursing, including
recipients of care, colleagues rescued from nursing dilemmas and
practitioners themselves, appreciates the value of this specialised area
of nursing. Where ever it functions the benefits are effective, efficient care and
rehabilitation programs for people with ostomies, problem wounds, incontinence
and allied conditions; and positive financial and social outcomes for health
agencies and wider society.
The currently held perception that ET nursing will move successfully onwards
through the year 2000 into the future should be well founded. However clouds of
change hang over a bright future. Could all ET posts eventually be sponsored by
appliance manufacturers? Could pouch vending machines with a computer print
out on management become a commercial reality? Will continent diversions or
bowel transplantation displace ET nursing? Unlikely, but flexibility, adaptability
and a touch of pragmatism will need to be part of every contemporary ET nurse’s
survival kit.
Expansion of ET nursing has assumed heroic proportions since Rupert B Turnbull
Jr, in 1958, enlisted Norma N Gill (now Norma Gill Thompson) to help his clients at
Cleveland Clinic, Ohio, USA to overcome the shock of ostomy surgery and resume
a normal, active lifestyle. It is unlikely that even Norma Gill envisaged that her
helping services would spread so far beyond Cleveland. But before long health
professionals flocked there from every corner of the globe seeking education
programs to quench their thirst for information about these rehabilitation
processes.
Clinical nurses with a strong bent for innovation and leadership appeared to be
attracted by the comprehensive nature of helping programs which re-established
individuals in society after ostomy surgery. Concerned nurses joined the campaign
to establish the right to a normal life style for this group of the population.
Soon most affluent English speaking countries had developed small groups of
professional nurses whose focus of interest was care of individuals with ostomies.
47
Patricia Blackley
Sensing the opportunity for a global crusade for stoma care for people in need
wherever they lived, Norma Gill Thompson encouraged these professional
nursing groups to weld into an international association — The World Council of
Enterostomal Therapists (WCET). The new organisation grew rapidly assuming a
leadership role which persists to this day. It represents the aspirations of health
professionals in 59 countries to provide effective ostomy rehabilitation services for
their populations. WCET mentors the ET education of nurses and emergent ostomy
rehabilitation services as needs arise, encouraging the establishment and growth
of enterostomal therapy nursing world wide.
Today ET nursing internationally may be viewed as forming a very long continuum.
Industrialised nations with sophisticated health services such as the United States
of America and Great Britain are at one end; and at the other, nations such as
Indonesia and Papua, New Guinea where comprehensive health services for the
general population has more recently become an issue. Growth across the last
decade has been rapid but could be expected to stabilise in the future while
economic reorganisation occurs in areas of the world that are currently unstable.
The function of ET nursing in the nations scattered along the continuum varies from
country to country. All have ET nursing services at different stages of evolution.
The core focus is ostomy rehabilitation with wound care, tube management, and
continence promotion included to different degrees in different places. Australia,
a large country with a population of only 17 million people, boasts a professional
ET nursing group of more than 400 members. The vast majority are qualified to
practice but not necessarily engaged in practice. The scope of ET nursing is covered
by education and in practice. Most people experiencing ostomy surgery are under
direct care and guidance from a stomal therapy (ET) nurse. Whereas Zimbabwe,
a geographically smaller country but with a similar population (16 million), has
only one qualified ET nurse. She single handedly manages the ostomy population
as best she can with assistance from nurses in distant locations whom she has
tutored in the rudiments of stoma care.
National reports on the function and status of ET nurses written by International
Delegates for the 10th biennial congress of WCET in 1994, identify the most
intransigent barriers to a productive future for ET nursing as severe constraints
on expenditure within national health care systems and the attitude of national
nursing bodies in specific countries to specialised nursing (WCET, 1994).
The reports indicate enormous difficulties in establishing official posts for ET
nursing in countries where this is a new concept of care. This situation is due
apparently to financial constraints on health expenditure (WCET, 1994).
Most newly qualified ET nurses in these situations already have invaluable backing
from their surgeons and ostomy association but would benefit from more support
48
by the international ET nursing community. Norma N Gill Foundation scholarship

holders and nurses sponsored from emerging nations by ostomy associations or
other organisations to travel overseas to attend education programs deserve moral
support on return to their own country. Some well established professional ET
nursing groups have adopted this concept. A body of ET practitioners established
within WCET for this specific purpose could mentor these isolated nurses by
correspondence during what must be a difficult period. Demonstrating concern
for professional ET nursing activities on the international scene may help future
extension of the specialty.
The WCET reports further indicate that in countries where ET posts have been
long established, rationalisation has led to enforced extension of services to
accommodate other unassociated “specialist” roles effectively reducing the
time spent in ET nursing practice. Elimination of ET nurse positions, or banning
establishment of new ET services is becoming commonplace. More and more
qualified ET nurses are helping people with stomas in ad hoc voluntary service
situations or employed in positions where they are expected to wear two
professional hats (WCET, 1994). It appears that continuous justification of the role
with support from ostomy associations and medical colleagues will be required for
survival. Further research to reinforce the concept of efficiency and effectiveness
of ET nursing practice will underpin the future for the specialty world wide.
It is clear from the reports that official nursing bodies in some countries believe
caring for the individual with an ostomy cannot be a specialised nursing practice
as it is basic nursing care (WCET, 1994). Yet neither tertiary nor hospital based
basic nursing courses teach enough about managing rehabilitation of people
with ostomies or allied conditions to ensure effective care. Paradoxically health
agencies in many of the same countries employ ET nurses who teach these skills in
clinical or continuing education settings (WCET, 1994).
The patient experiencing ostomy surgery may receive the best possible care that
can be offered by the nurses of the health care facility. However even in countries
with the most sophisticated health care systems without interventions from an ET
nurse it may not be sufficient to meet the individual’s needs.
Dorothy B. Smith in 1991 described ET nursing as “delivering optimum care
to a specific patient population... a true branch of Nursing” (Smith, 1991). The
professional groups are lobbying to achieve recognition as such in every country
faced with this problem. There is still a long way to go.
What will be expectations and needs of people who have ostomy surgery in the
years ahead? Amongst the multitude of variables affecting the future direction of
ET nursing is one constant. The effect of ostomy surgery on the individual human
being. Gwen B Turnbull spoke of this in terms of a life shattering event in a paper
49
Patricia Blackley
delivered at the 10th biennial congress of WCET in 1994. She further pointed out
that all the best in technology does not compensate for a spoilt body, loss of
control over excretion of wastes and an altered image of self (Turnbull, 1994).
Helping individuals who have experienced ostomy surgery come to terms with the
changes and adapt successfully to the new order of things has been the focus of ET
nursing from its inception. It should remain so as long as surgeons have no other
option but to divert gastrointestinal and genitourinary systems to restore function
temporarily or permanently to save lives. It is for this reason, that medical and
nursing health professionals from 59 countries of the world have become involved
in enterostomal therapy: to offer empathetic help to people so affected; to solve
physical problems with appropriate containment systems and allied products;
and to help individuals use appropriate coping mechanisms to manage their
psychosocial problems.
Despite years of predictions from surgeons that fewer stomas will be raised in the
future, there appears to be little change. The ageing of populations may be a factor
here. Men and women aged over ninety years now have ostomy surgery performed
quite routinely. Extension of life expectancy and the increase of populations at risk
of cancer in particular, may be counterbalancing the rate of continent diversion. A
focus on the needs of elderly clients who are slower to recover from surgery and
adapt and learn less readily will certainly be a feature of future ET practices.
It is ironic that in the countries with the most sophisticated nursing services the
trend which will affect future ET nursing is a move by practitioners to planning,
research and administration. Professional necessity is causing nurses who have
gone to great lengths to become qualified to help this specific population to
separate from direct interaction with their patients.
This questionable situation is brought about by the inalienable fact that
ET nursing is a true branch of nursing (whatever its critics might say). And
that as Nursing moves onwards and upwards claiming its place as a true profession,
its highly qualified practitioners are moving to roles where they deliver patient
care by proxy. In the case of enterostomal therapy the service provided would
be similar to the service provided by the ET nurse in Zimbabwe. The expert
practitioner instructs others less qualified to provide care for the individual most
in need of expert help. In future times it seems carers may not even be professional
nursing practitioners. This may leave the ET nurse’s specific patient population to
the ministrations of unqualified health care workers (presumably versed in the
rudiments of stoma care). Shall that mean we have travelled all this way to return
to 1958?
As health care systems of many nations pursue the line of economic containment
and professional nursing becomes a reality, the most expert nurses in all fields
50
are moving away from involvement with direct patient care into research and
administrative domains. The American Nurses Association’s Council of Clinical
Specialists cited by Hamric states “to fulfil the clinical nurse specialist role, the nurse
must have a client based practice.” Hamric goes on to incorporate that statement
in a response to the dilemma posed by the focus of practice:
It is clear from this statement that if the focus of practice shifts to education
the CNS becomes a nurse educator, if the shift is to research the CNS becomes
a nurse researcher. If the CNS does not maintain a clinical practice and focus on
the patient, client, family, that individual ceases to be a CNS and should not use
the title (Hamric, 1989).
In the case of ET nursing one must ask: can the nurse who no longer interacts with
patient, client, family any longer be an ET nurse?
Although changes in direction in health care systems appear to occur as frequently
as changes in weather patterns, rapid spread on the international scene of variations
of diagnostic related grouping and allied theories is occurring. Rationalisation
of financial support given to hospitals by central governments drives a shift to
short inpatient stays, an outcome of this change. Whilst the wound, tissue and
continence care roles of the hospital based ET nurses shall assume an even greater
strategic importance in these circumstances, will the postoperative role related to
ostomy surgery remain valid? Will the postoperative client absorb vital information
and self care skills after extensive surgery in a hospital stay of 4 or 5 days?
Innovation and leadership the hallmarks of ET nursing have triggered incorporation
of community services into existing hospital services, or a direct shift of services
to the community as a natural progression of events in response to short inpatient
stays. Teaching the patient in hospital becomes redundant if the patient is not in
hospital long enough to overcome the personal crisis of the operation and attain a
state of readiness to learn. Teaching relatives or other support persons so they can
care for and teach the patient may not be in the best interests of the individual.
There is no doubt that learning to care for a stoma at home is less stressful than
in unfamiliar, inconvenient and very public hospital environments. Recognition
of the need to accommodate this change has seen an increased focus on home
ostomy care services.
With all the change in the focus and delivery of ET nursing comes a need to think
of future ET nurse education programs.
A background in community health, gerontology, research and administration will
clearly be needed in advanced countries but what of the nurses occupying other
places on the ET nursing continuum? Recognising that parity between nations
in ET nursing education now or in the future is a fantasy will be an important
factor in maintaining cohesion within the international body of practising ET
51
Patricia Blackley
nurses. Looking into the USA from outside it seems extraordinary that ET nursing
education is likely to be limited to nurses already holding Master’s degrees. But 15
years ago it seemed equally unlikely that a Bachelor’s degree was a necessity.
The current guidelines for minimum acceptable standards for education programs
published by the education committee of the WCET need to be maintained at the
present level. This will ensure that implementation of ET nursing programs in less
affluent nations does not become an impossible dream.
Basic nursing qualifications have now moved into tertiary institutions in many
countries. More will be moving this way in the future. Following the trend, ET
nursing programs are moving into the tertiary sector as well. In most cases this
is encouraged by the professional ET group motivated by the desire to obtain
recognition of enterostomal therapy as a branch of nursing. In Colombia and Brazil
ET nursing programs commenced in the tertiary sector. In England to comply with
Project 2000, ET programs are being moved by decree to the tertiary sector. In
Australia one distance education course is conducted by a nursing faculty. New
Zealand and Germany conduct some of their courses in polytechnic institutes.
Another factor contributing to the move to the tertiary sector is the cost of
conducting hospital based education programs. Evaluation of costs to a hospital
will focus on the returns to that institution. Whether or not ET services are available
at other facilities will not be part of the future equation. It will become the task
of the qualified practitioner to persuade an employing health agency that an
ET service will be of financial value to the organisation rather than approaching
employers hoping for education sponsorship, then an ET post.
With theory on site at tertiary institutions and practice in a clinical setting,
achievement of a select range of competencies in preference to a definitive
number of hours spent in hands on practice may be the only financially viable
proposition for students and teachers. Clinical institutions will almost certainly in
the future charge tuition fees to either the university or the student. University
programs themselves are self funding so an element of uncertainty about their
continuity exists. If the program does not pay, it will be closed down. There is even
a potential that this trend may lead to total elimination of ET education programs
in a specific country. In consequence the cost of obtaining qualifications may
become prohibitive. Nurses in certain European countries are unable to obtain
formal ET qualifications now for this reason.
Shall we eventually see a world wide distance education ET program with a single
curriculum supplied in many languages set up by an enterprising, innovative
educational institution using computer assisted instruction, CD-ROM, Internet,
video tapes and other electronic wizardry to teach and to monitor competency to
practice? Why not?
52
Whatever may happen continuing education will remain central to credentialing

for ET nurses. Without undertaking one (or even two) Masters degrees how will
practitioners scattered across the globe otherwise keep abreast of trends in
practice, learn to market their services to the general public effectively, identify
the research projects needed to promote the specialty, or learn how to make their
voices heard by government agencies about the needs of clients.
Contemporary ET nurses in different countries such as England, Ireland and
Australia for example are learning through continuing self education the principles
of marketing in an endeavour to create a higher profile for the clinical services
offered by ET nurses. Who ever thought of wide scale marketing of ET nursing
services in 1979? We should have. Certain nurses have recently taken news of
the wide range of ET nursing services to the general public and colleagues using
a roadshow format. The outcome was increased utilisation of the service and
improved awareness of the role and function of ET nurses.
Communication, the core of continuing education and universal standards, is
hampered by language barriers. World wide links are vital to unity but perusing
journals or attending meetings where not one word is understood is wasteful
of limited time and resources. There may be a trend in WCET to divide into sub-
groups that share a common language and culture. Central to retaining global links
is strategic planning to ameliorate the losses from ineffective communications.
Professional ET nursing across the world loses dynamism as groups are each forced
to invent their own wheel.
Education through journals, videos and meetings will continue in the future,
electronic media has great potential for use as a universal language communication
channel. Nurturing emergent ET services in their own language, and each country
sharing skills and knowledge with the other may be the key to the survival of ET
nursing internationally.
ET nursing practices themselves will change to meet economic constraints. Teaching
clients, their carers and support persons to learn ostomy, continence or fistula care
using video technology shall become commonplace. While the individuals may
not be ready to learn self care, prospective carers whether health workers or family
can be introduced to the principles of care by watching the process on video
tape. So using photographic and video equipment to best advantage will become
an inherent part of practice. We have entered the age of nursing technology. ET
nursing will adapt to using technology for networking, teaching and research as it
has adapted to change in the past.
Technological developments by appliance manufacturers have always aided the
client and ET nursing in unison. ET nursing working with IOA SHARE and commerce
in newly industrialised nations across the world can be at the forefront of improved
53
Patricia Blackley
health care and cost containment. The aim to attain the common goal, ostomy care
for people who need it; with subsequent development into wound and continence
management areas.
ET nursing will continue to prosper in alliance with clients, surgeons, national
and international ostomy associations and other concerned health professionals
for as long as the specialty retains its focus on the specific patient population
that initiated its birth. If ET nurses become administrators rather than clinicians,
the specialty may well become a rudderless ship adrift on stormy seas.
REFERENCES
Hamric, A. (1989) History and overview of the CNS role. In The Clinical Nurse Specialist in
Theory and Practice, A. Hamric & J. Spross (eds), 2nd ed. Philadelphia: WB Saunders, 1-18.
Smith, D. B. (1991). Toward the future of ET nursing. Journal of ET Nursing 18(3), 77-78.
Turnbull, G.B. (1995). Quality of life of colostomy patients — the effect of pouching on
mental health. World Council of Enterostomal Therapists 1994, 10th Biennial Congress
Proceedings. Perth, Australia: Ink Press International.
World Council of Enterostomal Therapists. (1995). National Reports 1994. Perth, Australia:
Ink Press International.
54
History of the World Council of Enterostomal Therapists Journal
History of the World Council of

Enterostomal Therapists Journal
Mary Jo Kroeber, MSc (Hlth Sc), Grad Dip Admin, BA SocSc,
B App Sc (Nsg), RN, RM, FRCNA, ET, AFCHSE
W
hat is going on in Italy or Ireland in the world of ostomy, wound and
continence care? What are the trends in preserving continence for
individuals experiencing rectal neoplasms? Keep reading the World
Council of Enterostomal Therapists Journal and you may well find the answers.
From its inception in 1976 the WCET has held fast to its founder’s intention for
information on ostomy care to be shared with ETs throughout the world. Norma
N Gill, the first President of WCET (1977–80) introduced NEWSLINE in 1980. This
paperfold four (4) page information sheet might be considered a first trimester
embryo which eventually grew to become the WCET Journal.
The original idea of an international newsletter and journal began in Dusseldorf
in 1979 at the second WCET Congress. WCET was growing and clearly identifiable
as an international organisation. It was considered vital to have a communicating
voice which would allow interchange of information between ETs all over the
world; to publicise the specialty, and spread the word in countries which did not
have Enterostomal Therapists that much more could be done to help people with
ostomies.
At that time WCET lacked the funds and expertise to publish a journal. Outside
help was needed. Norma Gill approached Robert W Loy of ConvaTac-Squibb. He
kindly offered assistance. Nortrud Schindzielorz Loy a charter member of WCET
volunteered to be the first senior editor. It had begun.
NEWSLINE was made available to qualified ETs everywhere courtesy of ConvaTec-
Squibb. This company has supported world wide ET education from the earliest days
of WCET. Printing and distribution of NEWSLINE and its successor the WCET Journal
was wholly subsidised for the first four years. Without this initial assistance with
the earliest publications the existing WCET Journal may never have eventuated, so
those who were associated with the early publications remember that assistance
with gratitude.
To quote Norma Gill Thompson “Nortrud and ConvaTec-Squibb struggled through
the first two pioneering years.” All editors know good copy is hard to find.
55
Patricia Blackley and Mary Jo Kroeber
During those two crucial years there was considerable difficulty finding articles
and newsworthy items. Nortrud stood down from the Editor’s position in 1982
although she continued to assist as an advisor. She later returned to Germany
from Cleveland Clinic and established an eight week ET school in Dusseldorf. Her
strenuous efforts to keep the publication going on behalf of the WCET are not
forgotten. To her goes the credit of presenting in this international publication the
first item in a language other than English.
When Priscilla Stevens of South Africa took over from Norma as President of WCET
in 1980 she too fostered international communication and education through the
WCET Journal with regular contributions of educational material as well as reports
on her activities as President. In 1981 during her presidency NEWSLINE became the
WCET Journal. Like most healthy babies it had doubled its birth weight to eight (8)
pages.
When Nortrud Loy retired from the Editor’s position in 1982 she left a twelve (12)
page publication which was interesting to readers from start to finish.
To fill the vacuum left by her departure Norma N Gill accepted the role of Editor.
In her first editorial she wrote that she found it “rather scary to be the editor of
a journal”. Like most people Norma has probably found things scary at times
throughout life but it never shows. She just keeps on going, and the WCET Journal
kept right on going too.
Under Norma’s guidance items were published written by nurses and doctors from
The Netherlands, Japan, South Africa, Zimbabwe, England, USA, India, Argentina,
Australia, Italy — an exhaustive list would be too long. She managed all this along
with her travels to many countries promoting ostomy care and conducting a
business.
At about this time after the 4th WCET Congress in Munich, Patricia Blackley joined
the WCET Publications Committee at the behest of Mary Jo Kroeber, then Vice
President. A late night telephone conversation followed up by an audiotape of
conversations of a committee meeting held during the Congress in Munich
triggered some valuable WCET alliances. Pat had just finished a term as Editor
of the Australian Association of Stomal Therapists Newsletter. She had developed
a taste for publishing. With the assistance of then Chairperson of the WCET
Publications Committee, Evonne Fowler, she was introduced to the ramifications
of the wonderful world of WCET publications and the WCET Journal.
In 1983 ConvaTec again generously agreed to publish and distributed the Journal
for a further two years. Joseph Birkbeck of ConvaTec was appointed to liaise with
the WCET Editor and Publication Committee. Publication continued but by then
time constraints were posing some problems for Norma.
56
Publisher, Editor and Publications Committee all met face to face for the first time at
that wonderful 5th WCET Congress hosted by the Southern Africa Stomaltherapists
Association in the Transkei, Southern Africa.
This Congress gave evidence that the WCET was maturing as an organisation. It was
a time of many changes. Prilli Stevens completed her term of office as President,
with Mary Jo Kroeber of Australia voted in to the President’s position. Prilli took
up the position of chairperson of the Education Committee, and Patricia Blackley
became the chairperson of the Publications Committee. Norma Gill Thompson
continued as Journal Editor with ConvaTec generously offering to support the role
with an executive editor and graphic artist. This took a lot of pressure off Norma
and enabled her to continue her activities with a greater degree of flexibility.
Norma many times during this period of collaboration expressed her gratitude
to Executive Editor Kelley Fitzgerald for her unfailing interest and assistance. Joe
Birkbeck was a tower of strength providing sensible business advice and guidance
to the new Publications Committee.
Journal publication continued with considerable collaboration between Norma,
Kelley, Pat Blackley and the members of the Publications Committee. All were
working as a unit seeking, finding and publishing copy from most corners of the
globe. This is never an easy task, voluntary contributions from WCET members
were still a rarity. It was particularly fortunate to have Nancy Faller of USA who has
special skills in design as a committee member at this time. Her work was used as
the cover design for two WCET Journals during 1985.
In the years between 1984 and1986 it became quite clear that as President Mary Jo
Kroeber had a vision of extending WCET communications. She strongly believed in
contact with other health professionals as well as ETs using the WCET Journal as a
vehicle to spread the word far and wide. She believed that a formal, independently
published, professional journal would assist the WCET effort to achieve the goal of
“stoma care for all by the year 2000” by adding to the stature and status of WCET.
It also became clear as membership of the WCET accelerated, both in the number
of countries participating in the World Council and in private membership, that
dependence on the generosity of ConvaTec to meet the needs of an ever expanding
Journal circulation would have to cease.
Whether by design or by good fortune, Mary Jo Kroeber the WCET President and
Patricia Blackley chairperson Publications Committee lived in the same country.
Even though they were separated by 3000 miles of the Australian continent they
were easily linked by telephone. Planning to develop a self sustaining WCET
Journal began. The target date for the first publication was February 1986, in time
for presentation at the 6th WCET Congress. Was this feasible? Would it pay its way
or would WCET be faced with a large debt. Norma Gill Thompson quoted Charles
57
Patricia Blackley and Mary Jo Kroeber
Lindbergh in her last Editorial “What kind of man would live where there is no
daring. I don’t believe in taking foolish chances, but nothing can be accomplished
without taking a chance.” So we took the chance.
It is not possible to estimate the huge volume of work put into achieving this goal by
Mary Jo. The position of WCET President is extremely onerous requiring extensive
travel, and enormous amounts of personal time invested in communication by
correspondence with people involved in every aspect of ostomy rehabilitation.
Together with the presidential role Mary Jo was convenor and organiser of the
6th biennial WCET Congress which was to be held in her home State of Western
Australia, in April, 1986. Intermingled with all the activities she was called on to
perform for those two roles she organised publication of the first self sustaining
WCET Journal. Publishers and advertisers were found. Liaison with the WCET
Executive and ConvaTec on this rather risky venture was maintained.
Patricia Blackley as chairperson of Publications Committee was enlisted to help.
She suggested the layout and was to be responsible for the content. The two met
for a few hours in Brisbane, Queensland one steamy tropical day, spent some hours
together shut in a motel room with a large pot of coffee, developed goals for the
publication and set their short and long term objectives. A publisher from Western
Australia was chosen to develop the publication and later with their assistance art
work for the Journal and a cover design was selected which showed the flags of the
member countries of the World Council. Little did these two know at that time, that
in the future there would not be enough room on the Journal cover for the flags
of all the nations that would become members of the World Council. With the first
issue of this new WCET Journal in 1986 Patricia succeeded Norma Gill Thompson
as Editor.
The self supporting Journal will have been coming from the presses regularly for
a decade at the beginning of 1996. It has outstripped the short and long term
objectives set in 1985 by its planners, long since. It has filled the educational
and administrative needs of the WCET from that time on. Since 1987, true to its
international character, items in languages other than English, with an English
translation, have appeared in all issues with few exceptions. Norma Gill Thompson,
founder of WCET, has continued her contributions to every issue under her byline
“Around the World With you”.
Technological advances in printing and publication have seen a continuing
improvement in the production and appearance of the publication. Initially the
Journal was limited to black and white illustrations, with coloured illustrations just
a pipe dream. These became a reality in 1991. The cover has changed periodically
in an endeavour to keep abreast of the needs of an ever expanding organisation.
58
The Editorial Board was formalised in 1990 with Mary Jo Kroeber as inaugural
Chairperson. The Highley report of 1992 — a survey of membership satisfaction
— the basis of the strategic plan for WCET reports a high level of satisfaction
existing among the membership with the quality of the publication. This is barely
surprising considering continued improvement of the quality of the Journal has
been the prime objective of all the Editors and the Editorial Board to date.
The WCET Journal has been printed in Australia since 1986. Three different
publishing companies have helped over the years to promote and improve the
quality of the product. The assistance received from each one has been of great
value to the successive Publications Committees, Editors and Editorial Boards
involved with Journal production.
Commercial companies whose advertising has allowed the Journal to go free with
membership fees to WCET members, have been constant in their participation
in the publication. Without their involvement production of a Journal would
necessarily cause a considerable increase in membership dues.
Mary Jo Kroeber has filled the roles of Publications Committee chairperson
and Chairperson of the WCET Editorial Board since her term as WCET President
completed in 1988. Patricia Blackley filled the role of Editor until 1993 when
Donna Bull also an Australian WCET member took over this position and the role of
Chairperson of the Editorial Board. Patricia has remained a member of the Editorial
Board from the time of her retirement as Editor.
Since 1994 the World Council of Enterostomal Therapists Journal has been indexed
in the Cumulative Index to Nursing and Allied Health Literature. It undoubtedly
has a prosperous future. The embryo NEWSLINE which ventured forth in 1980
has grown through the efforts of many individuals, not the least of whom are its
contributors, to a well established professional journal of forty four (44) pages. All
those who participated in its development to this stage are entitled to be proud
of their efforts.
Acknowledgment: Thanks to Norma N Gill Thompson for her recollections of the
early days of the WCET Journal.
59
Bonnie Bolinger
Care of the Adolescent with an

Ostomy
PLEDGE TO CHILDREN
To you, our children, who hold within you our most cherished hopes, we, the members
of the Midcentury White House Conference on Children and Youth, relying on your full
response, make this pledge:
From your earliest infancy we give you our love, so that you may grow with trust in
yourself and in others.
We will recognize your worth as a person and we will help you to strengthen your sense
of belonging.
We will respect your right to be yourself and at the same time help you to understand
the rights of others, so that you may experience cooperative living.
We will help you develop initiative and imagination, so that you may have the
opportunity freely to create.
We will encourage your curiosity and your pride in workmanship, so that you may have
the satisfaction that comes from achievement.
We will provide the conditions for wholesome play that will add to your learning, to
your social experience, and to your happiness.
We will illustrate by precept and example the value of integrity and the importance of
moral courage.
We will encourage you always to seek the truth.
We will provide you with all opportunities possible to develop your own faith in God.
We will open the way for you to enjoy the arts and to use them for deepening your
understanding of life.
We will work to rid ourselves of prejudice and discrimination, so that together we may
achieve a truly democratic society.
We will work to lift the standard of living and to improve our economic practices, so
that you may have the material basis for a full life.
60
Care of the Adolescent with an Ostomy
We will provide you with rewarding educational opportunities, so that you may
develop your talents and contribute to a better world.
We will protect you against exploitation and undue hazards and help you grow in
health and strength.
We will work to conserve and improve family life and, as needed, to provide foster care
according to your inherent rights.
We will intensify our search for new knowledge in order to guide you more effectively
as you develop your potentialities.
As you grow from child to youth to adult, establishing a family life of your own and
accepting larger social responsibilities, we will work with you to improve conditions
for all children and youth.
Aware that these promises to you cannot be fully met in a world at war, we ask you to
join us in a firm dedication to the building of a world society based on freedom, justice,
and mutual respect.
So may you grow in joy, in faith in God and in man, and in those qualities of vision
and of the spirit that will sustain us all and give us new hope for the future (cited in
Broadribb, 1983).
President Roosevelt initiated White House conferences in 1909 to address how the
nation could best serve children. Conferences were then held every 10 years. This
pledge was adopted at the 1950 Conference. By 1980–81 controversy surrounded
the meetings. Agreement could not be reached as to what constituted a family.
Pro-life, homosexuality, abortion and people living together and single parent
families were dominant issues which reflected the tremendous changes in the
traditional family model. As we approach a new century the precepts of the pledge
still remain valid.
The word adolescence has its roots in Latin, meaning “to grow up.” The
emancipation process is marked by physical, intellectual and emotional changes
and adjustments. Erikson’s (1963) developmental stage for adolescents is “identity
versus role confusion,” which identifies the tasks of separating from family and
peers in order to develop a self concept from which to function as an adult.
PHYSICAL GROWTH AND DEVELOPMENT

Puberty involves an ordered sequence of events which creates dramatic changes
for the adolescent. These events do not occur at the same rate or age. Growth
spurts with subsequent change in body composition occurs. Sexual maturation
and the ability to procreate produces more than physical changes. Hormonal
changes alter thoughts, desires and emotions. Puberty marks the time when
61
Bonnie Bolinger
mature sex cells begin to be produced. Tanner (1962) classified and described the
progression of sexual development in both sexes (Foster, Hunsberger & Anderson,
1989). Rapid physical growth precedes puberty. There is an increase in height and
weight. Body proportions may not appear to be in harmony.
Physical changes in the female include an increase in the transverse diameter of
the pelvis, development of the breasts, change in the vaginal secretions, growth of
pubic and axillary hair, and menarche. As the young girl’s body begins to develop,
she will generally be taller than her male counterpart. Her figure will tend to be
chubby in the early adolescent periods. Breast development is a major concern.
She will compare herself with others and formulate a body image. Menstruation
and release of ova add a new dimension to life, the ability to procreate. Factual
information about menstruation, sex, and reproduction should be shared,
preferably by parents. Parents who provide support and encourage the adolescent
to share feelings and concerns will contribute to her developing a positive body
image.
Physical changes in the male include an increase in the size of the genitalia; swelling
of the breasts; growth of pubic, axillary, facial, and chest hair; voice changes, and
production of spermatozoa. The young boy finds his external genitalia changing.
The size and contour become significant as he has ample opportunity to compare
his own development with others during gym, in showers, and in public rest rooms.
Myths and beliefs about virility being directly linked to the size and configuration of
the penis abound, thus creating a dilemma when the adolescent’s genitalia begin
their change. He may become concerned about appearance or lack of appearance
of facial, chest and axillary hair. Our society’s concept about “machoism” and virility
are on public display for the young man to make comparisons.
Thoughtful, understanding parents and factual sex education by parents and
in school can provide opportunities for the adolescent to openly discuss “wet
dreams,” release of sperm, and his ability to procreate.
The adolescent has bodily sensations that evoke feelings never before experienced.
They can be exciting, embarrassing, confusing, gratifying, and even frightening.
The sensations felt coupled with obvious changes in physical appearance create
an atmosphere that warrants parental support and the help of knowledgeable
educators who can assist the adolescent as he searches for his body concept and
identity.
Somatic growth depends on a number of factors, including genetics, nutrition,
and health care. Adolescents with poor nutritional habits and/or history of chronic
illness may mature more slowly. Hormonal imbalances can also disrupt normal
growth.
62
Asynchrony occurs as different body parts mature at different rates. The stage is set
for the adolescent to be concerned about his body. As the girl’s pelvis widens she
may worry about becoming fat. The boy may be concerned that his hands and feet
are seemingly out of proportion to the rest of his body. It becomes increasingly
important to keep pace with peers and not be the exception. Height and weight
change rapidly during early adolescence and taper off as maturity approaches.
Deviation from the body ideal, whether in height or weight, the timing of
maturation, or the size and contour of body parts, is likely to have a profound
influence on the adolescent’s self-concept and peer relationships (Broadwell &
Jackson, 1983).
PSYCHOSOCIAL DEVELOPMENT
Erikson’s theory of eight stages of man outlines developmental tasks from infancy
through adulthood. Great variation will occur in all age groups. The central task for
adolescents is to strive for a sense of identity and intimacy. Also one must bear in mind
the previous developmental tasks: trust versus mistrust, autonomy versus shame
and doubt, initiative versus guilt, and industry versus inferiority. If any of these
tasks have been delayed then one cannot move toward mastery of adolescent
developmental tasks.
Moving from childhood to adulthood involves providing for basic necessities,
selecting a career, determining one’s core values and beliefs, attaining intimate
relationships, and establishing a sense of identity
CARE OF THE ADOLESCENT WITH A STOMA

The history and course of the disease process will greatly effect the integration
of a stoma or diversion into the body image. Howe maintains that a congenital
illness or disability or one that began in early childhood will be integrated
into the self concept more readily than one that arises during adolescence
(Howe, 1980).
Howe further notes that any illness or impairment during adolescence triggers
anxiety about one’s sexual identity. If the pathology is associated with the genitalia,
this will elicit greater anxiety. Alteration or diversion of fecal or urinary orifices
generates many concerns relative to sexual impairment or function.
The advent of internal diversions or pouches affords more options for those faced
with ostomy surgery. An external stoma is a very visible sign to the adolescent that
one’s body is very different than one’s peers. If a continent state can be achieved
without an external prosthesis, the adolescent may have less body image insult.
Further, peer acceptance is much more likely to occur. Studies to explore these
issues should be conducted. The medical-surgical management of children with
63
Bonnie Bolinger
alimentry or urinary tract disorders which necessitate an ostomy should include

the option to have an internal pouch constructed whenever possible.
Stan was an adolescent when his father and two brothers died of cancer due to
familial polyposis. He knew to possibly save his life he needed to have his colon
removed. He and his mother searched for the medical center where he could have
an internal pouch constructed. Stan planned to become a physician. He made
obvious moves to enter adulthood. He had a Koch pouch constructed, and after
recovery, entered medical school. After completing medical school, Stan married
and he and his wife made the decision for him to have a vasectomy. They are now
proud adoptive parents and he has a thriving medical practice.
If a child or adolescent has grown up with a stoma and seems to have adjusted
poorly or exhibits low self esteem, then if not contraindicated, the choice of an
internal reservoir should be an option that is offered for consideration. The child
or adolescent may not act upon the information at the time it is given. Having a
choice becomes extremely important. The option of having a continent diversion
is appealing to all ages. The same holds true of the child who may benefit from a
reconstruction of the urinary tract to obviate a stoma and institute intermittent
self catheterization.
Carl grew up with a urinary stoma. During his adolescence due to pronounced
torturous ureters and kidney failure, he and his family had to make the decision
to have a kidney transplant done. When his health status stabilized he was able
to have an internal urinary reservoir constructed that spared his urethra and
eliminated the need for a stoma. Carl no longer has an external stoma and he has
experienced great success with intermittent self catheterization. He was able to
pursue his dream of becoming a biochemist and enter adulthood with a good
sense of identity.
CHRONIC ILLNESS
Children who have learned to cope with chronic illness during childhood face the
developmental task of independence. Those with physical limitations face an even
greater challenge. Howe (1980) maintains those with chronic conditions may find
it especially difficult to achieve an identity that is not disproportionately taken
up by the disorder, whether or not the health problem is visible to themselves
or others. She further states that adolescents who have chronic illness that is
not readily detectable to others may not suffer greatly from peer rejection, but
confusion, grief and fantasy may make them withdraw from peer contact.
Considering Erikson’s model of psychological development, if a chronic illness
has impeded or prevented mastery of developmental tasks then the next stage
cannot be attained. Regression can occur, however, the drive for independence
64
will usually remain strong. The severity of the illness may necessitate reliance
on one’s parents, thus creating a crisis for the adolescent. One must address the
adolescent’s concerns. These concerns may not be the same as the parents or what
the health care worker perceives the focus should be.
Broadribb (1983) offers these guidelines when working with adolescents:
1. Assess the developmental level
2. Listen with empathy to their concerns
3. Encourage maximum participation in self care
4. Provide sufficient information to make this participation possible
5. Give clear concise explanation of treatments and procedures
6. Outline limits, rules and regulations
7. Offer a peer to discuss related problems
If chronic illness exists then a positive self concept may be difficult to attain.
Acceptance by one’s family, positive social and school experiences as well as clear,
concise information from health care providers will enable the adolescent to move
toward a positive self concept.
SUPPORT SYSTEMS
Peer acceptance becomes central to the task of establishing an identity. One cannot
move toward establishing intimate relationships if they withdraw to compensate
for perceived or actual inability to function at the same level as their peers. Family
members, peer and health care professionals provide the social support network
within which the adolescent may work through the illness or handicap.
United Ostomy Association sponsors an annual Youth Ostomy Camp. This milieu
has afforded many young people the opportunity to work through major life crisis.
In this well structured atmosphere many “mechanical” problems are addressed
which enables the young person to have freedom from worry over leaking
pouches or poorly selected equipment. The external management of an ostomy
plays a critical role in independence and function. In addition, simply meeting and
socializing with others who have similar stories, concerns or diagnosis helps to
dispel feelings of isolation as well as preventing withdrawal. During camp, health
care professionals have ample opportunity to address maladaptation. Sessions are
structured to provide a supportive environment in which the adolescent can safely
explore feelings and attitudes.
John was a bright 16-year-old who had been repeatedly reassured by his parents
that a medical miracle would occur before he went to college, that his congenital
defect which left him with malformed, distorted genitalia could be reconstructed.
John felt the clock of time ticking away and when he encountered other young
65
Bonnie Bolinger
men at camp he knew the miracle was not going to occur. A camp counselor was
able to intervene and seek appropriate counseling for him.
This case illustrates the major role parents and family play in adaptation and
rehabilitation. They can promote, delay or impede the adolescent’s adjustment.
Onset and duration are major factors in the adolescent’s response as well as the
parents and family. The grieving process will occur in varying degrees within the
family.
Yet there are stories of great courage and fortitude among the teenage ostomy
groups. Many have successfully entered adulthood. Karen was born with
myelomeningocele. Her parents were told to institutionalize her when she was an
infant. The years were marked with many surgical procedures including ostomy
surgery. Her feet and legs required many reconstructive processes. It appeared
drugs and alcohol would claim her fragile hold on life during adolescence. The
spark of life that was kindled in a drug rehabilitation program was a turning point.
Today, Karen is married, the mother of a boy and is completing work on her Masters
in Nursing.
The families of challenged children face issues which health care providers
struggle to comprehend. Not only are they expected to proceed with maintaining
a household with its inherent problems but give support, guidance and care to
a child with a severe physical ailment. Listen to some parental concerns. “Daily, I
wonder what our life will be?” “Can this happen to our other children?” ‘There is no
spark in our marriage.” “No one wants to listen anymore.” “What did I do to deserve
this?” “I wish it were me instead of my child.”
The adolescent’s support system has a profound impact on outcomes and quality
of life issues. Health care providers play an integral role in marshalling the resources
necessary for the patient and family to make informed decisions. Broadribb (1983)
reminds us of an important objective to bear in mind: Aim to help patients and
families live with the illness and the problems it creates, so that all family members
can realize their fullest potential.
REFERENCES
Broadribb, V. (1983). Introductory Pediatric Nursing (3rd ed.). Philadelphia: J.B. Lippincott.
Broadwell, D. & Jackson, B. (1983). Principles of Ostomy Care. St. Louis: CV Mosby.
Foster, R. L., Hunsberger, M. M., & Anderson, J. J. (1989). Family Centered Nursing Care of
Children. Philadelphia: W. B. Sunders.
Howe, J. (1980). Nursing Care of Adolescents. New York: McGraw-Hill.
66
The Evolution of the Urinary Diversion
The Evolution of the Urinary

Diversion
Todd D. Cohen, MD
T
he first attempts at supravesical urinary diversion were performed for
exstrophy of the bladder in 1851 by Simon who created a fistula between
the distal ureters and the rectum.1 Although this particular procedure was
ultimately unsuccessful, it provided the framework for future attempts. Since that
time the urinary diversion has gone through a considerable evolution culminating
in the orthotopic bladder substitution.
The initial obstacle in creating a successful supravesical diversion was the
formation of a ureterointestinal anastamosis. The earliest attempts by Simon
and others resulted in leakage of bowel contents into the peritoneum with
disastrous complications. Sutured ureterointestinal anastamoses were pioneered
in the late 1800s and were designed to limit bowel leaks. These were fraught with
complications of their own including anastamotic leaks, ureteral obstruction,
and reflux of bowel contents. Because of these problems, several investigators
continued to modify the technique. Implantation of the ureter at an oblique angle
to the bowel and closing the muscularis over the ureter helped prevent reflux,
however it was not until the concept of a submucosal tunnel together with a direct
mucosa-to-mucosa anastamosis was developed that acceptable results were
achieved.
For nearly a century after the first attempted urinary diversion by Simon, direct
ureterointestinal anastamosis, usually to the sigmoid colon, was the urinary
diversion technique of choice.
Ureterosigmoidostomy was performed for all indications necessitating a urinary
diversion. It rapidly became apparent that factors other than an adequate
ureterocolonic anastomosis were paramount to insure a successful diversion. Intact
rectal sphincter tone was needed in order to maintain continence. Preoperative
testing with anal manometry should always be done since the inability to hold
loose feces is a relative contraindication to the procedure. The metabolic state of
the patient must also be considered prior to ureterosigmoidostomy. In the early
part of the century, Boyd noted that a chronic acidosis occurred in the majority
of the patients.2 Twenty years later, Ferris and Odel suggested that large amounts
67
Todd D. Cohen and Andrew C. Novick
of chloride are reabsorbed in the large bowel because of the increased contact
time between the urine and bowel mucosa while bicarbonate is excreted resulting
in the hyperchloremic acidosis previously noted.3 Patients with underlying renal
insufficiency are at even greater risk of metabolic disturbances after diversion
but can be controlled medically. Additionally, ammonia normally secreted in the
urine can also be reabsorbed in the colon, thus ureterosigmoidostomy should
be avoided in patients with liver disease in order to prevent hyperammonemic
encephalopathy and other sequelae.
Ureterosigmoidostomy appeared to be the ideal solution for those patients
requiring urinary diversion. However, in 1929, Hammer first reported the presence
of adenocarcinoma at the site of ureterocolonic anastamosis.4 Since that time,
several studies have confirmed the risk of carcinoma in these patients occurring
because of the mixing of feces and urine in the colon.4-7 Apparently, bacteria within
the colon metabolize urinary contents into carcinogenic substances. The reported
incidence of carcinoma occurring in this group is approximately 5 to 40 per cent
which is between 350 and 7000 times that of the normal population.4-7 The lag
period between creation of the diversion and the development of carcinoma
varies between 7 and 49 years with an average time of about 20 years.8 Therefore,
these patients require close observation. Because of the findings by Hammer and
others, investigators were prompted to find alternatives to ureterosigmoidostomy.
In 1950, Bricker popularized the use of an isolated bowel segment as a conduit to
divert the urine.9 He suggested that this procedure became “necessary” as pelvic
evisceration developed as a viable treatment option for patients with locally
advanced cancers of the rectum, cervix, prostate, and bladder requiring removal
of the distal gastrointestinal tract. Thus, diversion into the sigmoid was not an
option in this group. He abandoned using sigmoid colon as the conduit as most
of these patients required concomitant colostomy, and the two stomas lied too
close together on the abdomen. He and his colleagues attempted to improve on
the technique by trying to create a continent reservoir using an ileocecal segment,
however they were unsuccessful in obtaining complete continence. With the use of
a “Rutzen bag” to cover the stoma, the “wet colostomy” became an acceptable form
of urinary diversion. Bricker felt the advantages of this alternative was the ease of
technical performance and the short transit time of urine through the reservoir,
decreasing the chance of infection as compared with the ureterosigmoidostomy.
Today the Bricker ileal conduit is still the most common form of urinary diversion
performed. However, the indications for its use have been greatly expanded beyond
pelvic exenteration to include urinary diversions for malignancy, congenital
anomalies, and neurologic disorders.
68
While the ileal conduit has withstood the test of time, a few modifications on the
technique described by Bricker have offered some advantages. In 1961, Turnbull
and associates reported the formation of a “loop-end” ileostomy especially for
obese patients and those patients with other abdominal deformities.10 He and
his colleagues described a marked improvement in the blood supply to the distal
ileal segment, and no retracted stomas occurred in over 600 cases (these were
also being done for gastrointestinal diversion). Emmott and associates compared
these loop-end stomas and true end stomas in patients with an ileal conduit.
They reported that over a 3 year period no patients with the loop stoma suffered
stenosis while 44 per cent of the end stomas became stenotic.11 They attributed
this significant difference to the improved blood supply with the loop technique,
and, together with Skinner, recommended that loop stomas be performed in all
patients requiring an ileal conduit.
Complications with ileal conduit construction can occur either early (perioperative)
or late. The early complications include those generally considered to be technical
problems with bowel and ureteral anastamoses or difficulties with the surgical
wound. As with any bowel surgery, intestinal obstruction or fistula formation
can occur. Ureteroileal anastamotic leaks can form either because of technical
problems or ischemia of the ureter at the site. Care must be taken when harvesting
the ureter as well as the ileal segment to insure adequate blood supply in order to
prevent leaks and/or subsequent ureteral stricture formation. Anastamotic leaks
can be obviated by use of long ureteral stents until the period of mucosal healing is
complete. Later complications include stomal retraction, pyelonephritis, and stone
formation. Prior to the widespread use of the Turnbull loop-end stoma, stomal
stenosis and retraction were common events often requiring revisions in up to 50
per cent of patients.12 Retracted stomas often leak causing peristomal dermatitis,
stomatitis, and chronic skin changes frequently making application of stoma
appliances difficult or impossible. The incidence of pyelonephritis is between 5
and 20 per cent but has been reported to be as high as 35 per cent in some series.13
Although bacteruria is present in approximately 80 per cent of patients with ileal
conduits, prophylactic antibiotic therapy is not routinely recommended in order
to prevent colonization or infection with resistant organisms.14 The exception to
this is in those patients with recurrent struvite stones where persistent infection/
colonization with urease producing organisms is a significant risk factor in the
formation of new calculi. Calculi, in general, form in 5 to 10 per cent of patients
with ileal conduits.14 This higher incidence than the normal population likely
occurs because of relatively longer urine transit times, hypercalciuria, and bacterial
colonization.
Unlike with ureterosigmoidostomy there is no risk of carcinoma associated with
the ureteroileal anastamotic site. Also, the incidence of metabolic abnormalities
69
are substantially lower with ileal conduits because of the shorter mucosal contact
time with urine limiting the reabsorption of chloride and secretion of bicarbonate.
However, with worsening renal function and conditions lengthening urine
transit times (i.e. stomal stenosis or excessively long ileal segments), metabolic
disturbances, especially acidosis, become of greater concern.
Although ileum appears to be the ideal bowel segment for urinary conduits,
other bowel segments can be used for a variety of reasons. In those patients who
have received pelvic and/or abdominal radiation, the ileum may not be suitable
for conduit formation because of attenuated blood supply and weakened tissue
integrity caused by the radiation. These conditions lead to a significantly greater
risk of anastamotic breakdown and leakage as well as stricture formation. In this
instance many choose to use jejunum or transverse colon for the conduit. These
tissues are usually outside of the radiation field and their use allows more proximal
ureteral segments to be used (which are less likely to have been affected by the
radiation). The use of jejunum, however, is complicated by potentially severe
metabolic problems in nearly 40 per cent of patients.15 This “Jejunal Conduit
Syndrome” is characterized by azotemia and hyponatremic, hypochloremic,
hyperkalemic metabolic acidosis, but can be readily controlled with oral sodium
chloride supplementation. Colon conduits, on the other hand, have little metabolic
effects and offer the advantage of constructing non-refluxing ureterointestinal
anastamosis which may protect the kidneys from potential damage. While this
appears to be of great benefit, the technical ease of constructing the ileal conduit
makes it the most expeditious choice for a conduit.
Despite the success of the intestinal conduits, over the past 15 years, there has been
a dramatic increase in interest in creation of continent supravesical diversions. This
is not a new concept, however. The ureterosigmoidostomy, as previously described,
is one type of continent diversion, but the risks of carcinoma and metabolic
disturbances make it a less attractive alternative. In 1888, Tizzoni and Foggi described
replacing the bladder with an isoperistaltic segment of ileum.16 This concept was
resurrected nearly 70 years later by Couvelaire and again by Carney and Le Due
in 1979.16,17 They found that daytime continence was achievable, yet nocturnal
enuresis always occurred. Others have used various bowel segments to attempt
to achieve total continence. Bricker reported use of an isolated ileocecal segment
with an ileal stoma to try to maintain continence; however, despite modifications
including imbrication of the fascia around the stoma and formation of fascial slings,
the patients remained incontinent, and he abandoned the procedure.9 In 1950,
Gilchrist and associates described their procedure also using an ileocecal segment
with a catheterizable efferent limb.18 The continence mechanism was believed to be
a combination of the ileocecal valve and the peristaltic action of the ileal segment
moving urine back into the pouch. They felt that a longer ileal segment (greater
70
than 5 inches) was necessary to maintain continence. In a long-term follow-up

study of these patients, they too found nocturnal enuresis to be the norm as was
incontinence at higher reservoir volumes.19
These problems prompted several investigators to search for new techniques or
devise modifications to improve continence. Nils Kock devised an ileal reservoir,
initially used for continent gastrointestinal diversion, with an intricate technique
of forming a continent limb.20 Perhaps the most significant contribution of this
technique, however, was the fact that he first detubularized the bowel segment
in order to prevent unidirectional peristalsis which can result in higher pressures
within the reservoir leading to reflux and/or incontinence. The detubularization
allows for uncoordinated contractions of the bowel muscle. This, in turn, leads to
both increased filling volumes of the reservoirs at substantially lower pressures
and lower maximal pressures generated by normal contraction of the bowel. Each
of these phenomena contribute to improved continence.
Other important modifications primarily centered around the valve mechanism.
Rowland and his associates at the University of Indiana improved upon the
Gilchrist procedure by detubularizing the right colonic segment, refashioning it
into a spherical reservoir, and reinforcing the ileocecal valve by plicating around
the valve after plication of the efferent limb over a 12F catheter.21 Ninety-seven per
cent of their patients remained dry at four hour intervals between catheterizations
after one year, while 80 per cent achieved dry, normal night sleep intervals without
need for catheterization.22 Similarly, Bejany and Politano described reinforcing the
ileocecal valve using a purse-string suture.23 Others report that intussesception of
the ileum into the detubularized colonic reservoir improves continence. Pressure
increases within the pouch force the edges of the ileum together preventing
extrusion of urine.24
Kock and others have developed urinary reservoirs comprised solely of
detubularized ileal segments. They describe the formation of a nipple valve for
the catheterizable efferent limb that mimics the intussuscepted ileal valve as
described as well as a similar nipple valve at the segment where the ureters are
anastamosed to prevent reflux.
Another popular approach, especially useful in children, employs the appendix as
the catheterizable limb (Mitrofanoff ). The appendix is separated from the cecum
on its vascular pedicle, reversed, and reanastamosed to the pouch in a tunneled,
submucosal fashion similar to that of the non-refluxing ureteral anastamosis.
Duckett and associates report good continence with this technique.25
While continent catheterizable reservoirs provide improved cosmetic appearances
and more normal functional results, complications do arise. As with any
reconstructive surgery early and late problems occur. The types and incidences
71
of these complications, however, usually depend upon the type of reservoir

constructed. Early complications include all those that arise with the intestinal
conduits together with pouch leaks or ruptures, difficulty or inability to catheterize,
and high pressure pouches. Metabolic disturbances occur with similar frequency to
those with intestinal conduits and are generally not problematic unless the patient
has underlying renal insufficiency. These reservoirs should be avoided in those
patients with a serum creatinine greater than 2 mg/dl. Later complications include
vitamin B12 deficiency, reservoir rupture, ureteral stricture, stone formation,
pyelonephritis, stomal stenosis, and renal deterioration.
With the significant improvements in creating continent urinary reservoirs there has
been a concomitant resurgence in the interest in orthotopic bladder substitutions.
These neobladders can not only provide the functional aspects of the bladder,
but offer the patient a potential return to normalcy. The neobladders themselves
can be fashioned from isolated segments of colon, ileum, or combinations of the
two similar to those with catheterizable limbs. In men, the continence mechanism
remains that of the retained striated urethral sphincter that is preserved following
cystoprostatectomy. In women, however, the urethra is generally completely
excised with the bladder. Although the sphincter mechanism is destroyed during
the procedure, a catheterizable stoma can be placed in the perineum, mimicking
a “normal” urethra. Recent reports also suggest that it may not be necessary to
remove the urethra in women with bladder malignancies in certain situations.26
Absolute contraindications to orthotopic reservoirs would include any situation
where the urethra would be at high risk for tumor recurrence or in those patients
with a non¬functioning sphincter (i.e. neurogenic disorders). Patients with
transitional cell carcinoma invading into the prostatic urethra or in the stroma
of the gland are at risk of urethra recurrence and must not have an orthotopic
bladder replacement. Relative contraindications include a history of high dose
pelvic radiation, recurrent urethral strictures, and tumor at the bladder neck.
Since Smith’s first failed attempt at supravesical diversion, a plethora of techniques
have been developed to help those in need of urinary diversion achieve an optimal
quality of life. The goal of any diversion is to allow for drainage of the kidneys
in such a way as to protect them while allowing a person to live as normally as
possible. In today’s world, detection and treatment of those illnesses that may
warrant a diversion are occurring at much younger ages, such that the patients’ life
expectancies are far greater than those in the past. For this reason and others the
urinary diversion has evolved to include those forms that pro¬vide near normal
functional replacement while maintaining cosmetic appearance. However, each
patient must be treated as an individual when selecting the appropriate form of
diversion. The continent diversions require longer and more complicated surgery
72
and are fraught with higher complication rates. These may not be appropriate
choices for the elderly or more ill pa¬tients. Also, with the advent of excellent
surveillance techniques for colon cancer, the ureterosigmoidostomy is, once again,
gaining popularity because of its technical ease and excellent continence potential.
With the abundant armamentarium of procedures available, each patient should
have the opportunity to have the optimal quality of life.
Urinary diversions whether continent or non-continent have offered many
patients an improved quality of life. Perhaps the most significant achievement that
has occurred during the evo¬lution of the urinary diversion was the development
of the spe¬cialization of the enterostomal therapist. These specialists learn, in
great detail, the intricacies of each type of diversion (both urinary and fecal) while
working in parallel with the surgeon. They provide the expertise that allows the
surgeon to properly place the stoma, act as mentors to the patients to instruct
them in the care of their new anatomy, identify and treat complications that occur
secondary to the stoma, and aid urologists in the overall care of these patients.
Prior to the presence of the enterostomal therapists, these actions were very often
neglected, and the patients suffered as a result. Enterostomal therapists certainly
have tremendously improved the care of these patients and have become essential
members of the urologic team.
REFERENCES
1. Smith T: An account of an unsuccessful attempt to treat extroversion of the bladder by a
new operation. St Bartholomew Hosp Rep, 15:29,1897.
2. Boyd JD: Chronic acidosis secondary to ureteral transplantation. Am J Dis Child.,
42L366,1931.
3. Ferris DO, Odel HM: Electrolyte pattern of the blood after bilateral ureterosigmoidostomy.
JAMA, 142:634,1950.
4. Gittes RF: Carcinogenesis in ureterosigmoidostomy. Urol Clin NA, 13(2)201,1986.
5. Eraklis AJ, Folkman MJ: Adenocarcinoma at the site of ureterosigmoidostomies for
exstrophy of the bladder. J Ped Surg, 13:730,1978.
6. Starling JR, Uehling, DT, Gilchrist KW: Value of colonoscopy after ureterosigmoidostomy.
Surgery, 96:784, 1984.
7. Stewart M, MacRae FA, Wiliams CB: Neoplasia and ureterosigmoidostomy: A colonoscopy
survey. Br J Surg., 69:414, 1982.
8. Warren RB, Warner TECS, Hafez GR: Late development of colonic adenocarcinoma 49
years after uretersigmoidostomy for exstrophy of the bladder. J Urol, 124:550, 1980.
9. Bricker EM: Bladder substitution after pelvic exenteration. Surg ClinNA, 30:1511,1978.
10. Turnbull RB, Jr., Hewitt CR: Loop-end myotomy ileostomy in the obese patient. Urol Clin
NA, 5:423, 1978.
11. Emmott D, Noble MJ, Mebust WK: A comparison of loop stomas for ileal conduit urinary
diversion. J Urol, 133:588, 1985.
73
12. Middleton AW, Hendren WH: Ileal conduit in children at the Massachusetts General
Hospital from 1955-70. J Urol, 115:591, 1976.
13. Pitts WR, Mueke EC: A 20-year experience with ileal conduit: The fate of the kidneys. J
Urol., 122:154, 1979.
14. Hampel N, Bodner DR, Persky L: Ileal and jejunal conduit urinary diversion. Urol Clin NA,
13(2)207, 1986.
15. Golimbu M, Morales P: Jejunal conduits: Technique and complications. J Urol., 113:787,
1975.
16. Hautmann RE, Bachnor R: Bladder substitutes for continent urinary diversion.
Monographs Urol., 15(3):47, 1994.
17. Carney M, Le Due A L’entero-cystoplastie apres cystoprostatectomie totale pour cancer
de la vessie. Ann. Urol., 13:114, 1979.
18. Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT: Construction of a substitute bladder and
urethra. Surg Obs Gyn., 90:752, 1950.
19. Sullivan H, Gilchrist RK, Merricks JW: Ileocecal substitute bladder: long-term followup. J
Urol., 109:43, 1973.
20. Kock N: Intra-abdominal “reservoir” in patients with permanent ileostomy. Arch. Surg.,
99:223, 1969.
21. Rowland RG, Mitchell ME, Birhle R, Kahnoski RJ, Piser JE: Indiana continent urinary
reservoir. J Urol, 137:1136,1987.
22. Rowland RG, Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol,
152:2247, 1994.
23. Bejany DE, Politano VA Stapled and nonstapled tapered distal ileum for construction of
a continent colonic urinary reservoir. J Urol., 140:491,1988.
24. deKernion JB, DenBesten L, Kaufamn JJ, et al: The Kock pouch as a urinary reservoir:
Pitfalls and perspectives. Am J Surg., 150:83, 1985.
25. Duckett JW, Snyder HM: The Mitrofanoff principle in continent urinary reservoirs. Sem.
Urol., 5:55, 1987.
26. Stenzl A, Draxl H, Posch B, Colleselli K, Falk M, Bartsch G: Risk of urethral tumors in female
bladder cancer: Can urethra be used for orthotopic reconstruction of the lower urinary
tract? J Urol., 153: 950, 1995.
74
Development of Enterostomal Therapy as an International Nursing Specialty
Development of Enterostomal
Therapy as an International
Nursing Specialty
INTRODUCTION: HISTORY OF SPECIALISATION IN MEDICINE AND

NURSING
To appreciate the giant steps made in the management of people with ostomies,
fistulae, draining wounds and incontinence over the past 30 years, it is necessary to
be aware that specialisation in medicine only came about in the post second world
war era of the 1950s. Colorectal and genito urinary surgery have been comparative
latecomers to the field of specialisation. There are many areas of the world where
all medical matters are handled by generalists with assistance from nursing staff
who gain their expertise in the management of intestinal stomas, fistula, draining
wounds and incontinence by trial and error.
The international development of stomaltherapy as a nursing speciality was
meteoric in some westernised areas of the world, whilst in others, difficult to
pioneer. There are still countries relying solely on rehabilitated ostomates,
untrained but caring nursing staff and manufacturers for information and support.
THE FIRST PIONEERS

It was in 1958 in Cleveland, Ohio that the first major cornerstone of enterostomal
therapy, or stomaltherapy nursing, as it is now known internationally, was put
into place. The story of Mrs Norma Gill, an ostomate teaming with her surgeon,
Dr Rupert B Turnbull in the colorectal service at the Cleveland Clinic Foundation
is legendary. They began the education and evangelisation of not only nurses
and surgeons in the USA, but through the clinic’s colorectal fellows and visitors
from many other world centres, the rest of the world! Their pioneering actions set
into motion an amazing chain of events that were to forever rock the world of
ostomy surgery, changing the attitudes of most colorectal surgeons and nursing
professionals worldwide in the management of stomas, fistulae, draining wounds
and incontinence.
Subsequently, many individuals have set out to pioneer the speciality in their
countries. Some have achieved great success, whilst others struggle to gain formal
75
Priscilla J. d’E Stevens
education or official permission to establish the speciality within either hospital or

community.
Cleveland gave its first rudimentary programme to lay assistants, based in the USA
— all of whom were rehabilitated ostomates. Subsequently, the Rupert B Turnbull
School of Enterostomal Therapy has become the gold plate school in worldwide
circles — and has provided formalised training for both national and international
nursing graduates.
INTERNATIONAL PIONEERS: THE FOUNDING OF THE WORLD

COUNCIL OF ENTEROSTOMAL THERAPISTS
Following on the heels of the Cleveland Clinic, the earliest countries to lay claim
to establishing a formalised stomaltherapy nursing service as an integral part of
rehabilitation provided by a colorectal and genito urinary service were, Canada
in 1968; England at St Bartholomews Hospital, London in 1969; Australia at the
Royal Prince Alfred Hospital, Melbourne, in 1971; South Africa at Groote Schuur
Hospital, Cape Town, in 1974; Scandinavia at the Gothenburg Hospital in Sweden
in 1976 and France, at the Hotel Dieu, Lyon in 1978. It was this nucleus of pioneers
who met in London in 1976 at the suggestion of Norma Gill, to form THE WORLD
COUNCIL OF ENTEROSTOMAL THERAPISTS.
THE WORLD COUNCIL OF ENTEROSTOMAL THERAPISTS:

FORMED 1978
Representatives from thirty two interested countries assembled in Milan, Italy in
1978 to constitute the WORLD COUNCIL OF ENTEROSTOMAL THERAPISTS (WCET).
Many of those attending were the sole representatives from their country. Only
professional nurses who had undertaken and passed a training programme
in stomaltherapy were accepted as full members — lay ETs who had been
functioning as stomaltherapists prior to 1980 were given full membership under
the grandfather clause — and all other groups of professionals, manufacturers
and interested persons were considered to be associate members. Many of those
attending were the sole voice within their countries. Some were surgeons, others
lay ETs and interested nurses, manufacturers and distributors.
The aims and objectives of the WCET were defined:
• To provide a corporate identity for those concerned with the rehabilitation
of stoma patients.
• To enable members to meet together to discuss matters of common interest.
• To create activities to help increase knowledge in enterostomal therapy
nursing.
• To promote increased awareness in the activities of the WCET.
76
Many of the “LONE VOICES” within countries such as Japan, India, Yugoslavia, Spain
and lately Singapore, China, Korea, and Taiwan, were tenacious people who single
handedly would attend WCET biennial meetings — and return to their countries
to wage battle with administrators and, in some cases, other medical and nursing
personnel, in an attempt to sell the concepts of stoma care as a specialist entity. It
has been most heartening to see the successful establishment of stoma services
within these countries over the last 10 years. Much of this success was due to
contact with allied international professionals during WCET or the International
Ostomy Association meetings.
The past thirty years have seen the emergence of the telex machine, facsimile
and computerised electronic mail, all of which have facilitated international
communication. Prime movers within the WCET have utilised many of these and
enhanced the international educational activities.
WCET BIENNIAL CONGRESSES

Since 1978, biennial meetings have been held throughout the world. The host
countries have included Italy, Germany, USA, South Africa, Australia, Sweden,
Canada, France, Japan and Israel. The success of these meetings has been obvious
for all to see.
The publication of conference proceedings has been circulated to all members
of the WCET and have been particularly important in contributing to ongoing
education.
For the hosting countries, a major spin off for all the hard work in organisation has
been a far greater awareness by the medical and nursing professions of the work
done by, and the necessity for, the services of stomaltherapy nurses.
Opportunity to establish links with stomaltherapists, surgeons, para medicals
and manufacturers from around the globe has been a unique experience for all
fortunate to belong to this organisation.
THE WCET JOURNAL

This quarterly publication has a world circulation and is read by many other than
WCET members. Most articles are written in English, the language agreed to be
the most commonly spoken within the organisation — however the journal has
features written in any language as long as an English translation is available.
SEMINARS IN EMERGING COUNTRIES

Introduction to Stomaltherapy nursing has been most successfully “marketed”
through the medium of seminars conducted within emerging countries, utilising
international stomaltherapy nursing and medical speakers in conjunction with
local experts. Many thanks are due to commercial institutions who over the years
77
have generously sponsored such events, facilitated international speakers and

encouraged and assisted in the establishment of new services.
STOMALTHERAPY EDUCATION
Formalised education in the art and science of stomaltherapy nursing has evolved
over the past thirty years. Initially, short basic orientation and practical courses
were given over a 2 week period, from which humble beginnings have arisen the
more extensive programmes of today designed for qualified nursing personnel
run over a minimum of 8 weeks. Utilising the high standards of nursing practice
demanded by countries such as Australia, Canada, England and the United States,
the WCET has woven quality standards, curricula and created guidelines for
emerging services to follow in order to receive world recognition. The majority of
these courses are run within a multidisciplinary hospital environment or university.
The centres running such courses have highly qualified stomaltherapy trained
tutors for both the clinical and theoretical component as well as utilising local and
national experts in many other fields associated with the speciality.
Credit for great contributions should be given to the Ferguson Droste Ferguson
Hospital, Grand Rapids, Michigan who devised a systematic approach to the
rehabilitation of ostomy patients and to all subsequent institutions in the USA and
Canada who were able to establish fine schools of enterostomal therapy in North
America and produce a first class Enterostomal Therapy Association. Other major
contributions have come from Australia, Canada, England, South Africa, France and
Scandinavia. Many of the members have been instrumental in assisting emerging
services nationally and internationally by willingly sharing their experiences
through conference presentations, literature, including text books, papers and the
making of audio visual aids and on site visitations.
The WCET has through its biennial meetings, identified many excellent speakers,
educators and administrators. The formation of an education wing to the
organisation has seen the expertise of the “world’s-established-best” contribute
to the standards of stomaltherapy nursing as well as the guidelines for education
and a curriculum. The education committee has subsequently divided the
responsibilities for different parts of the globe strategically. This has streamlined
responses for assistance. Schools in each country have been defined, and the
potential for accepting an international student on any one of their courses has
been heightened through establishment of educational bursaries and scholarships.
BURSARIES AND SCHOLARSHIPS

The Norma N Gill Foundation Scholarship
The founding of the WORLD COUNCIL OF ENTEROSTOMAL THERAPY IN 1978 with
the establishment of THE NORMA N GILL FOUNDATION in 1980 to honour our
78
founder and first President has been the cornerstone of international education in
stomaltherapy nursing. The bursary for the promotion of stomaltherapy worldwide
has enabled international students to receive education at a WCET recognised
school.
The Professor Bryan Brook Scholarship (Established 1988)
To fund the education of stomaltherapy nurses within Eastern Europe and for the
development of stomacare services.
The World Council of Enterostomal Therapists Post Graduate Scholarship (Established
1988)
To assist full members of WCET to promote stoma care nursing or to advance the
knowledge and clinical practice of stomaltherapy.
Thus, it is today that from the humble beginnings of one lone ostomate and her
proactive surgeon that the international development of stomaltherapy nursing
exists and grows today.
NEEDS ASSESSMENT OF STOMA SERVICES

A system of assessment of an area’s needs and the subsequent assistance to be
given through the WCET has evolved with either on site visitations and lectures
given by a recommended stomaltherapist, or the presentation of audio visual aids,
literature and other educational tools. The appointment of a WCET approved tutor
to assist in part of a programme for either short five day or two week introductory
course or to assist a first time formal programme working and assisting the local
trained stomaltherapy nurse and the other team members has been arranged on
several occasions.
On request for help and completion of a needs assessment form countries with
the greatest needs are invited to find suitable candidates to receive education
and, when finances are short or non existent, an award from the Norma N Gill
Foundation is given. Education is offered to international students at several of the
national schools. Candidates are advised to apply at the most proximate to their
country and, whenever possible, at a school able to give much of the education in
their language.
OSTOMY ASSOCIATIONS
National Ostomy Associations and The International Ostomy Association have
been great movers for the cause of establishing formal stomaltherapy nursing. It
has been noticeable over the past thirty years how threatened such organisations
felt by the apparent take over of the role of the support groups in some countries,
and yet how successful the team work has been in others between lay and
medical/nursing groups. Obviously the mutual pooling of resources and sharing
79
of information regarding assistance can be the only way to best serve the interests
of both the ostomates and the professionals caring for them.
HURDLES TO THE DEVELOPMENT OF ENTEROSTOMAL THERAPY

NURSING AS AN INTERNATIONAL NURSING SPECIALITY
In many highly sophisticated but still developing societies, with health care
focusing on the primary needs of their populations rather than higher technologies
and expensive specialisation, it is often difficult to impose Western intervention.
The enthusiasm of would be educators from other countries has needed to be
tempered in order to appreciate the variance of health and education systems
and available governmental support and approval. Many countries object to
foreign interference and tactful and diplomatic approaches have been required,
the best method being locally organised seminars with input from collaborating
international speakers. Great credit must go to Mrs Gill who has on many occasions
been the catalyst for such breakthrough visits. Subsequently, other globe trotting
emissaries such as Maria Siegl from Canada representing Friends of Ostomates has
contributed greatly to world awareness.
FINANCIAL RESTRAINTS
One of the greatest hurdles is the cost, not only of manpower but also of disposable
consumables. Manufacturers over the years have been highly successful with the
research and development of excellent products, but the reality is that many third
world and indeed, some first world countries, are finding the costs prohibitive.
Governments and administrators require statistics and demonstration on cost
effective management. In countries where stomaltherapists can show this, the
service continues but in others, without the ability or enthusiasm to promote the
advantages, the status quo will continue.
INTERNATIONAL STOMALTHERAPY 1995

In 1995, thirty seven years after the pioneering of stomaltherapy nursing in
Cleveland, Ohio, fifty five countries have recognised stomaltherapy nursing and
there are schools in 21 countries. Numerically, stomaltherapy nurses ebb and flow,
many finding their posts tenuous for financial reasons and also because of improved
clinical skills amongst their general nursing colleagues thanks to available ostomy,
wound and continence equipment. There are still many countries yet to commence
basic stomaltherapy and the WCET is committed to promoting and assisting these
endeavours globally. Nevertheless, the specialty has blossomed thanks to the
(foresight) initial efforts of one lone ostomate and her proactive surgeon. A great
debt of gratitude is owed to a very special person, NORMA N GILL.
80
REFERENCES
Anderson, F. (1982). History of enterostomal therapy. In D. C. Broadwell & B. S. Jackson.
Principles of ostomy care (pp. 14–16). St. Louis: CV Mosby.
Gill-Thompson, N. (1992, July). Enterostomal Therapy Past, Present and Future. In Proceedings
of the IX Biennial Congress of the World Council of Enterostomal Therapists (pp. 6–10).
Lyons, France. Libertyville, IL: Hollister, Incorporated.
Richardson, R. G. (1973). The abdominal Stoma (pp. 1–56). Abbott Laboratories.
World Council of Enterostomal Therapists. (1990–1992). National Reports. WCET Publications.
81
William Davidson and Joseph Fischer
History of Ostomy Products

Manufacturers
William Davidson
Joseph Fischer
INTRODUCTION
Bill Davidson: My initial experience in ostomy was one I will always remember. I had
just been promoted to Product Manager in the Squibb Pharmaceutical Company.
Norma Gill invited me to visit the clinic for a week of indoctrination; and what a
week it was! In the pharmaceutical business, you have little direct contact with the
patient. The tenderness and dedication demonstrated by the entire staff at the
clinic was a revelation. I realized, that I, for the first time could have a direct effect
on the well being of a suffering patient if I could motivate my company to develop
effective products. I went home with a passion and Norma and other ETs have kept
it fueled over the years.
Joe Fischer: Norma Gill has been my mentor and friend since 1971. I was a young
salesman for Davol and the Cleveland Clinic was one of my accounts. My first call
on Norma was a learning experience.
She took me on hospital rounds, showed me my first stoma and introduced me
to the world of Ostomy Care and ETs. After seeing two or three stomas, a funny
thing happened to me. As Norma counseled, trained, laughed and cried with her
patients, I began to see them as real people with real needs. I was focused on the
pouch; she was focused on the person. ETs have the amazing ability to raise the
focus from the contents of the pouch to the content of the patient’s mind.
Ostomy Business: With the help of many individuals from Surgery, ET Nursing, and
industry we have attempted to piece together the history of the development of
the ostomy products industry.
Retrospectively, it is obvious that there were four major voids that retarded its
growth. They include the absence of networks which would lead to a consensus
and communicate product needs, the lack of long lasting polymer adhesives
providing tight seals and long wear times, the need for an odor proof plastic film
and a fragmented distribution system. The industry progressed rapidly once these
basic hurdles were overcome.
82
History of Ostomy Products Manufacturers
Innovation, which resulted in an improved quality of life, evolved through three

distinct periods (Pre-Network Period, Information Sharing Period, Bureaucratic
Period) as these deficiencies disappeared.
PRE-NETWORK PERIOD
Before ETs, the ostomy patient would make product choices by trial and error.
There were no national ostomy networks to share product ideas, successful
techniques, or failures. There were no national distributors to facilitate ostomy
product marketing. People with ostomies were on their own.
Prior to 1960, there were approximately 25 companies in the ostomy business.
Most of these companies were small, regional, entrepreneurial ventures. Many
owners either had an ostomy themselves or had a family member with a stoma.
In 1776, there was talk of a pouch made of leather. A Davol Rubber Company
catalog from 1915 had a picture of a rubber colostomy pouch. In 1920, the H.W.
Rutzen Company offered a rubber pouch, held in place with rubber cement. In
1929, John F. Greer formed a company to market his “Colostogator” irrigation set.
The theory was to empty the bowel by an enema so that the patient would be free
from colostomy discharge for 12–24 hours.
This quote from Murle Perry, Perry Products, is typical of most of the ostomy
pioneers. “In 1938 I had a permanent colostomy. It was this operation, and my
inability to find a colostomy appliance that would give me comfort, that prompted
me to design a colostomy cup for my own personal use. When my doctors saw what
I had made, they became interested in the possibilities of supplying other patients
with the same type of appliance. It was at my doctors’ request that I started the
manufacture of the Perry Colostomy Cup.”
In the 1940s Mason Labs, Marsan Mfg. Co., Torbot Co., and Perma Type Co. entered
the market. Here is a quote from Irving Botvin, who had ileostomy surgery in 1941
and developed his own appliance. “We started things rolling in my cellar. Ted
Torman (friend with an ileostomy) put in as many hours as he could during the
day, and I carried my end at night, after my regular job. We took the first part of our
last names and formed the company name “TORBOT”. The idea that this business
might grow or amount to anything never occurred to me. The only gains I could
measure were the initiative that I saw stimulated in Ted, and a little pocket money.”
In the 1950s Atlantic Surgical, Marlen, Coloplast, United Surgical and Nu-Hope
entered the ostomy market. Not much had changed. Ostomy product development
suffered from limited technology and resources. Stoma construction suffered from
poor surgical techniques. Stoma care suffered from lack of nursing infrastructure
and no standard of care.
83
Leon Burger of Atlantic Surgical describes the situation after his ileostomy
surgery in 1952. “Post surgery in the hospitals was a nightmare of malodors and
skin breakdown. The discharge digested the skin around the stoma, creating an
inflamed, weeping and painful situation. The odors emanating from the absorbent
dressings destroyed any vestige of ego and self-worth.
Removing the appliance frequently exacerbated any moist, inflamed area, adding
to the problem of adhering the appliance to a surgically scarred abdomen. These
problems apparently were not being addressed by the handful of manufacturers
who supplied ostomy products. They seemed content with what they were offering,
but what they offered did not address my problems.”
In 1958, Edmund Galindo, a silk screen printer in Los Angeles, had a “Bricker” urinary
diversion. He designed an appliance to meet his own need. When local urologists
discovered his appliance they asked him to make more. In fact, his young son,
Gene, was invited to fit “Nu-Hope” post-op appliances in hospitals in Los Angeles.
During the 60s, there was extensive use of heavy rubber pouches and hard lead
and rubber face plates were the norm. Some of these devices demonstrated the
desperate attempt to contain effluent and protect the skin from irritating drainage.
A variety of approaches were taken, some of which involved many pieces to the
appliance (Davidson, 1995).
The first attempts at designing urostomy pouches were made by several
companies: Davol, Perry, Atlantic, PermaType and Nova. Perry and Davol were the
major manufacturers of drainable pouches in this time period also. All of these
products were cumbersome and uncomfortable to use. Obtaining a tight seal was
always difficult. However, these devices were the cornerstone of modern ostomy
management and one of them, the Rutzen rubber pouch is still used today. In the
60s the permanent rubber reusable appliances dominated. They were most often
physician ordered and were used primarily in the home setting.
It was during this period that a degree of sophistication started to emerge in
the design of ostomy appliances. United, a Division of Howmedica, Greer and
Marlen introduced vinyl pouches which were lighter in weight than rubber and
much more comfortable. They were considered to be semi-disposable appliances,
and were reused for up to 12 weeks. These were the first “two piece” appliances
and they utilized plastic or rubber face plates, either flat or with some degree of
convexity for attachment to the body. Liquid adhesives or double faced adhesive
discs sealed the face plate to the skin.
Tincture of Benzoin, a skin toughener, first used for attaching condom catheters
to the penis, was also used around the stoma to assist in the prevention of skin
irritation. Norma Gill discovered a high level of sensitivity when it was used under
an appliance and broadly communicated her findings. It has been reported by Mel
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Aronson from Suburban Ostomy, that Ellen Knight, R.N. and the Deaconess Stoma
Clinic in Boston used cherry rezin as a substitute in 1972 (Gill, 1995).
United’s vinyl urostomy pouch was introduced in the early 70s, providing a unique
tap, (the anti-reflux valve in a urostomy pouch did not appear until the mid-70s).
While the vinyl pouch was a major improvement over rubber, it performed poorly in
the area of odor management. Liquid stool tended to penetrate the vinyl over time.
There were a total of 12 companies marketing vinyl pouches by 1971 (United, Marlen,
Nu-Hope, Greer, Mason, Gricks, Nova, Marsan, Torbot, See-Proof, Da vol, Perry).
The old marketing axiom, “Find a Need and Fill It,” was the order of the day. Enter
Dr. Rupert Turnbull and Norma Gill.
One piece disposables first appeared in 1962 by the Atlantic Surgical Company.
Rupert Turnbull, then Chief of Colon and Rectal Surgery at the Cleveland Clinic,
motivated Marlen Manufacturing to develop the post operative pouch. It utilized
the plastic films commonly used in freezer bags, had a two inch stoma opening, no
collar and was glued to the skin with a liquid adhesive. Norma Gill remembers that
it was referred to as the “FURR BAG” for the resident who designed it.
It was during this time that the role of the skin barrier was established. Rupert
Turnbull discovered the wet tack adhesive characteristic of karaya powder and he
encouraged Marlen Mfg to market the powder as an ostomy adhesive (Gill, 1994).
Shortly after this, Atlantic Surgical and Marlen marketed karaya in a washer form.
Hollister, United, and others with plain karaya washers followed. Mason and C.R.
Bard introduced karaya amalgams utilizing glycerin to extend wear. All of these
products became the mainstay for most ostomates at this time. The rubber based
adhesives started into decline in the early 70s but even today rubber cement is
still used.
These developments naturally led to a one piece disposable pouch which utilized
karaya as a built-in skin barrier. Hollister’s “karaya seal” pouch was the first of these.
It quickly moved into a position of dominance in the U.S. market and by the mid
70s had cornered a market share greater than 80%.
PVDC odor proof films emerged as part of the Hollister and Coloplast products
(C.R. Bard had the exclusive license to market the Coloplast line in the United
States) and a permanent position was created for this type of product. Hollister
and Marsan were the first companies to introduce pre-sizing in their product lines.
The 60s and 70s saw many advances in both surgical procedures and products.
Ostomy products were rapidly changing from reusables to disposables. Lightweight,
low cost, odor barrier plastic films were adapted from the food industry to the
manufacture of disposable ostomy pouches. Much effort was focused on the
development of filters for closed pouches and Coloplast’s Filtroder™ stimulated
much interest in the late 70s.
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The creation of the United Ostomy Association in 1962 by Norma Gill and Archie
Vinitsky provided the first nationally organized network run by and for the benefit
of people with ostomies. The interaction among people from different chapters
stimulated the recognition of the newer products and how they contributed to
better care. During the late 50s, Enterostomal Therapy was created at the Cleveland
Clinic as the brain child of Rupert Turnbull. Norma Gill was his first ET and together
they established the first school in 1961. By 1968 there were 23 ETs and several
in the initial group spearheaded the development of the American Association
of Enterostomal Therapists, (later to become the International Association for
Enterostomal Therapy and WOCN today). These events stimulated a great deal of
cross pollination of ideas and effectively ended the “pre-network” period.
INFORMATION SHARING PERIOD — 1970s TO LATE 1980s

The 70s saw an extremely high level of cooperation among surgeons, ETs, the ostomy
patient and industry. This led to an accurate assessment of the current situation
and needs of the patient. Surveys also indicated that a wide range of problems
existed due to poorly sited and constructed stomas. Post operative hospital stays
ranged between two and four weeks. Ostomy management was complicated with
a wide range of products being utilized on a single patient. Products were most
often ordered by the physician. Irrigation was promoted by surgeons routinely for
most patients with an end colostomy. Home care was fragmentary at best and
the ostomy (surgical) dealer provided a substantial amount of information for the
patients.
In 1970 United Surgical introduced a new class of products, Skin Prep®, a water
soluble skin barrier (Priest, 1995). It became widely accepted and was used in
combination with other skin barriers or separately. The initial version was brushed
on to the skin and later a wipe type product was introduced. Later in the period,
many other companies marketed similar products.
In 1972, Squibb introduced “Stomahesive” wafers, the first hydrocolloid skin barrier.
Physicians and ET nurses regard this as one of the most important developments
in the history of the ostomy industry. It revolutionized care by providing a polymer
based, skin friendly, reliable seal that would extend the wear time of the appliance
from one or two to five to seven days.
Davol introduced “Reliaseal” the second hydrocolloid skin barrier at about the
same time and it found wide use with patients with urinary diversions.
It was during the early 70s that industry started to employ sophisticated marketing.
Focus was put on consumer need and marketing research identified the principle
concerns of people with ostomies.
86
A major marketing research study was conducted by Squibb, the newcomer on the
ostomy scene. The results demonstrated that security, comfort, odor management
and convenience were the principal concerns of most ETs and patients. It recognized
that different products were needed in the hospital and home environments.
Longer wear time with predictable security were the most important features
sought in ostomy appliances. Low skin sensitivity to the adhesive and pouch
materials were a must. The value of a lightweight appliance also surfaced. Pouch
quietness and low cost were the least concerns of the consumer. This was the first
time that ostomates and ETs discussed profile and cleaning requirements in the
design of the appliance. Over the years, this type of survey has been conducted
at many times by several companies and the rankings were virtually the same
in each. However, as the industry achieves success in satisfying the needs in the
higher rankings the lower needs tend to become more important. This type of
data stimulated industry throughout the 70s to focus on synthetic skin barriers,
improved plastic films, one piece appliance designs and products which would
help in maintaining the integrity of the skin.
No fewer than seven new synthetic skin barriers from six different companies
emerged by the end of the period (see Figure 1). During the 70s several new one
piece appliances were also introduced to challenge Hollister’s dominance, but
their position was further secured with the marketing of the KarayaSeal® pouch
with microporous collar. Disposability of the ostomy appliance was becoming an
important issue.
Figure 1. 1970s
Synthetic Skin Barriers
Stomahesive® 1972 — Squibb
Reliaseal® 1972 — Davol
Skin Prep® 1970 — United
Crixiline® 1976 — Danal
Purified Karaya Mid 70s — Blanchard
Silicone 1977 — Spenco
Hollihesive® 1979 — Hollister
Holliseal® 1980 — Hollister
Disposable Plastic Pouches
Stoma Urine Bag® 1971 — Coloplast/Bard
Free-Flow® 1971 — Marlen
Zip Close® 1973 — Marlen
Featherlite® 1975 — United
High-Pockets® 1976 — Nu-Hope
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A broad range of accessory products were also introduced including improved

irrigator mechanisms by Geer and Hollister, Banish® an effective pouch deodorant
by United and Skin Gel® and karaya paste by Hollister.
In 1978 Squibb once again triggered a dramatic change in the direction of the
industry with the introduction of Sur-Fit®, their two-piece snap-on system. This
technology allowed the patient to simply snap the pouch onto a flange welded to
the Stomahesive® wafer. It allowed easy observation of the stoma and the erosion
rate of the skin barrier. It precipitated a resurgence of the two-piece appliance. It
also stimulated Squibb to create ConvaTec®, a new Division focusing on ostomy
and wound care.
During the 80s many dramatic changes were occurring in America and most were
stimulated by the government. Medicare (federal health care insurance system
for the elderly) enacted a program which altered the method for reimbursing the
hospital for services performed. Essentially all hospital admissions fell into one of
257 diagnostically related groups and a specific fee was allowed for each diagnosis
(DRG). In effect, the hospital was rewarded for reducing costs and in-patient stays
for patients falling under each DRG. The result was that the new ostomy patient
was sent home within seven days or less. Increased care for the new ostomate in
alternate settings evolved.
Malpractice litigation reached new heights and the era of informed consent and
patient advocates came into being. A much higher level of caution pervaded the
health care industry. The emphasis on the patient as a consumer also stimulated
significant changes in surgical practice. The physician was acutely mindful of
patients’ rights issues and the need to fully appraise patients and their family on
their condition and the management alternatives that were available. Second
opinions were encouraged. The annual physical became routine with much of the
population and it yielded earlier diagnosis of cancer. This has had a decided impact
on longevity. New surgical procedures (such as low anterior resections, ileo anal
reservoirs) and the use of surgical staplers became accepted practices. Both have
had major impacts on ostomy and have contributed to a dramatically improved life
standard. Both developments have also contributed to a reduction in the number
of permanent ostomies.
During this period, Enterostomal Therapists became integral players in the
management of ostomy programs. ET nursing continued its dedication to the
patient by adopting higher education and certification standards. Much of the
consumer education was administered through them. They became involved
in assisting the surgeon in locating the optimal site for the stoma. They taught
colostomy irrigation as an alternative rather than the norm as surgeons previously
promoted the practice. By this time ET nurses routinely prescribed the appliance.
88
With this responsibility they were alert to stoma plane dynamics and demanded
more convexity in ostomy appliances. Virtually all products that they ordered were
disposable. Their insights guided industry toward greater sophistication in ostomy
appliance design.
All industry participants were significantly challenged during the 80s. Competition
was extreme in all segments and consumer needs for a variety of products
were addressed. There was a virtual explosion of new product introductions
(see Figure 2).
During the 1980s six new two piece systems (Figure 2) entered the market and
by the end of the period, each of the major companies offered one. Significant
attention was given to the development of line extensions designed to make the
two piece systems suitable for all types of ostomies. These developments resulted
in the majority of new patients leaving the hospital in two piece appliances.
However, this is not to say that one piece appliances completely fell out of favor
as seven new products and significant improvements to other one piece systems
also emerged.
The second generation hydrocolloid skin barriers started to appear in the mid 80s.
ConvaTec’s Durahesive® was positioned for urostomies and difficult to manage
stomas, and provided wear times double those of Stomahesive and even up to 20
days for some users. United’s XL14® provided extended wear and was the keystone
for their Soft and Secure® two piece system. These products were introduced in
1986.
Prior to the 80s, the only paste products were Hollister’s Karaya paste and Skin
Gel®. In 1981, ConvaTec released Stomahesive® Paste which effectively resisted
erosion. This was followed by Hollihesive® paste in 1982 and Hollister’s Premium®
paste in 1983.
Figure 2. 1980s
Two Piece Ostomy Systems

“Sur-Fit Flexible” 1981 — ConvaTec
Floating Flange 1982 — Hollister
“Sur-Fit” Accordian Flange 1982 — ConvaTec
“MC2002” 1984 — Coloplast
“Durahesive” 1986 — Squibb
“Soft & Secure” 1986 — United

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Two Piece Accessories & Extensions

“Sur-Fit” — Irrigation Sleeve 1980
“Sur-Fit” — Urostomy Pouch 1980–1983
“Sur-Fit” Mini Pouch/Flange Cap 1980
“Sur-Fit” OR Sets 1980
Hollister Irrigator 1983
Hollister Sterile Sets 1983

One Piece Systems
“Active Life” 1984 — ConvaTec
“Hi-Pockets” Convex 1984 — Nu-Hope
“Dermaform” 1986 — Greer
“Marlen Ultra” 1987 — Marlen
“VPI Non Adhesive” 1981–1986 — Vance
“Microskin” 1988 — Cymed
Palex 1988
“Integrale” 1989
Figure 3. 1980s

Paste: Pediatric Equipment:
Stomahesive® — 1981 Greer — 1982
Hollihesive® — 1982 Nu-Hope — 1982
Premium® — 1983 Hollister Premium® Drainable — 1984
Little Ones® — 1989
Skin Care Products: New Management Alternatives

Sween® — 1975 Maclet® — 1979
UNI® One — 1979 Conseal® — 1987
Bard® — 1979 Nuval® — 1988
A concentrated effort was focused on pediatric products during this period also
(Figure 3). Greer, Nu-Hope, Hollister and ConvaTec all introduced systems which
addressed the needs of small statured individuals. Industry was amazed at the
sales volume that these products have generated.
V.P.I., a Cook Group Company, entered this market in the mid-80s with a unique
non-adhesive appliance for use by urostomates. Its success led to the introduction
of a similar product for ileostomies before the end of the period. These products
utilize a flexible silicone ring to create convexity and conformity with the body and
are recommended for use without a skin barrier.
90
In this time span, three innovative non-traditional devices appeared. Coloplast’s

Maclet®, a system which utilized a magnetic device implanted into the facia
was actually introduced in 1979, was heavily promoted in the early 80s. In 1987,
Coloplast launched their second novel device, Corneal®, a colostomy plug, which
was inserted into the stoma and eliminated the need to wear a pouch. It held back
stool while it deodorized flatus. Johnson and Johnson entered the ostomy business
with Nuval® an inflatable ostomy plug to be used with an ileostomy. While none of
these devices were major successes, they reflect a creativity which will certainly be
seen again the future.
The 80s saw the emergence of skin care products, a new class of goods for the
ostomy market. It was initiated by Sween with a range of products to clean the
skin, (Periwash®) and to treat irritated areas (Sween Cream®) and a barrier ointment
to protect the skin from corrosive effluent. These became the gold standards in this
class of goods. Shortly thereafter most of the major companies marketed products
in this fast growing niche.
DISTRIBUTION
Another important piece of the puzzle dropped into place during the 70s and 80s
and today a very sophisticated ostomy distribution system exists which guarantees
access to the full range of products available. Early on, the patient was left to search
for the most appropriate products. A few lines had national distribution but most
products were regional in nature. Davol, which provided a broad range of rubber
products (from the early 1900s), distributed them through the drug wholesaler.
When Squibb entered the market with Stomahesive wafers in 1972, they also used
their well established relationships with druggists and wholesalers to gain a quick
distribution for their product.
In 1960, Norma Gill opened Gill Ostomy, one of the first dedicated ostomy dealers
in the United States. Sometimes the patient’s local pharmacy would attempt to
acquire the appropriate product but most often they were unsuccessful. It was
often the pharmacist who had an ostomy himself who sought out the needed
supplies and created a surgical pharmacy. This was the case with Suburban
Pharmacy in Boston Massachusetts. Mel Aronson, a partner with Herb Gray in the
pharmacy, had an ostomy (Aronson, 1995). He learned to manage his own ostomy,
accessed a broad range of products, and assisted others in his community. Other
pharmacists knowing of his personal situation, would call for advice, or order a
small supply of the appropriate product for their customers. Mel and Herb realized
that pharmacists all over the United States were in the same situation. In 1977,
they founded Suburban Ostomy, the first pharmacy-ostomy wholesaler in the U.S.
(Gray, 1982). They gained access to most brands of ostomy products and developed
a mail order catalog. Their unique approach included the supply of part packages
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to the ordering pharmacies. This was an appreciated service by the pharmacies

and the business quickly became very successful. The concept spread and in the
80s St. Louis Ostomy and others became competitors.
By the mid-70s, Bruce Medical, a surgical pharmacy in Waltham, Massachusetts,
had a full range of ostomy products. Its founder, Richard Najarian, realized that
many ostomates were reluctant to visit a store to purchase their ostomy supplies.
He decided to create a situation where they could purchase their needs at home
from a catalog. He used a variety of mechanisms to develop his mailing list.
His results were outstanding and today he has one of the leading direct mail
businesses in ostomy. This success was experienced by several other surgical
pharmacies including Shield and Stein Medical, now American Ostomy Supply.
The AARP pharmacy service has a reach to the bulk of the U.S. population over
the age of 50. For many years they were reluctant to stock ostomy supplies. They
added ostomy products to their catalog by the mid 80s and today they have a
separate ostomy catalog. In conclusion, it is safe to say, that the ostomy business
enjoys one of the most sophisticated distribution systems in the health care
products market.
BUREAUCRATIC PERIOD — LATE 1980s-1990s

The name of this period was chosen to reflect the heavy impact of government
regulations and new business practices which are affecting every aspect of ostomy.
The implementation of the government’s (DRG) Medicare program was already
creating a need for a major overhaul of ostomy management. The demands to
curtail medical costs have precipitated much more focus on the delivery system of
care. Treating the patients in alternate sites such as nursing homes, rehabilitation
centers or their home became a major objective. Hospital stays following ostomy
surgery were reduced to less than seven days in most instances and in some cases
down to three or four. The position of the ET nurse was also severely challenged.
In some hospitals, ETs were forced to take on additional responsibilities. Many
responded by establishing stoma clinics or home care practices.
HMOs were the end product of the Health Maintenance Organization Act of 1973,
considered an attractive alternative and a method for reducing costs. They provide
a wide’ range of comprehensive health care services for a specific group at a fixed
periodic payment. The HMO can be sponsored by governments, medical schools,
hospitals, employers, labor unions, consumer groups, or insurance companies. The
HMO contracts with groups and individuals to deliver all needed health care for
a pre-paid monthly premium using a managed system of providers (Bitoy, 1995).
Private insurance carriers were also feeling the “squeeze” by the high cost of care.
Their programs, most often funded by the employer, sought relief and HMO’s
created for them an opportunity for significant savings. All government and
92
private payer insurance systems addressed the costs for both surgery and long
term management. These developments heralded the era of “Managed Care”
and no segment of the ostomy industry escaped its attention. These events have
triggered a major shift in the control of medical practices. Frequently, professionals
have had to modify their treatment modalities to comply with newly imposed cost
standards.
Outcomes research is now dominating the thinking of medical care providers.
Appropriateness of surgical procedures is being evaluated on an on-going basis.
Management practices are being analyzed. Utilization of resources of any type is
being questioned. Much energy is focused on weeding out and perfecting surgical
alternatives (Fazio, 1994; 1995). The new stapler is obviating many permanent
colostomies and the pelvic pouch procedure is reducing the number of permanent
ileostomies. In the face of all of this, new treatments, drugs and devices were
extending the life span of the cancer patient. The goal of creating an even better
quality of life for the person with an ostomy moves forward unimpeded.
INDUSTRY 1990s
As might be expected, the flood of new products in the 80s was followed
by somewhat of a drought in the early 90s. Most companies addressed the
convenience aspects of their appliances by marketing both one and two piece
products with pre-cut stoma openings. They utilized improved films and comfort
panels on their pouches. Emphasis was placed on the locking capability of two
piece systems, Center Point Lock™ by Hollister and The Lock Ring™ by Coloplast.
ConvaTec’s Gentle Touch™ post operative device was marketed to address
abdominal tenderness and demonstrated a low force needed to secure the pouch
to the flanges.
Nu-Hope refueled interest in convexity with the introduction of their convex
inserts in the early 80s. These could be utilized with most of the one and two piece
systems in the market and it represented a major breakthrough. Shortly thereafter,
virtually all of the companies which sold two piece appliances offered their own
convex inserts.
Marlen Manufacturing was the first into the market with their Ultra®, a one piece
system offering convexity and a precut skin synthetic barrier. Hollister’s Convex®
Premier™ FlexTend™ and ConvaTec’s Active Life® Convex appliances followed.
ConvaTec launched the Durahesive® with Convexlt®, a convex two piece system
and Marlen responded with their Ultra Duet™ two piece system.
Cymed®, a new West Coast Company, introduced an ultra-thin product line called
MicroSkin® in both one and two piece configurations. This product practically
eliminates profile in the appliance. ConvaTec launched their one piece Active Life®
93
Flush-away™ (flushable) pouch in 1994. These are examples of industry’s attempt

to now address the lower level of needs of the ostomate.
As we approach the mid-point of the 90s, we can expect “cost effectiveness” to be
the key issue with every aspect of ostomy treatment. Managed care will force cost
out of procedures, services and products. LETs hope that this will not distract the
participants in the industry from their previously set “Quality of Life” objectives.
Today all of the hurdles which delayed the maturation of this industry have been
removed. There is excellent communication among the care givers (surgeons and
ET nurses), the manufacturers and the distribution channels. Needs are quickly
addressed and the right product is being made available to the person with an
ostomy in the most convenient manner.
AUTHORS’ ACKNOWLEDGEMENT
We investigated the history of ostomy products with help from Norma Gill and
Delores Voltz, RN, Canton OH, retired. Delores wrote to all of the early manufacturers
and asked them for their history.
This chapter was developed from the input of Delores, our personal experiences,
and interviews among ET nurses, ostomy product distributors and manufacturers.
We have attempted to develop an accurate presentation of the facts as they
occurred. However, we realize that in our research we might have overlooked an
important development or listed a wrong date. We apologize for any omissions or
errors.
REFERENCES
Aronson, M. (1995, May). Personal Communication.
Bitoy, V., Director of Reimbursement and Payer Alliances, ConvaTec,® A Bristol-Meyers Squibb
Company. (1995, March). Personal Communication.
Davidson, W. (1995). 1965–1994 A Revolution in Ostomy Management. ConvaTec Internal
Publication.
Fazio, V. (1994,1995). Personal Communication.
Gill, N. (1994, 1995). Personal Communication.
Gray, H. (1982, October). Wholesaler distribution of ostomy and home health care supplies.
Surgical Business.
Najarian, R. (1996, February). Personal Communication.
Priest, A. (1995, June). Personal Communication.
94
Childhood Ostomy Surgery: A Developmental View
Childhood Ostomy Surgery:

A Developmental View
T
he indications for childhood ostomy surgery are varied. In many instances
the need for fecal and/or urinary diversion in children is temporary. There
is a paucity of research focusing on children with either temporary or
permanent ostomies. Early works by Katherine Jeter (1982) and Bonnie Bolinger
(1982) highlighted the need to examine the child’s physical and psychosocial
needs. The importance of family support was noted. However, as Branden (1983)
observed “Even with the best intentions parents who are overprotective may
cripple self-esteem in a child.”
CONCEPTUAL FRAMEWORK
Psychosocial development centers on the premise that there is a series of normative
crises all individuals experience across the lifespan (Erikson, 1963). The manner in
which individuals progress through these crises is influenced by a variety of factors.
Newman (1986) stressed the significance of the meaning ascribed to life’s events
and crises by a client and family. While normative crises are universal, clients’ and
families’ reactions to them are not. It is the role of the nurse to identify the patterns
which emerge as a client and family evolve to an expanded level of consciousness
(Newman, 1986).
PSYCHOSOCIAL DEVELOPMENT
Erikson’s (1963) conceptual framework for psychosocial development draws on a
variety of disciplines; among them are psychiatry, psychology, and anthropology.
The overriding emphasis in his conceptual framework lies in Freudian
psychoanalysis. By exploring past experiences which have aided or impeded the
development of a strong ego, psychoanalysts attempt to guide their clients toward
a stronger ego identity (Erikson, 1963).
Erikson (1963) identified a sequence of phases of psychosocial development
across the life span and believed there are universal crises all children experience.
The manner in which they proceed through these transitional periods is based
on unification of “social images and of organismic forces” by one’s ego identity
(Erikson, 1959, p.23). These external and internal forces influence the formation
and maintenance of one’s ego identity across the lifespan (Erikson, 1963). Erikson
95
Paula Erwin-Toth
placed emphasis on psychological events such as anger, aggression, and repression

which can affect a child’s psychosocial development. Based on this premise, one
could suppose other internal events, such as disease or disability and the external
forces which react to the event, such as family or teachers, could affect a child’s
psychosocial development.
During infancy a sense of trust versus mistrust is established. Trust denotes an
attitude of security in oneself and the environment. The ability to trust is integral
to the formation of a positive self concept (Schilder, 1951). Failure of infants to gain
a sense of trust can lead to feelings of dissatisfaction and anger toward themselves
and others (Erikson, 1963). A hospitalization that interrupts the bonding process
between the infant and parent could contribute to a sense of mistrust in the child
and possibly delay the parent’s attachment to the child (Erwin-Toth, 1988).
As toddlers manifest mastery over their bodies and attempt to assert control
over their environment, a sense of autonomy develops. Failure of children to gain
confidence in themselves and some degree of control over their environment
can result in feelings of shame and doubt (Erikson, 1963). If appropriate, toilet
training of the child with a non-ostomy involved system can begin (that is, bladder
training in a child with a colostomy). In addition, during this time the child with an
ostomy will gradually become aware when the pouch is full and can begin to alert
care givers who should respond in a positive, supportive manner. Although total
ostomy care is conducted by the primary care giver, the child should be included
in care to promote a sense of autonomy. For example, the child can hold the stoma
measuring guide after the corners have been rounded off and can help peel the
paper backings from the pouch or skin barrier once it has been started (Erwin-
Toth, 1988).
Preschoolers attempt to establish initiative versus guilt. If children’s efforts at
independent action are fostered, they gain an increased sense of accomplishment
and self-worth. Erikson (1963) stated a system of mutual regulation should emerge
during this stage. The child’s attempts at control are tempered with a sense of
moral responsibility toward others. Teaching should be undertaken as a joint effort
with the child and primary care givers. The child’s heightened sense of body image
will make him even more aware of an alteration in body structure and function.
Loving support and acceptance of the child by the family will help foster a positive
self-concept.
The preschooler is intensely curious. The ET nurse and care giver should
channel that curiosity in a positive manner. As the child matures, he or she can
undertake certain aspects of ostomy self-care, such as peeling off paper backings,
helping to cleanse the peristomal skin, and assisting with pouch emptying and
clamp manipulation. The primary care giver should continue to perform work
96
involving scissors, complete the cleansing of peristomal skin, and oversee each
pouch emptying and manipulation of the clamp. Although improved eye-hand
coordination is developing, the primary care giver is generally the one to actually
apply the ostomy pouching system. Encouraging the child to practice on a
teaching aid generates an enthusiastic response. The attention span of a 3 year-
old child is approximately 10 to 15 minutes, 20 minutes for a 4 year-old child, and
about 30 minutes for the child of 5. Simple, concrete, “here and now” instruction
and explanations are most effective. Positive reinforcement is useful to emphasize
success and minimize failure (Erwin-Toth, 1988).
The school age child gains a sense of industry versus inferiority. The actions of the
child become purposeful and productive. A sense of pride and accomplishment
from a successfully completed task is developed. If children are unsuccessful with
their attempts at mastery of various skills and interactions with others, they may
feel inadequate or inferior (Erikson, 1963).
School age children manifest a desire to become productive and derive pleasure
from work by perseverance and completion of tasks. Interaction and cooperation
with peers is important during this stage (Erikson, 1959). Erikson (1963) viewed
the danger at this stage to be a formation of a sense of inadequacy and inferiority.
If ostomy surgery disrupts a child’s sense of independence and accomplishment,
it could have a negative impact on ego development. Conversely, children who
are able to gain control of their bodies and gain a mastery over themselves could
emerge with a strong sense of industry (Brunnquell, 1987). ET nurse interventions
for the younger school-aged child (6–9 years) are similar to those for the pre-
schooler. The child’s active participation and competence in ostomy self-care
increase. Manipulating the clamp and emptying the pouch are tasks that are easily
managed. Adult supervision while using scissors, cleansing peristomal skin, and
applying the appliance is strongly indicated.
The preadolescent (9 to 12 years) can be encouraged to perform the majority of
ostomy self-care activities independently. Families are included in the teaching
sessions to offer support and reinforcement. Some parents resist independence on
the part of the child out of concern for the child’s physical condition or fear that the
child will not perform the care competently. Although they are well intentioned,
such concerns may cripple the child’s self-esteem (Branden, 1983). Peer activities
are important during the school age years. School children are most concerned with
their ability to play and participate in desired activities. The presence of a stoma
need not bar a child from active participation in extracurricular events. Foresight
and planning by the parents, teacher, scout leader, and others can enable the child
to gain the peer acceptance needed for normal development (Erwin-Toth, 1988).
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Paula Erwin-Toth
Erikson described adolescence as the “last and concluding stage of childhood”

(Erikson, 1959, p. 110). During this stage the child progresses toward formation of a
lasting pattern of inner identity. Identity formation is characterized by an evolving
configuration of ego synthesis and re-synthesis (Erikson, 1959). Adolescents are
grappling with an emerging sexuality, the need to establish themselves with peers
and the community, and the need to assert their independence (Murray & Zentner,
1985). This turbulent time is a normative crisis characterized by the adolescents’
“Fluidity of defenses” (Erikson, 1959, p.117). This fluidity enables them to react to
the onslaught of inner and outer demands that are inherent in adolescence.
The critical phase of adolescence is described by Erikson (1963) as establishment
of identity versus role confusion. Young persons develop a sense of who they are
and how they fit in with peers, family, and society. Their changing bodies require
a reassessment and reintegration of their body image (Murray & Zentner, 1985). If
they feel isolated or insecure, have problems relating to others, or are unable to
cope with life’s stresses and strains, their sense of self may become lost or diffused
in the process.
Adolescents who are confronted with integrating an ostomy into the formation
of their ego identity have a formidable task. If the ostomy was created during the
school age period and the child did not establish a sense of industry, the formation
of identity may be impaired. A child with an ostomy who has established a sense
of industry may be better able to face the challenges of adolescence. This may
require a reintegration and reassessment of the ostomy as they face transition to
young adulthood. A heightened sense of body image, emerging sexuality, and
the ability to consider the long term effects of their condition will confront school
aged children with ostomies as they enter adolescence (Bolinger, 1982).
Psychosocial development is a cumulative process. An individual who has been
unable to resolve the developmental crises of earlier phases may not be able to
establish true intimacy during young adulthood. Failure to establish close ties in
a sexual union or other outlet, maintain close friendships, and conduct personal
reflection could lead to isolation and self absorption (Erikson, 1963). The manner
in which a child has fared with a multitude of inner and outer stresses, including
an ostomy, could influence the child’s ability to establish a sense of intimacy versus
isolation in young adulthood. Erikson (1959) stated that in order to understand
childhood it is necessary to start at the young adult and work backward.
HEALTH AS EXPANDING CONSCIOUSNESS

In the introduction to her text, Health As Expanding Consciousness (1986), Newman
related a personal experience which influenced her nursing paradigm. As a young
woman she was faced with her mother’s chronic illness and subsequent death.
She found the experience fraught with periods of exhaustion, restrictions, and
98
difficulties. She also discovered intensity, loving, and an expanding consciousness

during the same experience. She stated “I had the feeling that I was preparing for
something else” (Newman, 1986, p. 2.)
Newman viewed disease as a meaningful aspect of health wherein an individual’s
consciousness is expanding via an evolving pattern. The pattern is unfolded in
an endless variety of life experiences including illness and disability. Newman
characterized health and illness as a single process manifested by peaks and
valleys and varying degrees of organization and disorganization. An individual
who is able to embrace and interact with an event, such as an ostomy, will emerge
with increased power and personal awareness (Newman, 1986).
Newman did not suppose these interactions would be easy. She stated higher
levels of consciousness are always preceded by a fluctuation or crisis. Disease is
an integrating factor in the evolutionary development of an individual (Newman,
1986). Newman viewed disequilibrium caused by disease as vital to the growth
and development of a person. While she recognized the existence of universal
developmental crises, Newman believed all events should be viewed within the
unique patterns of individuals and their environments (Newman, 1986).
All persons experience a constant exchange of energy and interaction from within
and without. Newman viewed disease as an “integration and transformation
factor in the family sector” (Newman, 1986, p. 30). An ostomy could be a mechanism
of growth for both the child and family. As open systems, the interaction
of the child and family with the community will influence the new reality they
experience after the ostomy event. The nurse applying Newman’s (1986) paradigm
would not approach ostomy surgery as being an isolated event. The nurse
would examine the impact of the ostomy surgery within the context of meaning
ascribed to it by the child and family. By identifying patterns which have emerged
as a result of the ostomy event the nurse can act as a facilitator to enhance
the child’s and family’s progression to an expanded consciousness
(Newman, 1986). In order to be effective in this endeavor, nurses need to be in
tune with their own patterns (Newman, 1986). The nurse-client interaction is
characterized by mutuality. There is a continuous exchange of verbal and non-
verbal communication between them. Since patterns are continuous and flowing,
the nurse should create an atmosphere conducive to the unfolding of a client’s
pattern (Newman, 1986).
Newman operationalized her health model by describing the dimensions of time,
space, and movement as manifestations of consciousness. These interrelated
entities are continually evolving and fluctuating. Assessment of these dimensions
in the client by the nurse can reveal areas where energy is blocked, depleted,
diffused, or overloaded (Newman, 1983). An ostomy causing disequilibrium in the
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Paula Erwin-Toth
child and family could be a mechanism for the attainment of a higher consciousness.
Individuals who are able to call on their inner resources and environmental support
to transcend space and time will be transformed to a higher level of consciousness
(Newman, 1986). Thus childhood ostomy surgery could provide for an atmosphere
of growth for the child and family.
AUTHOR’S NOTE
I became interested in this topic as the result of personal and professional
experiences in my life. I became curious about the differences in the people who
had grown up with stomas. I encountered people who had grown up with ostomies
who were leading rich, full, and productive lives. I also encountered people who
had very similar physical conditions or, in some cases, fewer physical problems
who did not cope as effectively.
As a co-editor of this text honoring Norma Gill-Thompson, I would be remiss if I did
not add a personal note to this chapter. My first interaction with Norma occurred
in 1965. It was a hot August day in Akron, Ohio. I was ten years old with a five
day old ileal conduit that was performed as a solution to manage extrophy of the
bladder. I remember having tincture of benzoin painted on my skin and a blue
post-operative drainable pouch applied, several times a day. This pouch leaked
continually and the nurses, although they were compassionate, seemed at a loss
as to what to do. Most of them confessed they had never seen a stoma before and
simply did not know how to manage one. By this time my skin was red and sore.
I was in pain from the surgery and tired of being soaked with urine. My urologist
and surgeon offered some pouching suggestions, but they seemed as bewildered
by the leakage as the nurses.
My urologist, Dr. Manley Ford and my surgeon, Dr. William Sharp called in a woman
whose work at the Cleveland Clinic with ostomy patients was becoming well
known in the Akron area. It seems the Fates were smiling upon me. Not only was I
blessed with two gifted and wise surgeons and a loving family, but Norma actually
lived in Akron and agreed to come to see me after her work day in Cleveland was
completed.
Norma breezed into the room and took stock of the situation. I will always remember
how her confidence was contagious. She calmly and assertively explained to my
surgeons, nurses, my mom and me what needed to be done and proceeded to
show them how to do it. I was astounded to watch the faces of that group as they
gave Norma their undivided attention. It was immediately apparent to me that this
was a woman to be reckoned with.
100
By today’s standards the equipment was archaic. The cement and latex pouches
caused me to experience sensitivity reactions. The solvent to remove the cement
felt as if I was being set on fire. But Norma persevered. She communicated the
problems she was having with “her kids” to ostomy manufacturers. After nearly a
year of daily leaks and skin irritation, the quality of my life dramatically improved
with the introduction of Marten’s double faced adhesive discs and vinyl, pediatric
urinary pouches. Even though I did not allow the frequent leaks to curtail
my activities, the security of a 5 to 7 day seal improved the quality of my life
considerably.
These were the years when the only place to acquire supplies was from Norma’s
basement. If she was not going to be home she would leave them in her garage.
If money was a problem she would do her best to be sure “her kids” got what they
needed. Annual check ups were performed in Norma’s bedroom with her poodles,
Pierre and Snookie, closely observing the visit from start to finish from the corner
of the bed.
This chapter would not be complete if I did not tell what Norma and I fondly
call the “Belt story”. When I was about twelve years old, Norma had just finished
refitting me with new ostomy equipment. In the process she threw away my old
ostomy belt. When I requested a replacement she refused. She would not budge.
She said with the better double faced adhesive discs, belts were no longer needed.
I was sure my pouch would fall off. Despite my temper tantrum to the contrary,
Norma remained firm. Even my mother sided with her. I was outraged! Despite my
predictions of doom, Norma was correct. It nearly killed me to admit it to her at
the time.
But wait! There is more to this “Belt Story”. After I became an ET and was reminiscing
with Norma, I recounted my fury with her over the belt incident. Norma paused and
chuckled, “There’s more to that story than you know. It was Rup’s (Dr. Turnbull’s)
idea to stop using belts. He said the better adhesives made belts unnecessary and
the belts caused more problems then they were worth. Frankly, I (Norma) was
skeptical. I had worn a belt the entire time I had my ileostomy. So I decided to take
the belts away from “my kids”. Since you were more active than most I figured if you
didn’t leak without a belt then it would be safe for me to throw mine out!!!” I do not
think I have ever laughed so hard in my life. In fact every time I think of the “Belt
Story” it brings a smile to my face.
As an ET nurse, I have taken care of people on permanent disability who have less
physically wrong with them then I do today. What more can I say about a woman
who has been my ET, mentor, and friend? As long as I live I will be thankful that I
was and always will be one of “Norma’s Kids”!
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Paula Erwin-Toth
REFERENCES
Bolinger, B. (1982). The adolescent patient. In D. Broad well and B. Jackson (Eds.). Principles
of Ostomy Care, (pp. 534–544). St. Louis: C.V. Mosby.
Branden, N. (1983). Honoring the self: Personal integrity and the heroic potentials. Los Angeles:
Jeremy P. Tarcher, Inc.
Brunnquel, D. (1987). Hospitalizations. In A. Thomas and J. Grimes (Eds.), Children’s needs:
Psychological perspectives, (pp. 289–97). Washington, D.C.: The National Association of
School Psychologists.
Newman, M. (1983). Newman’s health theory. In I. Clements & F. Roberts (Eds.). Family Health:
A Theorectical Approach to Nursing Care. New York: John Wiley and Sons.
Erikson, E. (1959). Identity and the life cycle. Psychological issues. New York: International
Universities Press, Inc.
Erikson, E. (1963). Childhood and Society (2nd. ed.). New York: W. W. Norton and Company,
Inc.
Erwin-Toth, P. (1988). Teaching ostomy care to the pediatric client: A developmental
approach. Journal of Enterostomal Therapy 15(3), 126–130.
Jeter, K. (1982). The pediatric patient. In D. Broadwell and B. Jackson (Eds.). Principles of
ostomy care, (pp.489–533). St. Louis: C. V. Mosby.
Newman, M. (1986). Health as expanding consciousness. St. Louis: C.V. Mosby.
Schilder, P. (1951). The image and appearance of the human body. New York: International
University Press.
102
ET Nursing Education: A Global Perspective
ET Nursing Education:
A Global Perspective
I
n 1983, Ellis identified a triangular model of nursing knowledge — nursing
practice, nursing education, and nursing research (see Figure 1). She further
clarified these knowledge activities.
• Nursing practice: is the use of nursing knowledge
• Nursing education: is the transmission or acquisition of nursing knowledge
• Nursing research: is the development and evaluation of nursing knowledge.
It is my personal belief that any discourse on education must be done within
this framework. Therefore, the global perspective of ET Nursing Education will be
presented by examining ET nursing practice, ET nursing education, and ET nursing
research.
ET NURSING PRACTICE
The international association of ET nurses (the World Council of Enterostomal
Therapists, WCET) has identified ET nursing as a specialized field of nursing
practice providing expert care for individuals with specific needs — ostomies,
continence, and actual or potential impaired skin integrity (1995). In addition, this
association has identified four ET nursing practice roles: clinical, educational, research,
and professional development. An omitted but implied ET nursing practice role is
administrative.
Figure 1. Ellis Model of Nursing Knowledge
Practice
Education Research
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Nancy A. Faller
Clinical
The clinical practice role holds ET nurses responsible for using the nursing process.
We must employ nursing assessment and implement nursing interventions, to
identify and respond to not only actual but also potential ET nursing problems.
This clinical practice role encompasses two inherent sub roles: communication
and long term planning.
Communication
Communicating clinical assessments and interventions includes the obligation for
verbal exchange as well as written documentation. Communication must embrace
both the client/family unit as well as all members of the health care team (Alvarez,
1992; Ingersoll & Jones, 1992).
Documentation is a critical component of ET nursing. Accurate notation of initial
subjective and objective data related to stomas, continence, and skin integrity
along with ensuing changes in status provide the framework for evaluation by not
only ET nurses themselves, but other members of the health care team as well.
The tendency of ET nurses to ignore the significance of documentation has been
reported (Alvarez, 1992).
Long term planning
A key component of the nursing process is planning, both for short and long term
outcomes. This includes case management across the continuum: acute, long term,
home, and outpatient services. Specialty nurses have made a major impact in this
area, resulting in decreased hospital stays and decreased readmissions (Gift, 1992).
A study by the American association of ET nurses (International Association for
Enterostomal Therapy, IAET) showed that hospitals with ET nurses had shortened
length of stays for ostomates (Jeter, 1982). Crossing nursing practice settings
provides ET nurses with a unique opportunity for long term planning. Working
across the continuum of care allows us to facilitate the movement of clients to a
less intensive and less expensive care level. The ET nurse with consulting contracts
in long term care, home care, and outpatient care, in addition to acute care, can
facilitate a smooth transition of the client to the least intensive, least expensive
level of care. This movement may be from intensive care to ward care or from
extended care to home care. The overall flow reduces the total cost of management
for the health care delivery system.
Educational
The educational practice role holds ET nurses responsible both for nursing and
allied health education as well as for client and consumer education. Nursing and
allied health education occurs both in formal and informal situations. We may also
share our skills by role modeling, precepting students, and mentoring colleagues.
104
Client and consumer education includes one to one teaching plus the assessment
of needs and the design of specific teaching tools, developed for the lay person.
Patient education by specialty nurses has been credited with improving clinical
outcomes (Gift, 1992).
At both the professional and nonprofessional levels, ET nurses should be relating
their experiences in both clinical and lay publications. Writing for publication is
especially significant for ET nurses as we garner experience in a narrow field that is
particularly valuable to other nurses.
Research
The research practice role holds ET nurses responsible for both the use of research-
based practice as well as participation in research activities. We are accountable for
maintaining a research-based practice using the most current studies available.
At the same time we must be alert to practice-based research questions. Inherent
in using research is the requirement to read studies critically to avoid making
inappropriate assumptions about the results, (van Rijswijk & Krasner, 1987). We are
continuously presented with clinical practice situations in need of investigation
and must scientifically investigate the solution(s).
Professional Development
The professional development practice role holds ET nurses responsible for
participating in the activities of their national ET nursing association, continuing their
educational endeavors, and reviewing current literature.
Administrative
The administrative practice role holds ET nurses responsible for two sub roles:
management and change. As previously noted, this role is not specifically stated by
international association of ET nurses (the World Council on Enterostomal Therapy
(WCET), however it is implied by the topics within their ET nursing curriculum.
Management
ET nurses are accountable for the management of their service. This service may
be as small as a one person operation or more extensive, incorporating an office,
a clinic, a unit, or a department. The management sub role encompasses two
inherent sub roles: fiscal responsibility and controlled growth. ET nurses must be
able to function within the constraints of an operating budget. We must validate
both income and expenditures related to the direct services we are providing as
well as to the equipment used in providing these services. The cost effectiveness
of direct services on clinical outcomes must be considered. Equipment to be
considered must include specific items utilized for clients and capital purchases
by the institution.
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Nancy A. Faller
ET nurses must also have their eyes on the future, being alert to opportunities
for expanding services. Marketing skills will assist ET nurses in promoting their
service while assuring fiscal responsiveness and structured growth. Opportunities
for marketing ET nursing services may be as simple as word of mouth or more
formalized (Weissman, 1988).
Change
ET nurses are also accountable for change. The change agent sub role includes
the identification of problems, the analysis of possible solutions, and the
implementation of the appropriate intervention(s). This is the nursing (scientific)
process applied to non-clinical situations. We continuously identify and act on
numerous possibilities for change.
Discussion
There is a recognized difficulty in the linear approach used in this analysis. It
does not give sufficient credit to the cross-over of roles. A number of examples
can be cited. Communication, to include documentation weighs heavily in the
administrative role in addition to the clinical role. The use of research can by
rights be considered more aligned to the clinical role than the research role. The
evaluation of equipment and services can be conducted in such a way as to make
it more cohesive with the research role than the administrative role.
ET NURSING EDUCATION
The international association of ET nurses (the WCET) has recognized the need for
preparing nurses in the specialized area of ET nursing. Therefore, this association
has established guidelines for comprehensive ET nursing education programs.
Three areas related to these programs will be discussed, credentialing for entry into
ET nursing education programs, curriculums of ET nursing education programs,
and methods of offering ET nursing education programs.
Credentialing for Entry into ET Nursing Education Programs
In the early days of ET nursing, there were minimal prerequisites for admission
into a course of study. Many of the pioneering students were housewives with an
ostomy or... siblings, spouses, and mothers of a person with a stoma. Over the years
ET nursing education programs have been formalized and the entry requirements
were raised. The international association of ET nursing’s (the WCETs) guidelines
specifically limits students to registered nurses with postgraduate experience
(1995).
Curriculum of ET Nursing Education Programs
The ET nursing practice roles previously described in section one must be
addressed in ET nursing education programs. Although traditionally the clinical
106
role is heavily emphasized, efforts to present the educational, research, professional

development, and administrative roles must be utilized. This holistic approach will
prepare the ET nursing student for the challenges of maintaining an active and
viable ET nursing practice.
Clinical Practice Role
The common thread in ET nursing education programs is the clinical practice
role. For our ET nursing forerunners, this was care of the person with a stoma.
Curriculums have gradually expanded to include a fuller scope of practice:
ostomies, continence, and actual or potential impaired skin integrity. When
preparing curriculums, ET nursing educators cannot assume that students come
with the necessary communication and long term planning skills. Efforts to model
these behaviors must be planned.
Educational Practice Role
ET nursing education programs must introduce the ET nursing student to the
educational practice role. We must be ready not just to develop and present
educational workshops and programs but also to devise the necessary syllabus.
The use of audiovisual materials must be included. In addition to professional
education, students must be introduced to the development of educational
materials for clients. These might include but are not limited to teaching books,
stoma and wound models, and discharge instructions.
ET nursing students must have their writing skills sharpened. Many of us have
found unique solutions to clinical problems, developed innovative educational
programs, identified a research based answer to a question, or developed a new
administrative tool. These ideas should be shared with colleagues through nursing
publications. Encouragement must be provided, so that ET nurses can overcome
the initial fear of manuscript rejection.
Research Practice Role
ET nursing students must be primed to embark on a research-based practice.
Every day, we must make critical decisions regarding costly equipment, from beds
Table 1. Models of Providing ET Nursing Education
Theoretical skills Technical skills

i on site on site
ii on site off site
iii locally off site
iv at home off site
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Nancy A. Faller
to biofeedback. Without the skills to skeptically evaluate clinical trials, costly,

inappropriate decisions can be made.
Professional Development Practice Role
ET nursing educators can not “teach” the skills necessary for the professional
development role. However, educators can demonstrate behaviors that expose
their ET nursing students to the need for continued development. Furthermore, ET
nursing students must be made aware of the available professional development
opportunities, to include ET nursing associations, journals, and congresses.
Administrative Practice Role
It appears that very little emphasis is placed on the administrative practice role.
Two nagging themes seem to support this supposition. Many ET nurses do not have
permanent ET nursing positions. Despite their education, they are working as staff
nurses often not even on surgical wards. In addition, many permanent ET nursing
positions are being cut. They are the first to go when budget belts are tightened.
To ensure the safety of ET nursing positions within this health care environment,
ET nursing students must be carefully groomed for this role. A wide range of topics
must be introduced. These might include but are not limited to justifying and
managing budgets, marketing ET nursing services, evaluating existing ET nursing
services, and collecting and using statistics.
Method of offering ET Nursing Education Programs
Within each of the ET nursing practice roles previously defined, ET nursing
education programs must direct their efforts towards imparting critical thinking
skills and hands-on skills. In other words the whys and hows of ET nursing practice
must be explicitly discriminated. This division of skills has been the catalyst for
the evolution of multiple, diverse methods for offering ET nursing education
internationally.
Our pioneering ET nursing students attended a six week, hospital-based, integrated
theoretical and technical course. Over the years, three additional patterns of
educating ET nurses have emerged. This has left us with four models (see Table 1).
Additional models are likely to emerge.
With the increased cost of transportation and housing, it is likely that off site
options will continue to increase. ET nursing educators will be challenged to
consider novel ways of offering their programs. The computerized information
highway will open many new opportunities for educating ET nurses.
ET NURSING RESEARCH
As noted in the discussion after section one, this linear approach does not
adequately allow discussion of the interplay between facets. The impact of ET
108
nursing research on ET nursing practice and vice versa has been put forth. The
responsibility of ET nursing educators to present a research based practice has
been discussed. However there is an additional interplay between research and
education.
The international conference on Expanding Boundaries of Nursing Education
Globally (EBNEG) (October, 1993) (Alexander et al., 1994) has pointed out the
need for research to investigate educational strategies which are associated with
positive client health outcomes. In addition, this auspicious group has encouraged
the investigation of relationships between level of nursing education and client
health outcomes. Finally, the EBNEG advocated multisite, international, cross
cultural research which would permit the increased generalizability of any research
findings.
SUMMARY
There is a strong interplay between ET nursing practice, ET nursing education, and
ET nursing research. However, these bonds need continual strengthening if ET
nursing is to survive as a nursing specialty in the 21st century.
REFERENCES
Alexander M, Bajnok I, Conway–Welch C, Fitzpatrick P, Helembai H, Hochnegger–Haubmann
B, Loutfi Z, McCarthy G, McGivern D, Modly D, Mundinger M, Poletti P, Ryan S, Salvage
J, Slajmer–Japelj M, Stankova M, Tallberrg M, Tratter K, Zanotti R. (1994). A blueprint for
changing nursing education globally. WCET Journal, 15(1), 10–15.
Alvarez, C.A. (1992). Are consultation notes always necessary? Clinical Nurse Specialist, 6, 217.
Ellis, R. (1983). Nursing knowledge development. Proceedings: Epistemological Strategies in
Nursing, Jun 21–24.
Gift, A.G. (1992). Effectiveness of the CNS as Educator and Discharge Planner. Clinical Nurse
Specialist, 6, 201.
Jeter, J. (1982). A research study on the current and future role of ET nursing practice. Irvine,
CA association of ET nursing.
van Rijswijk, L. & Krasner, D. (1987). Reading right An exercise in critique. Ostomy Wound
Management, 38, 46–51.
Weissman, G.L. (1988). Perceptions of health care needs and satisfaction with nursing care
of the ostomate population: implications for marketing independent nurse practitioner
services. Dissertation. New York, NY: Columbia University.
World Council of Enterostomal Therapists (1993). Members Handbook. Mississauga, ONT:
World Council of Enterostomal Therapists.
World Council of ET Nursing (1994). Members Handbook. Mississauga, ONT: World Council
of ET Nursing.
109
Victor Fazio
Current Trends in Ostomy

Surgery
INTRODUCTION
T
he evolution and history of ostomy surgery has been well outlined in many
different texts, manuscripts and national presentations. No current article
or book — or for that matter — no such treatise made in the last quarter
century, would be complete without heavy referencing to the work of Norma
Gill … and her colleague Rupert Beach Turnbull. The era of these two giants in the
field saw the evolution of the idea of primary maturation of the ostomy, particularly
ileostomy, to prevent that dread complication of pre-1950s ileostomy surgery —
ileostomy dysfunction. This entity, described in detail by Warren and McKittrick of
Boston, carried a physiological effect of profound dehydration and shock due to
pseudo-obstruction, this resulting from a fierce serositis and submucosal, and
muscular thickening from the exposed serosa of the non-matured stoma.
Brian Brooke preferred and used the more straight forward remedy — primary,
simple maturation and suture, designed originally to correct the late sequelae of
the “conventional” operation, namely stricture of the late maturing stoma. Turnbull
and Crile had identified the same solution, namely primary maturation, but with
the more complex addition of stripping the muscular coat from the exteriorized
ileum prior to maturation. Both techniques worked and instantly solved the
problem of ileostomy dysfunction. However, the Turnbull technique never caught
on due to its more complex nature.
Another post ileostomy construction complication that was about as problematic,
if not in frequency, at least in severity, was ischemia of the exteriorized bowel. At
best, this would produce a flush stoma and problems of provision of adequate
seal. At worst, necrosis of the stoma within the peritoneal cavity would mean
a re-laparotomy in a recently operated patient, usually under more difficult
circumstances than the one leading to the earlier surgery. The Turnbull ileostomy,
as it has come to be known, is the loop ileostomy (and its variant, loop end
ileostomy). The survival and vascularity of the stoma is predicated upon the
avoidance of undercutting the mesentery with division of the vasa recti as obtains
with end ileostomy. Thus, this technique is now common place with:
• ileostomy construction in the obese patient
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Current Trends in Ostomy Surgery
• any situation where making an end ileostomy leaves the patient vulnerable
to ischemia
• to divert the fecal stream with construction of a loop stoma: to ensure
diversion, either temporary or permanent, the down stream end may be
simply stapled and divided with such instruments as the GIA60®.1
It is also about this time that there was increasing recognition of the value of
primary maturation of colostomies and the myth of enhanced parastomal sepsis
rates with this technique became dispelled.
The late fifties and early sixties saw the introduction of the first valuable skin
barriers with Karaya and later Stomahesive®2 in the sixties. However, the major
advance was the recognition of the plight of patients requiring ostomy surgery
— where rehabilitation was left to under-educated nurses, pharmacists, patients
… and doctors where interest was often low and frustration often high. The
advance referred to is the evolution of ENTEROSTOMAL THERAPY as a profession
and specialty … and the training schools to educate and further the cause. The
remarkable pioneering and innovative work of Norma Gill placed this particular
advance as the one most far reaching and having the most impact on patient care
where ostomies were concerned.
It was also during this time that national and international ostomy
associations for both practitioners and patients developed. As well, the modern
technique of colostomy irrigation was developed that enabled appropriate
patients to be spared of the need for constant wearing of pouches. Other seminal
contributions to ostomy development include Nils Kock’s pioneering work on
the continent ileostomy. Also, the principle of continence surgery for urinary
conditions have involved similar antireflux techniques stemming from much of
Kock’s work. In turn, complication rates initially were quite high, in the 50–60%
range, but as techniques evolved and patient selection improved, so results have
improved as well.
There are many other innovations one might mention e.g. the Prasad stoma (after
bowel resection, the end stoma is created with the distal oversewn stump kept in
immediate proximity to the end stoma); valve-wall stapling for maintenance of
continence in the Kock pouch; laparoscopic stoma construction … all designed to
improve quality of life and render easier any future surgery.
CURRENT TRENDS IN OSTOMY SURGERY FOR BOWEL CONDITIONS

AND THE SOCIOECONOMICS OF OSTOMY CARE
The following represents one surgeon’s view of trends or changes in the surgery
and management of ostomies for bowel conditions, namely ileostomies and
colostomies. As well, there is some discussion about the way in which trends in
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Victor Fazio
ostomy care delivery systems are affecting surgical practice, in particular, the
effects of socioeconomic changes in ostomy care.
Primary Surgery
Preoperative stoma marking and informed consent. While this has always been a
desirable part of the preoperative preparation of the patient, it has now emerged
that preoperative stoma marking is becoming more or less routine in the elective
setting. The process of informed consent has taken on the extra aspects of
including a full and detailed discourse of the general condition affecting patients
and the options available to them with respect to choices. These choices include a
discourse on relative risks and merits of ostomies, either permanent or temporary in
this setting. Mentioned below are aspects of further trends with respect to length-
of-stay reduction in the current health care setting, restricting acute hospital care
to only those things which must be accomplished in the hospital. Thus it is that
outpatient teaching has taken on a new dimension in terms of its completeness
prior to admission to hospital.
Loop ileostomy versus loop colostomy. The last decade has seen the change in
emphasis regarding temporary fecal diversion, wherein loop ileostomy is gradually
replacing loop colostomy. The basis of this rests with the fact that loop transverse
colostomies commonly require a large collecting device and are located in a site
(supraumbilical) that patients do not particularly like. In addition, the temporary
fecal diversion often ends up being protracted for many months, and sometimes
becomes almost a permanent condition. In such situations, loop colostomies are a
poor type of permanent diversion. Other advantages for loop ileostomies includes
the relatively non-odorous discharge, an appearance somewhat more acceptable
than loop colostomies, and finally when the loop ileostomy is closed, there is a
much lower rate of incisional hernia at that location than in situations where the
loop colostomy is closed.
Stoma avoidance. Major centers dealing with large volumes of colorectal and
intestinal surgery have long been able to use stoma avoidance surgery for cancer,
namely low anterior resections with low colorectal anastomosis or coloanal
anastomosis. This has not, until the early 1980s been readily available for patients
with ulcerative colitis and indeterminate colitis. However, with restorative
proctocolectomy (also known as a total proctocolectomy with ileal pelvic pouch
anal anastomosis), this operation has gradually become the standard operation
for patients with ulcerative colitis. Thus, the operation of proctocolectomy with
Brooke ileostomy now assumes a role of some 5–10% in most series, in terms of its
frequency of use, whereas the restorative proctocolectomy is used for about 90%
of the patients undergoing definitive surgery for ulcerative colitis. There remains
a small number of patients who will have continent ileostomy, and even smaller
112
number who will have ileoproctostomy as the treatment for ulcerative colitis
surgery, but nowhere near the order of magnitude as in the early 1980s.
While such patients with ulcerative colitis will have restorative operations, almost
all (90%) will have temporary ileostomy for three months. With this operation,
there is a 3 to 5% failure rate necessitating permanent ileostomy in the long run.
One of the controversies about this surgery is whether or not one can perform this
operation in a one stage fashion, i.e. without temporary ostomy. This is being done
in about 10% of cases, although some centers will use this much more frequently.
The complications of this are that of anastomotic leak in 10%, and half of those
patients require an ostomy being made at that same hospitalization with a second
surgery. With respect to restorative operations for colorectal cancer, the coloanal
anastomosis with colonic J pouch has emerged as one of the major trends in rectal
cancer surgery. By providing a J loop of approximately 10 cm limbs, bowel function
after cancer surgery can be improved considerably, as evidenced by reduced
frequency of stooling and by reduced urgency.
Short stay/length-of-stay reduction. In the USA, governmental attempts to reduce
health care costs led to attempted passage of a comprehensive health care
reform bill in 1994. While this failed as a government initiative, industry and in
particular, private insurance companies, along with some other medical groups,
have altered health care by a system currently known as managed care. In many
ways, this comes down to management of costs, and one of the most important
ways in which costs can be contained has been with length-of-stay reduction. In
the 70s, average length-of-stay for a major inflammatory bowel disease surgery
or colon cancer was in the 12 to 14 day range. Currently, these length-of-stays
have been reduced to five to seven days. This has in turn led to many changes
that affect the enterostomal therapist, the surgeon, and most importantly, the
patient when it comes to overall delivery of medical care. Specifically, with respect
to ostomy care, there is now a heavy involvement in the teaching process for
patients before admission to hospital and during the course of the hospitalization.
While in the past, the rods of a temporary loop stoma would be kept in position for
approximately seven days (to ensure that the ostomy itself would not retract back
into the abdominal cavity), this has changed considerably. It is the rule rather than
the exception for the supporting rods to be now removed around day three or four.
This also helps prevent the partial obstruction that sometimes occurs with patients
having a compressing rod in place for a prolonged period of time. Secondly, this
allows for a much earlier training with respect to the patient self-pouching the
stoma, that has been more or less mandated to reduce length-of-stay. It is now
technically feasible to have the patient be discharged as early as day five or six for
many of these operations. Recognizing that ostomy function in its optimal form
takes several weeks, this earlier discharge probably has had little bearing on this.
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Victor Fazio
Parallel with this has been the recognition that there has been no enhanced rate
of complications (e.g. stoma recession), as one might have expected. Furthermore,
this has led to early removal of the nasogastric tube, (e.g. the day after surgery),
and in certain cases, no nasogastric tube is used. This in turn has helped shorten
length of stay. Other techniques that are used to reduce length-of-stay include the
use of care tracks for patients, the use of case managers, the publishing of length-
of-stay guidelines (e.g. Medicare and California data for the major DRGs 148 and
149 that constitute major large and small bowel procedures with and without
comorbidity for colorectal surgical practice). Visual aids, discharge instructions on
video and discharge instruction booklets, all are used to enhance the experience
for the patient when these discharges occur. The patient’s recovery continues after
discharge and this has meant, in certain cases, discharge to subacute care facilities.
In many cases home health care nurses visit the patient in the home setting. This
has become a burgeoning or expanding aspect of postoperative care. Indeed,
more and more hospital enterostomal therapists are being recruited into this
particular role.
Restorative Proctocolectomy (RP) vs. continent ileostomy. The continent ileostomy
has served well with respect to its being a viable alternative to the Brooke
ileostomy for patients who wish to avoid wearing an external appliance. However,
the operation of RP has largely superseded the continent ileostomy as there is no
necessity to have a regular intubation, carry the equipment necessary for continent
ileostomies, as well as the fact that defecation per the anus is largely accepted
as being preferential by patients. There still is the recognition, however, that
restorative proctocolectomy carries a certain rate of complications of somewhere
in the range of 5 to 12% for pelvic sepsis. About 5% of patients get pouch/vaginal
fistulas. About 4 to 5% end up losing their pouch because of complications or
the development of Crohn’s disease. Finally, the continuing ongoing problem of
pouchitis mandates the usual continued care of many patients, upwards of 30%
who get this complication, after surgery.
Laparoscopic surgery. The operation of segmental colectomy traditionally involves
laparotomy. In the last four to five years, segmental resection for such benign
conditions as diverticulitis of the sigmoid colon, Crohn’s disease, benign villous
adenomas of the colon, and recurrent sigmoid volvulus, have been treated by
laparoscopic surgery techniques in increasing numbers. The technique is very
demanding and requires special skills after the surgeon attains special competence
and training. At present, the total number of patients having their surgery done
in this way is quite small, but the purported advantages include much reduced
length-of-stay, reduced postoperative pain, earlier return to work, and a much more
cosmetic appearing abdomen with no large laparotomy wound. At present, there
is a major controversy going on about the role of laparoscopic surgery for cancer
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of the colon. This issue is currently being tested in at least two major randomized
controlled clinical trials in the United States, one being at Cleveland Clinic.
Finally, laparoscopy has been used for simple stoma construction. The setting
in which this occurs has been patients having distal fistula repaired (e.g. certain
rectovaginal fistula and complex recurrent high anal fistula). In such cases, a
laparoscopic approach can be used to construct a loop ileostomy or colostomy
to prevent contamination of the repair. This can also be used to cover a sphincter
repair such as a sphincteroplasty, or be used for palliation in patients who are
having severe radiation reactions in the preoperative treatment of rectal cancer.
This is one particular circumstance in which laparoscopy is particularly valuable as
a technique to construct the stoma.
Emerging trends in the past decade. The emerging trends in the past decade have
seen the use of CT guided drainage of pericolic and pelvic abscesses associated
with perforative diverticulitis. In the past, such conditions would be treated by
segmental resection of the sigmoid with construction of an end sigmoid colostomy
and oversew of the rectal stump (Hartmann operation). With the downstaging
now possible with pre-operative CT guided drainage of the abscess, such patients
may often be brought through the acute illness such that they can have definitive
surgery done in one stage around three to four weeks later. This surgery would
consist of a sigmoidectomy and colorectal anastomosis.
Reoperative Surgery
The current trends that are occurring with respect to ostomy surgery include the
surgery of parastomal hernia. While conservative management is still the rule,
operation is often ultimately necessary. At our institution, the trend has been
increasingly to avoid relocation unless this is a multiple recurring hernia. Instead,
local repair is commonly used. In this case, sometimes the repair can consist of
simple relocation through an adjacent piece of rectus abdominous muscle in
situations where the stoma has been brought out external to the muscle. In other
situations however, especially for large hernias, Gortex mesh is used to support
the repair.
Ileostomy Recession
There is a lessening need for surgery for ileostomy recession as a result of the major
advances made by industry in respect to skin barriers and equipment. Occasionally
this is still required, and in certain cases, two directional myotomy is used.
Prolapse and Ileostomy Bleeding
Usually this consists of prolapse of a loop transverse colostomy. In such cases the
current trend is towards closure of the loop colostomy and construction of a loop
ileostomy. This may often be achieved without requiring a formal laparotomy.
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Victor Fazio
With respect to ileostomy bleeding from caput medusa, this condition has usually
been treated by circumferential disconnection of the mucocutaneous junction.
This continues as does the periodic use of sclerosing injection. However, with
the much wider use of liver transplantation, such patients are increasingly being
considered for liver transplantation to correct permanently this condition of portal
hypertension.
Surgery for Fecal Incontinence
When traditional measures (e.g. sphincteroplasty) fail, instead of going directly to
colostomy, there is increasing use of a technique called the stimulated graciloplasty.
This consists of mobilizing the gracilis muscle and wrapping the anal canal and the
weakened anal sphincters with this skeletal muscle At a later date (e.g. two months
later), a stimulating electrode is placed onto the muscle. As this stimulator works,
so it converts the skeletal muscle into a type more resembling smooth muscle.
Temporary fecal diversion is required for this operation.
At the Cleveland Clinic we have been using gluteal muscle transplantation without
stimulation with some success. Finally, there have been isolated reports of the use
of these muscle surrounding techniques in patients who have already undergone
permanent colostomy following a Miles resection of the rectum. In such cases, the
end colostomy is taken down and brought down to the perineum and sutured
there as a cutaneous stoma. At the same operation a loop colostomy is made.
Approximately three months later, bilateral facilis muscles are then used to make a
new sphincter and are bilaterally innervated. When continence has been confirmed
by the ability of the patient to hold a tap water enema, the proximal loop transverse
colostomy can be closed. This is an emerging technique and technology is not
widely used as yet. The experience of those special centers who are reporting this
will need to be reviewed and verified before any endorsement can be given.
The above represents a brief and highly selective overview of the more recent
trends in surgery and ostomy care. One might make the final observation that
one trend is present for all seasons, the recognition of the importance of the
Enterostomal Therapy Nurse in the care rendered to our patients. Such nurses in
fact do stand on the shoulders of their teachers. None have broader shoulders
than Norma Gill.
REFERENCES
1. US Surgical, Norwalk, Connecticut
2. ConvaTec®, A Bristol-Meyers Squibb Company, Skillman, New Jersey.
116
Reminiscence
Reminiscence
Leonard Fenton
I
n 1949 or early 1950 Dr. Wilhelm Kolff of the Cleveland Clinic called and asked
for my assistance on a research project in which he was engaged. Our first
project involved my designing a blood oxygenator for use in heart surgery and a
filtering system for kidney dialysis. This led to another project with the Orthopaedic
Department that involved the finalizing of the design and construction of an air
splint for emergency use, and was followed by a project with Dr. Buonocore for the
Radiology Department for a barium air spray.
Dr. Rupert Turnbull was talking to his colleagues one day and heard about the work
I was engaged in at the Clinic. He got in touch with me and our first meeting was
in his office. Dr. Turnbull showed me several latex pouches, which were discolored
from use and all that was available at the time for ostomy patients. At this time I
knew nothing about an ileostomy or colostomy.
Our first meeting proved to be a brief one. I listened and he spoke.
Several weeks went by before I received a phone call from Dr. Turnbull, who asked
if I was working on his project. I had to admit that I was not. The good doctor
decided that it was time for another meeting.
We discovered that we lived several blocks from each other in Shaker Heights and
one summer evening I walked over to Dr. Turnbull’s house. While we sat outside
on the front steps he once again pulled out those poor quality rubber bags and
suggested that I attempt to do something for ostomy patients. That evening
I committed myself to designing a new type of equipment. The first pouch I
experimented with was made from nylon neoprene. This material was completely
odor proof but, unfortunately, was black in color. These first nylon neoprene
pouches were handmade and were in use for many years.
This led to the development of an early two-piece appliance with a separate stoma
plate (semi-convex) that attached to the pouch and was removable. The next
development was a white latex pouch exterior that had an inside liner of odor
proof neoprene.
By this time 1952, Marlen Manufacturing was organized and dedicated to the
manufacture of ostomy appliances.
About 1954 we made the first plastic vinyl pouch. We then developed a urostomy
pouch that was followed by the first post operative pouch, which was made in
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Leonard Fenton
conjunction with Dr. Eugene Furr. Other developments followed — the introduction
of karaya powder and then the first double-sided adhesive disks. Karaya powder
was an innovation suggested by Dr. Turnbull. The years that followed saw the
creation of many new products for the ostomy field.
One day Dr. Turnbull and I were in a meeting at his Clinic office when Dr. Crile
popped in and said he was going to lunch and was looking for company. When he
saw the two of us together he laughed and said he knew Dr. Turnbull would rather
talk about improvements in the ostomy field than eat. He was still laughing as he
left the room.
In 1954 I was called to deliver an ostomy set to the Cleveland Clinic for a young
woman whose name was Norma Gill. That was the beginning of a long friendship
that continues to this day.
Norma was not content to stay at home after her recovery, but suggested to Dr.
Turnbull that she could be of assistance to him in rehabilitating patients. Norma
traveled by bus from her home in Akron in order to work at the Clinic. Thus the first
stoma care nurse was created. Later, of course, an organization was started. Dr.
Turnbull and Norma Gill were instrumental in the organization and accreditation
of the newly formed ET Association.
During the ensuing years Dr. Turnbull and I became the best of friends. Our families
would visit each other, especially at Christmas time. We also became close boating
companions, belonging to the same yacht club. Our friendship lasted over 35 years.
I am proud and feel very fortunate to have been associated with Dr. Rupert Turnbull
and Norma Gill, ET.
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T
he history of the Journal of Wound, Ostomy and Continence Nursing closely
reflects the growth and development of enterostomal therapy, and the
WOCN Society. In her Notes on Nursing,1 Nightingale began the search for
the laws that comprise the profession and the science of nursing, and admonished
nurses to write down their observations, lest they be lost in the daily struggle to
provide care. Her admonition remains true today, but it has evolved far beyond
personal observations to a rich literature of peer reviewed, academic journals,
textbooks and other media that comprise the written record of nursing science.
From its inception, Norma Gill-Thompson and her colleagues realized the
significance of a journal of the collected experience of enterostomal therapy. The
first issue of this ongoing document was titled the ET Journal. It was published in
the Summer of 1974, under the direction of editor Kathleen Burns, RN, ET, and it
evolved from a quarterly newsletter published for members of the North American
Association of Enterostomal Therapy and, subsequently, the International
Association of Enterostomal Therapy (IAET). The Journal was described as the
official publication of the IAET, and it contained clinical and professional practice
articles. Kathleen Burns’ first editorial outlined the mission of this new publication.2
She stated that the Journal should provide a resource for education, a forum for
the evolving role of the enterostomal therapist, a medium for the announcement
of professional association activities, and a publication defining enterostomal
therapy to related health care professionals. She defined this ET Journal as a “source
of current information on the total care and rehabilitation of persons with fecal
or urinary ostomies or other situations of uncontrolled drainage (page 1).” This
visionary statement is remarkably consistent with the Journal’s current mission to
provide the source for full scope ET nursing practice, including the care of patients
with ostomies, and uncontrolled drainage from chronic wounds, tubes, and urinary
and fecal incontinence.
Within its initial stages, the ET Journal primarily reproduced articles from other
professional publications. Soon, however, reprints were replaced by original articles
authored by ETs. Although largely unacknowledged by the Journal, this change
represented an important transition as ETs began to generate the knowledge base
that comprises wound, ostomy and continence nursing. The conclusions of these
early authors were based largely on clinical experience, case studies, and intuitive
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Mikel Gray
observation. Nonetheless, their experiences and observations remain a rich part of

our growing body of knowledge, and many of their beliefs have been supported
by objective research.
Over the ensuing years, the Journal lost the presentation of a “newsletter” and
gained the appearance, as well as the infrastructure, of a peer reviewed professional
publication. In 1982, the renamed Journal of Enterostomal Therapy was published
under arrangement with the C.V. Mosby, Company. During this important period of
growth the Journal was edited by Frances J. Anderson-Ciambor, RN, ET followed by
Victor Alterescu, RN, MBA, MPH, ET, Patricia Kynes, RN, BSN, ET and Joan Halpern-
Landry, RN, MS, CETN. Each of these Editors brought her or his own unique
perspective and skills to the Journal, while sharing certain essential characteristics.
All of the Journal’s captains have acted as developmental editors, assisting authors
to learn to write, while encouraging them to publish their observations in their
professional journal.3,4 This tradition of the editor as a mentor to novice authors
continues with the Journal today, which publishes cutting edge, original research
reports as well as student papers reviewing pertinent and current clinical and
professional practice issues.
Like the Journal, the IAET grew and gained in sophistication during this period. In
his final Editorial in 1984, Victor Alterescu reflected on the evolution of the field of
enterostomal therapy and its professional association.5 His editorial captured not
only the “state of the association”, it demonstrated the group’s growing identity as
the creators of change rather than simply reacting to changes imposed by others.
This growth in the vision of the association and its Journal also can be seen in
a 1985 editorial by Patricia Kynes6 who presented a solid plan for ET nurses to
respond to the latest trend in health care financing (the diagnosis related-group)
using resources written and distributed by the IAET.
In 1991, the title Journal of Enterostomal Therapy was modified to the Journal of ET
Nursing. In this first issue with a redesigned cover and new name, Journal Editor
Dot Smith reflected on the profound changes that had occurred in the field of
enterostomal therapy nursing and in the Journal.7 She noted several controversial
issues in particular, including the development of an accreditation process for
ET Nurse Education Programs, the introduction of a certification process for ET
nurses, monitoring of national leader’s relationships with industry, the addition
of skin and incontinence care to the professional practice scope of the ET nurse,
and the possibility of a name change for the organization. As an ET nurse with
a distinguished history as a member of the IAET, Dot stated that many of her
colleagues could recall “personal memories” as well as “battle scars” from each of
these “painful dilemmas” (page 79).
120
The Editor went on to comment on the change in name from the Journal of
Enterostomal Therapy to the Journal of ET Nursing.7 She wrote that the change in
the Journal’s name reflected the evolution of this specialty practice in nursing. She
observed that the Journal was a symbol of ET nursing. She defined the Journal as
representing the scope and depth of ET nursing practice, both to its practitioners,
and to the physicians, health care administrators, allied health care professionals
and basic and applied scientists who worked in collaboration with its constituents.
She accurately predicted that that change in the Journal was only one of many
changes ET nurses would face in the coming years. However, she also observed
that these changes were not to be feared or despised. Instead, Dot noted that “if
we stop growing, stop learning, stop taking risks, we will fold” (page 79).
In 1992, the Journal of ET Nursing contained a guest editorial by Margaret
Heitkemper, RN, PhD, Professor of Physiologic Nursing at the University of
Washington in Seattle.8 In this historic document, Heitkemper noted that research
had been identified as one of the three priority areas for the IAET, and that ET
nurses who were not directly involved in ETNEPs were less likely to be involved
in clinical investigations, either as primary investigator or data collector. She
noted that over the past 5 years (1986–1991), the IAET had increased its efforts
to support research activities, by finding specific studies, through presentations
at the national conference, and through the inclusion of research production and
utilization in ETNEPs.
Heitkemper’s Guest Editorial is significant because it reflects a significant step
in the evolution of wound, ostomy and continence nursing, and in its Journal.
The addition of original research reports to the Journal’s contents is an essential
component to the growth of our specialty practice. Less than 20 years prior,
the first issue of the Journal contained a single clinically based article for ETs,
reprinted from a medical journal. In contrast, the September/October, 1992 issue
of the Journal contained articles on a research based risk assessment tool for a
pressure ulcer prevention program9 and an original research report of a clinical
trial of the Braden Scale on an acute care hospital ward.10 Although the Journal still
comprised primarily research reviews, case studies, or articles based on clinical
experience, the crucial element of original research had grown from an idea to a
regularly appearing feature.
By 1993, Dot’s foreshadowing of a possible name change for the IAET had become
a reality, and the IAET became the Wound, Ostomy and Continence Nurse’s
Society.11 Volume 20, Issue 3 of the Journal celebrated the pioneers of ET nursing,
and provided a “Hall of Fame” of professionals significant to the growth and
development of enterostomal therapy and ET nursing, including past presidents of
the organizations and past and current editors of the Journal. In a special feature,
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Mikel Gray
titled a “Moment in Time”12, she compared stoma care in the 1950s to ostomy care
in the 1990s. She further reminded readers of the development of the WOCN, from
its inception as a 33 member organization called the North American Association
of Enterostomal Therapy to the IAET, to the WOCN Society. Her article focused on
one of the principal pioneers of ET and ET nursing, Norma Gill-Thompson. Dot
observed that after 43 years of living with the impact of an ostomy, Norma had
helped to found the WOCN and the World Council of Enterostomal Therapists,
had founded the first ET education program, and she continued to teach the
foundations of enterostomal therapy, having recently completed a tour of China.
Editor Dot Smith also informed the readers that the Journal would be unveiling
a new title and design, which would be announced at the organization’s 25th
National Conference, held in San Antonio, Texas, and in 1994 our current title, the
Journal of Wound, Ostomy and Continence Nursing became official. This change in
title was accompanied by a change in editors, and I began my tenure as editor of
this remarkable Journal.
The Journal of Wound, Ostomy and Continence Nursing (JWOCN) continues to serve
as a symbol for ET nursing, as well as the resource for wound care, ostomy and
incontinence specialty track nurses. Appearing six times annually, the Journal
is divided into four sections: wound care, ostomy care, continence care and
professional practice. Each of the sections of the JWOCN is edited by a section
editor with particular clinical expertise in that aspect of ET nursing practice.
Internationally known ET nurse Gwen Turnbull edits the ostomy care section,
Barbara Bates-Jensen ETNEP Director for UCLA edits the wound care section and
Dr. Mary Palmer, research scientist at the National Institute of Aging, edits the
continence care section. In addition, a regular feature of the Journal, Options in
Practice, provides an opportunity for wound, ostomy and continence nurses to
share ideas about varying approaches to the common clinical problems we face
in everyday practice. Options in Practice was originally edited by Maureen Hanlon,
an ET nurse practicing in Texas, and her name has become closely associated with
this immensely popular feature of the Journal. The Journal continues to regularly
publish original research, case studies, clinical series, and literature reviews
pertinent to wound, ostomy and continence nursing. Because of the growing
demand for clinical and professional practice materials in the Journal, the WOCN
now publishes a separate newsletter.
The JWOCN reflects the rapid growth of the field of ET/wound, ostomy and
continence nursing. It still serves as the official publication for peer reviewed
articles for the WOCN. It is a symbol of current clinical and professional practice
issues that impact and define our practice in the latter 20th century. The Journal
is as an ongoing monument to the remarkable vision and perseverance of the
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pioneers of ET nursing, and to the newest practitioners of its skills. As its current
editor, I can foresee a day when the Journal may be published “online” or a day
where it arrives in the mail as a diskette for the computer rather than the “hard
copy” we currently enjoy. I can foresee a day when the Journal will be published
monthly, and a day when it will updated even more frequently. However, I also
know that the heart of the Journal, its focus on the compassionate, skilled care of
persons with ostomies, as well as those with wounds and incontinence will remain
with us, as will its commitment to excellence through peer review, editing, and
revision. Dot Smith was absolutely correct when she once described the Journal as
a symbol.7 It is a monument to the history, current trends and future growth of our
practice. It is the living record of the laws, postulations, theories, and innovations
that comprise our clinical practice, and the opinions and insights that describe our
history and predict our future.
REFERENCES
1. Nightingale F: Notes on Nursing. Philadelphia: Lippincott, 1992.
2. Burns K: Quarterly takes new name, editor. IET Journal 1974; 1(1): 1.
3. Alterescu V: On writing. Journal of Enterostomal Therapy 1983; 9(4): 121-2.
4. Halpern-Landry J: Editorial perspectives. Journal of Enterostomal Therapy 1988; 14(1): 3.
5. Alterescu, V: Diablerie. Journal of Enterostomal Therapy 1984; 10(6): 207-8.
6. Kynes P: On surviving diagnosis related groups. Journal of Enterostomal Therapy 1985;
11(1): 3-4.
7. Smith D: Toward the future of ET nursing. Journal of ET Nursing 1991; 18(3): 79-80.
8. Heitkemper M: Research and the ET nurse. Journal of ET Nursing 1992; 19(3); 82-3.
9. Fournier L, Kemp M, Farley K, McMyn R, Paulford N: A research-based risk assessment
tool as the cornerstone of a pressure ulcer prevention program. Journal of ET Nursing
1992; 19(5): 155-59.
10. Salvadalena GD, Snyder ML, Brogdon KE: Clinical trial of the Braden Scale on an acute
medical unit. Journal of ET Nursing 1992; 19(5): 160-65.
11. Smith D: A silver celebration. Journal of ET Nursing 1993; 20(3): 91.
12. Smith D: A moment in time. Journal of ET Nursing 1993; 20(3): 101.
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Katherine F. Jeter
ET Nursing and Continence Care:

History and Perspective
T
he genesis of enterostomal therapy was in the gut and confined to the
gut. This history and perspective of ET nurses’ involvement in urologic
patient care and, more specifically, care of patients with incontinence is
a personal as well as an organizational reflection. Dates of events and activities
within the organization are helpful in considering trends and directions. These
dates have been used as markers to analyze the move of ET nurses from the care
of gastrointestinal stomas toward leaking urethras. Many have said that ostomies
and incontinence are similar conditions. That can be debated. An ostomy is “done”
to a person to cure a disease. Incontinence more often “happens” to someone
gradually. In fact, clinical experience suggests that patients in whom incontinence
is the result of an operation, such as a prostatectomy, do, indeed, have similar
responses and needs as patients who require an ostomy. However, the 52-year-
old female who has become increasingly incontinent since the birth of her fourth
child 25 years previously has little in common with the ostomy patient or the post-
prostatectomy patient. Current and future perspectives are clouded by uncertainty
about the American health care system, enormous changes in the mode and place
of health care delivery, and the varied settings in which ET nurses practice. Since
the factors which influenced the ET specialty at its inception differ drastically from
those which will influence its future, pre-dieting the ET nurses’ role in incontinence
care in the future is pure conjecture.
My earliest training in the care of urinary stomas was “OJT” — on the job training
— with our young son who had a urinary stoma. By 1963,1 had found the United
Ostomy Association and others who had taken their personal interests into
hospitals and medical settings to help other patients. My professional (paid) career
as an ET began in the summer of 1968 in the Department of Urology at Columbia-
Presbyterian Medical Center. Shortly after I arrived, I was asked to see a patient with
a colostomy and another with an ileostomy. I enjoyed caring for these patients and
felt comfortable with my knowledge base, most of which had been acquired at
ostomy meetings! So much for the rigorous requirements for academic and clinical
training! I often look back on those early days when we sat patients up on the
third to the fifth postoperative day and walked them into the toilet to teach them
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ET Nursing and Continence Care: History and Perspective
to irrigate their colostomy. What would we non-nurses have done if a patient had
suffered a cardiac arrest? Thank goodness, unless there are some skeletons hidden
in the ET history closet, there were no known casualties during the time that well-
intentioned lay people were sent onto the wards after two weeks of training to be
enterostomal therapists.
In 1969, Norma Gill invited all people who were functioning as enterostomal
therapists to attend a meeting at the Cleveland Clinic. Only two of us at that meeting
did not have stomas. We had children with urinary stomas. It was agreed that all
present at that 1969 meeting would be “grandfathered” into the organization,
which was named the “North American Association of Enterostomal Therapists.”
Kay Carlsen and I will never know all the facts and the politics, but we were the
only two who were not made charter members of the NAAET. Subsequently
Elizabeth McConnell came and tested me on my knowledge of bowel diversions
in a hotel somewhere in New York City. I shall never forget sharing that room with
her and wondering where all this was leading. Two years later, Edith Lenneberg
came to Columbia-Presbyterian Medical Center to observe my practice and hear a
day-long presentation on urinary diversion. Finally, it was decided by some group
in the organization at the annual conference in San Francisco that Kay and I could
become ETs if we attended part of the training program at Emory University. Each
of us attended Jane Walker’s class at separate times. Thus, I am listed as a 1972
graduate of the Emory program when, in fact, I had been working full time as an
enterostomal therapist since 1968 and before that had been volunteering my time
and expertise in stoma care in cities and communities where my husband was
stationed with the military.
The work of the majority of the founding enterostomal therapists was confined
to ileostomies and colostomies because they themselves had an ileostomy or a
colostomy and they had been hired by a general surgeon or a colorectal surgeon.
Some of the first ETs we met in Cleveland had not yet cared for a patient with a
urinary stoma. I remember feeling somewhat “different,” since I had been hired and
mentored by a urologist and urology was my primary interest.
From the mid-1970s through the early 1980s an increasing number of urinary
diversions were performed. The ileal conduit, which had been re-introduced in
the literature by a gynecologist from St. Louis, Dr. Eugene Bricker, became the
gold standard for diverting urine away from a diseased or dysfunctional bladder.
(This procedure replaced the old ureterosigmoidostomy, which had been fraught
with complications, none the least of which was a high incidence of cancer in the
bowel segment where urine and stool mixed.) Since children were not allowed in
public school during those years if they did not have urine and bowel control, it
was common practice to perform urinary diversion for “social reasons” There was
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much to learn and to teach about these stomas. Stomal stenosis was common.
What the Cleveland Clinic referred to as pseudoepetheliomatous hyperplasia, we
in New York called “gray warty things.” These were lesions that erupted around
stomas when the appliance opening was too large and alkaline urine bathed the
skin. It was exciting to learn that we could prevent this painful condition, and treat
it when it occurred, simply by hydrating the patient, cutting the stomal opening
of the appliance to fit close to the stomal base, and acidifying the urine with
Vitamin C. Usually, as the peristomal lesions resolved, the stomal stenosis resolved.
My mentor, Dr. John Lattimer, believed that everyone in his department should
do research, publish research, and present research. We had at least one paper
or poster each year at the American Urological Association’s annual meeting.
While Dr. Turnbull and Norma were “barnstorming” all the colorectal meetings,
Dr. Lattimer and I were making the rounds of the urological meetings. Soon Dot
(Rodriquez) Smith of the M.D. Anderson Hospital in Houston and Rosemary Watt of
Stanford University became leading authorities on the subject of urinary stomas.
There followed a small but energetic group in the organization who had a passion
for urologic patient care. Nancy Faller, who was among them, was so focused on
urology prior to becoming an ET nurse, that she asked if she could take only the
urinary portion of the course at the Harrisburg Hospital! However, in the early and
mid 70s, many ETs, with and without nursing credentials, remained “purists” and
confined their services to patients with stomas from the small or large intestine.
The devastating, social, economic, and physical sequelae of urinary incontinence
was brought to my attention by Dr. Lattimer within days of my arrival at Columbia-
Presbyterian. Dr. Lattimer had specialized in the management of children born
with bladder exstrophy. In a series of surgical procedures, Dr. Lattimer and his
colleagues would reimplant the child’s bladder, and repair, as best they could, the
dreadful deformities of the genitalia which accompany this congenital anomaly.
All of the children were incontinent of urine before and after their surgery. Dr.
Lattimer recognized what a toll this condition took on his young patients. He
believed that the problem could and should be solved.
Our first step was to contact NASA to see how they handled urine collection
during space flight. We learned that condom catheters were customized for each
astronaut. Replicating their technique, we mixed huge amounts of Geltrate® (this
is the dental amalgam that is used to make a mold of your teeth and gums in the
process of fitting braces or making dentures) to begin our mold-making process.
The astronauts were able to insert their penis into a small cup of the Geltrate®.
Our patients, unfortunately, were either boys with smaller-than-average genitalia
because of their defect or girls with no external genitalia. We had to either quickly
spread the amalgam over the pubic area or put large amounts of the amalgam in
big institutional sheet cake pans and lay the patient across the slurry and mash
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the patient’s pubic area into it until the amalgam set. Since the amalgam set up
quickly, we had to work fast. The result was a reverse (negative) impression. The
next step was to pour plaster of par is into the impression. Once the plaster of
paris dried, the Geltrate® was peeled away; and we had a perfect replica of the
genitalia. We used this replica to make collection devices from silastic material or
latex. Sadly, our efforts were without success. Even the devices that appeared to
fit most perfectly would leak as soon as the patient changed position. When all
was said and done, after four years, we had offered little more to our incontinent
patients than solace, if that. Disposable diapers for infants were still emerging
into the sophisticated products we take for granted today. They were bulky. They
leaked when full, and they did not control odor. As our young patients grew, they
became too large for the baby diapers. Disposable adult diapers were not available
in those days. Many of the mothers made absorbent cloth pads and pants and
shared their patterns and ideas in our discussion groups. Parents quickly learned
that black, navy blue, and dark brown skirts and slacks of polyester and cotton
fabric did not show moisture like lighter colors and other materials. Our urology
clinic waiting area looked like an Amish meeting hall.
During those years from 1970 to 1972, Dr. Lattimer and I approached most of the
major urological device companies urging research and development efforts to
solve the incontinence management problems our pediatric and adult patients
were facing. Simultaneously, urologists across the country and around the
world were continuing to try to provide continence surgically for children born
with bladder exstrophy, spina bifida, and other spinal cord anomalies. The quest
continues to this day.
The discomfort and embarrassment experienced by our patients during my time
at Columbia-Presbyterian Medical Center was all-consuming then, as it is now.
I attended every urological meeting in hopes of hearing about a breakthrough
in a paper or seeing progress reported on posters and in exhibit halls. Nothing.
Then came the exciting news from the University of Michigan that many patients
with a neurogenic bladder could be taught to catheterize themselves. It sounded
heretical because it was contrary to all that physicians and nurses had been taught
about the importance of asepsis. (Ben Franklin is said to have kept a catheter
wrapped around his hat band in order to catheterize himself when his bladder
stones obstructed the outflow of urine.) Dr. Jack Lapides and his nurse, Betty Lowe,
insisted that the catheter could be clean, not sterile; and it could be reused. Betty
Lowe became an ET nurse. She amazed participants at our annual conference in
1973 when she described the procedure and then showed movies of children
catheterizing themselves. She demonstrated that enterostomal therapists could
and should be the ones to teach patients how to catheterize themselves. I shudder
to think how many non-nurse ETs, without any professional training, simply began
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Katherine F. Jeter
passing catheters. There is no record of any damage done by non-licensed personnel

carrying out this nursing procedure. Surely love for the patients, enthusiasm for
our work, and good intentions protected us all. Mercifully, we and our bosses were
unaware or unconcerned about the risks of some of our actions. Passing a catheter
into the urinary bladder seemed very similar to threading a catheter six inches
into the colon during colostomy irrigation, which was common practice before the
cone. It was interesting, however, that many ETs, nurses and non-nurses, ignored
this urological opportunity, leaving it to urologic techs and urologic nurses.
Another challenge in urology, which begged ET ingenuity, was the application
of the condom catheter. The urinary meatus was dripping; an appliance was
available; and various adhesives and amalgams could be used to secure the device
to the patient. It was similar enough to what was required in stoma care to be a
reasonable task to be given to an ET. Many were called, but not so many chose, to
become involved with this new group of patients — mostly spinal cord injured
patients and some debilitated frail, elderly males. The rehabilitation nurses became
the experts in condom catheter management.
In 1981, the IAET received a grant from Bard Home Health Care Division (now
Bard Medical) to develop a Strategic Plan for the organization. Working on that
committee were Debra Broadwell, Bettie Jackson, Katherine Jeter, Warren Todd
of C. R. Bard, and John T. Jeter of Infomedics Research Group, hired by Bard for
the project. (John T. Jeter was no relation to Katherine Jeter). According to the
summary findings published in 1982, “Directionally, 98% of ETs would like to see
greater emphasis placed on the non-ostomy related aspects of the philosophy
through continuing educational materials and changes in the P.E.P. [Professional
Educational Program] curriculum. Of these, 71% indicated they would strongly
favor a broader scope in wound management. Likewise, 66% strongly favored
including tissue management/skin care in this broader scope of services. ETs were
divided, however, over changing the title of their specialty to something more
reflective of the wound management concept.” Survey data gathered during the
Strategic Planning Process revealed that ETs were spending only 2.6% of their time
on incontinence care. Thirty-eight per cent (38%) of respondents said they spent
no time at all on incontinence care. However, since the IAET had established itself
(since 1976) as a nursing specialty, it seemed appropriate that certain aspects of
incontinence could and should be included in ET nurses’ scope of practice.
In 1987, the IAET published Standards of Care: Urinary Incontinence. After the
Strategic Plan of 1988, which was published as the Blueprint for the 1990s, the
association publicly escalated its emphasis on the role of ET nurses in incontinence
care and management. Test questions about the anatomy and physiology of
the urinary tract, diagnosis of incontinence, urodynamics, and treatment and
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management options for voiding dysfunction were incorporated in certification

examinations.
In June 1992 the International Association for Enterostomal Therapy changed its
name to the Wound, Ostomy and Continence Nurses Society, An Association of ET
Nurses. There is a delightful anecdote that has been circulated since then. It may be
fictional, but it merits retelling here for posterity. The new name allegedly proposed
for the organization was the Continence, Ostomy, Wound Society until someone
realized that the initials would be “COWS”! The order of the conditions cared for by
ET nurses was immediately reversed. The new name, the addition of a continence
track during the Association’s annual conference, and more frequent articles about
incontinence in the WOCN Journal imply that most ET nurses are actively involved
in assessment, treatment, and management of incontinence. In fact, in 1994 the
Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) began
offering a certification examination specifically for nurses who manage urinary
and fecal incontinence. Upon satisfactory completion of this exam, clinicians may
use the designation “CCCN.”
In 1995, one would assume that all or the majority of ET nurses include urinary
and bowel incontinence in their scope of practice. My Letter to the Editor [WOCN,
22(1):68, 1995] questions ET nurses’ actual practice and interest in incontinence in
the second half of the 1990s.
To the Editor:
In a 1990 President’s Message in the Journal of Enterostomal Therapy (1990;
17:95-97), Kristy Wright proposed that ET nurses ought to be identified as “skin
care specialists.” Our members were mostly aghast and “against it.” Perhaps
our membership should have considered her suggestion more seriously. At
the marvelous annual educational conference in Baltimore in June 1994, Dr.
Greenough spoke on the “Prevention and Treatment of Diarrhea — Methods for
Reducing Fecal Incontinence.” The room was packed. People were standing along
the side walls and leaning against the back walls. Diarrhea? that is something we
all know a lot about. We can bag it, and we are frequently called to treat the skin
that has been denuded by it. At the conclusion of his session, there was a mass
exodus. Fewer than 100 people were left to listen to a superb presentation on fecal
incontinence as a result of pelvic floor dysfunction by Dr. Brubaker.
On Thursday morning, the room was packed when Dr. Margolis talked about
wound care. Hundreds were in attendance. Extra chairs had to be brought in
to accommodate the crowd. Meanwhile, down the hall, Dr. McGuire gave a fine
presentation on new surgical options for the treatment of urinary incontinence.
Thirty-six people were there to listen.
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Katherine F. Jeter
Exactly what aspects of incontinence do most members include in their scope of

practice? I suspect that most of the WOCN membership does not, as our name
implies, identify, assess, treat, and manage incontinence in patients in acute care,
home care, and extended care. I suspect that most of the WOCN membership is
presently attending to the maintenance or restoration of skin integrity in patients
with urinary and bowel incontinence. Are we stretching to practice what our name
says we do, or should we define the facets of continence care in which we are
actually involved?
The HIP (Help for Incontinent People) staff was amazed and disappointed [at
the annual conference] by how many WOCN members were unaware of our
organization’s vast resources for patient and public education, and how many
were unaware of the benefits they would derive from joining HIP. These indicators
cause us to worry that the WOCN is not poised to be the organization to serve
the estimated 20 million Americans affected by loss of bladder and bowel control
and related disorders. It is honorable and sufficient to confine incontinence efforts
to skin care and containment. This would, however, be a compelling reason to
revisit Kristy Wright’s proposition that ET nurses identify themselves as skin care
specialists. We at HIP would welcome your response.
Meanwhile, the American Urological Association Allied continues to advocate
for Continence Nurse Specialists among their membership. The Association of
Rehabilitation Nurses emphasizes the restoration of bowel and bladder function
and management of incontinence in their scope of practice. The Section on
Women’s Health of the American Physical Therapy Association has designated itself
as the ideal group to oversee behavioral therapies and pelvic muscle re-education
programs for incontinent women. At their 1995 combined section meeting, they
had a program on male incontinence. Among physicians there are turf battles
between urologists and gynecologists. A growing number of urogynecologists
are offering specialized care for females with voiding dysfunction. Currently, the
majority of male urologists treat incontinence surgically or pharmacologically.
Conversely, the majority of female urologists offer a stepwise approach to the
treatment of voiding dysfunction, beginning with least invasive therapies and
progressing as needed.
It is unclear how the Clinical Practice Guideline on Urinary Incontinence in Adults,
published by the Agency for Health Care Policy and Research in March 1992
has impacted ET nursing practice. As the health care environment changes,
reimbursement continues to affect the way clinicians practice and the care
and supplies that patients receive. ET nurses have been admonished that they
must be able to offer a variety of services to include wound and incontinence
management if they are going to retain their positions. However, many ET nurses
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have their hands full simply caring for chronic wounds and ostomies in hospitals
with more than 200 beds. In recent years, a small but highly effective group of ET
nurses has distinguished itself in the public policy and reimbursement arena. This
group has devoted thousands of hours to reimbursement issues for wound care
and urological supplies for Medicare recipients. Many federal, regional, and local
agencies and organizations look to ET nurses for counsel when it comes to product
use and cost of services and supplies. These same ET nurses, who have been so
effective on the legislative front, may not be actually be caring for incontinent
patients in their own community.
What role will the ET nurse play in continence care in the 21st century? There
are too many external forces and issues to permit prediction: managed care,
reimbursement for nursing services, Centers of Excellence, home health care,
assisted living, and collaborative group practices. With as many as 20 million
Americans afflicted to some degree by incontinence, and people over the age of
85 becoming the fastest growing population group, there is an opportunity for
history to repeat itself for the ET nurse. Just as the first ETs of the ‘60s championed
the cause of underserved and embarrassed patients with ostomies, the ET nursing
specialist of the ‘90s is in an optimal position to meet the needs of patients with
bowel and bladder dysfunction. Time, politics, organizational leadership, and
industry pressure, will, no doubt, converge to influence the scope of practice of
ET nursing. Until then, at this writing in March 1995, the WOCN can claim fewer
than 20 active members who devote the majority of their working hours to the
assessment, treatment, and management of incontinence. And there is little to
indicate that the WOCN is taking a position of leadership among the organizations
and societies that currently focus on the diagnosis, treatment, and management
of incontinence.
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Diane Krasner
ET Nursing and Wound Care:

Embracing the Challenge
INTRODUCTION
It’s a funny thing … this being an ET. Many of us ETs can only vaguely remember
a time when we weren’t ETs. I believe this reflects, in part, what is so special about
the ET commitment to care. Also, because the majority of us who are practicing
today became ET nurses during the last decade (1985–1995), most of us cannot
remember the role without wound care. A brief glimpse back through the short
history of our specialty helps explain why.
THE HISTORICAL FOUNDATION FOR SKIN AND WOUND CARE

While the first ETs were devoted exclusively to the care of patients with stomas,
skin and wound care became part of the early enterostomal therapist’s concerns
due to the need for peristomal skin care and care of surgical incisions. Some
early ETs, who were patients themselves, also had personal experience caring
for IBD-related ulcerations — most notably Norma N Gill-Thompson herself who
suffered pyoderma gangrenosum on her legs, trunk, chest and face. Whether it
was peristomal skin protection, prevention of skin breakdown, care of actual skin
breaks or care of surgical incisions, early ETs developed a whole “bag of tricks” to
care for skin and wounds. Their magical potions for peristomal skin care included
tincture of benzoin, aluminum paste, antacids and karaya powder, all of which
seemed to help patients (despite the lack of research back then to support their
safety and efficacy). ETs somewhat incorrectly called skin breaks “excoriations”
instead of “erosions” or “denuded areas” (Goode, 1987), but everyone KNEW what
they MEANT. So, the foundation was laid for greater accomplishments in skin and
wound care.
By the mid-1970s, Norma Gill was writing down her ideas in a series of white papers
that she personally distributed to others. In Unusual Skin Problems for the New E.T.,
Part I (1977), she addressed peristomal skin and incisional care. For example, for
healing delays due to the proximity of the wound to a stoma, Norma advised:
If the suture line is still weepy, put a “thin layer” of gauze or telfa into the
incision (never higher than skin level) and then apply the skin barrier on top
and proceed as usual.
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ET Nursing and Wound Care: Embracing the Challenge
Advice that works to this day! Norma concluded her paper on unusual skin
problems with this sage counsel:
In conclusion, one must never hesitate to include a physician, dermatologist,
or call on an Enterostomal Therapist who has had more experience for answers.
I am certain that Norma’s guidance in those early days of our specialty lighted the
way for later generations of ET nurses, so that we could see the value of some very
important principles:
• collaborating with other disciplines
• mentoring each other as ETs
• knowing one’s limitations
• sharing our knowledge and experience freely with others.
What an incredible role model our specialty has had in Norma Gill-Thompson!
Early texts which appeared in the 1970s on enterostomal therapy gave short shrift
to skin care and did not address wound care at all (Gross & Bailey, 1979; Vukovich &
Grubb, 1973). Vukovich and Grubb’s chapter entitled “Skin Excoriation” was only six
pages long, but it did address issues that are still of great concern today (although
we may refer to them differently):
• normal skin • resting the skin
• change in skin color • allergy to skin cement
• weeping skin • skin irritation caused by yeast invasion
• sloughing • encrustation
• subskin orifice caused by pancreatic fistula
By the late 1970s and early 1980s, however, the importance of skin care was
recognized and there was serious interest in broadening the ET role to include
wound care. In clinical settings, ET nurses were being called upon by colleagues to
trouble-shoot all kinds of wounds, including draining wounds and fistulas. Wound
care was often learned by ETs on the job, through trial and error and by extending
the principles of peristomal skin care that they learned from caring for ostomates.
When Broadwell & Jackson’s “Bible of Enterostomal Therapy,” affectionately known
as “The POC,” was published in 1982, two chapters listed under a section entitled
“Related Areas” at the very end of the book dealt with wound care. Marilyn K.
Dunvant’s superb chapter on “Wound and Fistula Management” and Hebert &
Alterescu’s outstanding review of “Pressure Necrosis” presented basic information
about these topics in this classic text. These chapters served as the academic
foundation for the extension of the ET nursing role into wound care. We were
getting prepared to embrace the challenge.
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Diane Krasner
This willingness to “take on” wound care was also reflected in the IAET Strategic
Planning Report, Part 1, issued in 1983:
The International Association for Enterostomal Therapy (IAET) believes that
enterostomal therapy is a specialty area of practice within the framework of
nursing, and, as such, endorses the rendering of health care to all individuals.
The IAET subscribes to the philosophy that all persons with abdominal stomas,
fistulas, draining wounds, incontinence, and pressure sores have the need for
care and expertise and the right to benefits from those services.
While this expansion of the ET nurse role was being eloquently proclaimed on
paper, one must be honest and point out that in practice the idea was getting
mixed reviews. Many ETs were already performing wound care. But there was a
small group of ETs who only wanted to do ostomy care and feared that ETs were
abandoning the needs of ostomates and their roots by embracing the “full scope
of practice” (which also included incontinence care in addition to wound care).
In her President’s Message of 1983, IAET President Debra Broad well offered the
following assessment:
Not everyone wants to see the role of the ET change. They like what they do,
how they do it, and the circumstances surrounding the job.
Not everyone will change or evolve. However, research reveals that changes
are occurring. ET nurses are no longer limited to ostomy care. If you work in a
major institution, your practice may be limited to ostomy care, but if you work
in a community hospital, your practice may be more diverse.... The IAET has a
responsibility to provide resources that support ET nurses in their practice. If
we are to be prepared for the future, it will help us to anticipate and direct the
future (Broadwell, 1983, p.2).
So, with our esteemed leadership urging us on, most of us in the next generation
of ET nurses — MY GENERATION — took on the challenge of wound care with
enthusiasm and pride.
EMBRACING THE CHALLENGE OF WOUND CARE

In the early 1980s, the ET nursing literature began to reflect the serious expansion
of the specialty into the wound care arena. First came “Case Notes” in The Journal
of Enterostomal Therapy on wound and fistula management, soon to be followed
by “Clinical Rounds,” including Alterescu’s memorable and oft-cited classic ‘Toward
a physiologic approach to the topical treatment of open wounds” (1983). Finally
came “Original Articles” on wound care. There were no “Letters to the Editor”
questioning ET Nurse involvement in wound care. Involvement in incontinence
care, however, was another story! There were very few protests about taking on
wound care at national meetings. Most ET nurses seemed content to embrace the
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challenge of wound care, perhaps because it was so much a part of the specialty
from the very beginning.
By 1987 the importance of wound care for sustaining ET nursing practice and jobs
was being publicly acknowledged. In the widely published 1987 white paper on
the cost benefits of ET nursing in modern health care delivery, Kynes, Brown-Etris
and Snyder wrote:
Although primarily known for their expertise and resourcefulness in ostomy
care, ET nurses have consistently demonstrated skills in wound and skin care
that uniquely qualify them as necessary members of the health care team in
any setting.
ET nurses are experts in some very difficult and potentially expensive areas of
health care delivery... the prevention and treatment of incontinence, the care of
fistulas and draining wounds, and stoma care are areas that frequently stymie
even the most dedicated health professional. But these are precisely the areas
of ET nursing expertise (Kynes, Brown-Etris & Snyder, 1987, p. 95).
In the early nineties two texts appeared devoted exclusively to wound care and
both were edited by ET nurses. My own text, Chronic Wound Care: A Clinical
Source Book for Healthcare Professionals (Krasner, 1990) was written for all
healthcare professionals with an interest in chronic wound care. There were
numerous ET nurses among the contributors. A book edited by Ruth Bryant,
Acute and Chronic Wounds: Nursing Management (1992), was published in a
series of three texts that became the core curriculum for the U.S. Enterostomal
Therapy Nursing Education Programs.
“WOUND” GETS FIRST BILLING

In 1992 the primary importance of wound care in the 1990s was officially recognized
when the IAET changed its name to Wound Ostomy and Continence Nurses Society
(WOCN). The first issue of the Journal of ET Nursing published by the newly-named
association was a special issue on wound care — no small coincidence (Volume 19,
Number 5, 1992). In an editorial in that issue WOCN President Ruth Bryant wrote:
All of this enthusiasm for wound care is great. In fact, it is about time! But it also
presents a challenge and a threat. The challenge is to establish the distinction
between the person who is knowledgeable in wound care and the person who is a
specialist in wound care. The former knows products and uses them appropriately
to manage the wound. But the specialist knows products and has a scientific
foundation of knowledge from which a comprehensive plan is developed to
manage the total care of the patient with a wound. The threat is that this distinction
will not be made and managing the wound, rather than managing the total care of
the patient with a wound, will become the norm (Bryant, 1992, p. 151).
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Diane Krasner
Thus we began the next chapter for ET nurses in wound care, with emerging
challenges relating to specialization, sub-specialization, an ever-broadening scope
of practice and a growing body of ET nursing knowledge and science related to
wound care.
WOUND CARE CHALLENGES: TODAY, TOMORROW AND BEYOND

As I write this chapter at the beginning of 1996, with a new millennium just around
the corner, for most ET nurses in the United States at least, wound care is the
busiest aspect of their practices. With people all over the globe living longer, this
trend is certain to continue. ET nurses will be in great demand, caring for chronic
wounds related to chronic conditions in aging societies.
One of the many challenges for ET nurses in the future will be to sustain their
enthusiasm for wound care. For unlike ostomy care where healing most often
occurs in a timely fashion and where there are often relatively quick successes,
the day-to-day drudgery of dealing with pressure, venous and diabetic ulcers can
become a burden. Chronic wounds are slow to heal, so the rewards of patient care
are slow to come, if at all, since many patients die before we can heal them. Instant
gratification is a rare phenomenon in wound care. Each ET nurse must find a way
to sustain her/himself in the face of the difficult challenges that patients with
wounds present.
Another significant problem in the future will be to hold on to wound care and not
let others take it away. Many other health care professionals are now interested
in wound care and the patients and dollars it may represent. Physicians, physical
therapists, and others seen green pastures filled with wound care patients. The
challenge for ET nurses is to maintain our expertise, hold on to our services, while
collaborating with the interdisciplinary team that is really required for holistic care
of patients with wounds. We ET nurses must clearly articulate and communicate
our special skills that qualify us as unique members of the wound care team. If we
fail to meet this challenge, we may find ourselves left out in that pasture.
CONCLUSION
The challenge ahead will require determination and strength, for if we are to
remain leaders in wound care, we ET nurses must continue to demonstrate our
leadership in many areas: clinical practice, education, public policy and research.
We must heed the example of our early ET leaders, like Norma N Gill-Thompson,
who had both the vision and the strength to carve out and hold on to a specialty
practice for a very special group of patients. Like Norma, who to this very day
at age seventy-five, travels tirelessly around the world spreading the gospel of
Enterostomal Therapy, we must be in it for the long haul. We owe it to our patients,
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to our specialty’s founders and to ourselves as committed healthcare professionals

and proud-to-be ET nurses.
REFERENCES
Alterescu, V. (1983). Toward a physiologic approach to the topical treatment of opened
wounds. Journal of Enterostomal Therapy, 10(3), 101-107.
Broadwell, D. (1983). President’s message: The future of ET nursing. Journal of Enterostomal
Therapy, 10(1), 1-2.
Broadwell, D., & Jackson, B.S. (1983). Principles of Ostomy Care. St. Louis: C.V. Mosby.
Bryant, R. (1992). Wound care: Everybody’s doing it, but is that enough? (Editorial). Journal
of ET Nursing, 19(5), 151-152.
Bryant, R.A. (ed.). (1992). Acute and chronic wounds: Nursing management. St. Louis: Mosby
Year Book.
Gill, N. N. (1977, January 4). Unusual skin problems for the new E.T., Part I. Unpublished
paper.
Goode, P. (1987). Irritation, not excoriation (Letter). Journal of Enterostomal Therapy,
14(1), 46.
Gross, L., & Bailey, Z. (1979). Enterostomal Therapy: Developing Institutional and Community
Programs. Wakefield, MA Nursing Resources, Inc.
International Association for Enterostomal Therapy. (1983). Strategic Planning Report, Part
1. Journal of Enterostomal Therapy, 10(1), 5-9.
Krasner, D. (ed.). (1990). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals.
King of Prussia, PA Health Management Publications.
Kynes, P.M., Brown-Etris, M., & Snyder, M. (1987). A white paper: The cost benefits of ET
nursing in modern health care delivery. Journal of Enterostomal Therapy, 14(3), 95-100.
Vukovich, V.C., & Grubb, R.D. (1973). Care of the Ostomy Patient. St Louis: Mosby.
137
Alfred R. Priest
Manufacturers’ Role in the

Development of the W.C.E.T.
Alfred R. Priest
W
hen a representative or principal of an ostomy related product
manufacturer wanted to learn the ostomy business it was important to
get around and visit the ET schools where new things were happening.
When these individuals visited The Cleveland Clinic initially they met Dr. Rupert B.
Turnbull, Jr. who was a pioneer Rectal and Colon Surgeon. They would also meet
Norma Gill who not only helped care for Dr. Turnbull’s patients but also played a big
part in creating and heading up the world’s first School of Enterostomal Therapy, a
term created by Dr. Turnbull.
People from all over the U.S., as well as 17 foreign countries, attended this school.
Many graduated and went back home to establish new and much needed ET
schools in their own areas. In addition, surgeons from all over the world came to
work with Dr. Turnbull.
Norma traveled extensively throughout the U.S. and the world to spread the word
about good ostomy care with missionary zeal.
The Cleveland Clinic became the world pioneer in creating the stoma which was
fashioned to anticipate that the ET and patient had to manage this new bodily
opening and its output, often for the rest of the patient’s life.
It had to be divine intervention that brought Dr. Rupert Turnbull and Norma Gill
together to create the surgical opening that could be managed by an ET, often
utilizing improvised materials.
Enter the proud ET who brought specialization to one of the least dignified tasks in
the hospital. She became so adept at handling all kinds of bodily discharges that
she was soon in demand throughout the hospital as a proficient “bag lady.”
In 1961 the tasks that these ETs performed enabled them to be recognized
professionally as Enterostomal Therapists. The need for this new specialty was
integrated closely with the development of new surgical interventions developed
by innovative surgeons.
As enthusiasm grew from the graduates of ET Schools so did the desire to develop
a truly international professional organization. An initial meeting was held in
Toronto in 1976 and in Milan in 1978 the organization officially became “The World
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Manufacturers’ Role in the Development of the W.C.E.T.
Council of Enterostomal Therapists.” A journal followed in 1979 and in 1986 it

became possible to place advertisements in the journal. This helped all concerned
spread the word about new techniques, new products and industry news. Norma
Gill helped see another dream of hers become a reality with the establishment of
the Norma N Gill Foundation. This foundation was established in 1980 to provide
financial assistance to nurses to attend an ET School or receive ET education “on
site.”
The establishment of the WCET (World Council of Enterostomal Therapists) helped
further the tenets of good ostomy care. The opening of each WCET conference with
flag bearers from each country testifies to the spirit of international cooperation
which has led to the expansion of ET knowledge and professionalism worldwide.
Ostomy product manufacturers were able to cooperate in the development of the
WCET. Most companies were small and the ostomy profession was in its infancy.
It was possible through hospital visits, conferences and regional meetings to get
to know many of the persons in the industry. The industry and the Enterostomal
Therapists needed each other to communicate product needs and evaluate and
“fine tune” ostomy needs.
ETs were willing to help new company representatives learn about caring for the
patient. It was in the best interests of all concerned. The WCET needed to hold
conferences in the U.S. and foreign countries. Manufacturers needed to spread
the word about their products. Once again it was a case of there being a mutual
dependency that helped the relationship to thrive.
It is a pleasure to pay tribute to the ETs themselves who expanded their proficiency,
not only in stomal care but wound care, skin care, and incontinence. ETs taught
patients and other health care providers how to manage these areas of care.
International travel made it possible for companies to learn that some of the third
world countries needed product donations to help make it possible for surgeons
to undertake, with the help of ETs, new ostomy surgical procedures.
It was clear that there were deserving nurses that could not afford the cost of travel,
food, lodging and tuition to attend ET school. Manufacturers joined together to
establish an annual scholarship to enable deserving nurses to attend ET school in
honor of Dr. Rupert B. Turnbull, Jr.
The patients through the ET and The United Ostomy Associations, deserve much
credit for their part in helping others cope with their ostomies. Many had to
undergo a good deal of trial and error before products were developed that made
their stomal care more bearable and manageable.
In closing, Norma Gill Thompson has asked that these particular persons be given
her heartfelt thanks for their help with the WCET and The Norma Gill Foundation:
Bill Davidson, Peter Hurrin, Bob Loy, Al Priest, and Ozzie Rapin.
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Bonnie Sue Rolstad
The Student Experience:

Living the Legacy
If we are to find our way across troubled waters,

we are better served by the company of those who have
built bridges, who have moved beyond despair and inertia.
— Marilyn Ferguson
I
t’s July, 1994, the World Council of Enterostomal Therapists is in session in
Yokohama, Japan. Internationally known figures in the field of enterostomal
therapy casually lounge in the hallways or lean into an eastern breakfast of egg
drop and vegetable soup. They have gathered in an age old ceremony to exchange
scientific information and renew valued friendships. Among them, most notably,
is Norma Gill-Thompson. Since 1958, she has carried the mantle of enterostomal
therapy.
At breakfast are Norma, her husband Herb and my 12 year old son, Joshua. It’s
been many years since I’ve seen Norma, and the conversation flows. On the way
to the hotel restaurant my son inquired, “Who is Norma Gill?” I hesitate. I explain
briefly that she was the beginning of everything and she continued to persevere
throughout the years to represent her values and beliefs. She has dedicated her life
to the benefit of millions of people struggling with disease. That was the capsule
version, but, as with most things in life, there’s really much more to it than that.
I first met Norma Gill in a letter when I was accepted as a student in the enterostomal
therapy course at the Cleveland Clinic. “One should have empathy for the patients,
and a willingness to work with them in their daily care above anything else. Don’t
consider your personal gain first. If you start the course, and at the end of the first
week you want to drop out, your money will be refunded” (Gill, 1971). She was
revealed: patient-centered, empathetic, direct and fair.
She recognized the need. Estimates in 1970 indicated that 86,000 abdominal stomas
were created in the United States annually (Commission, 1970). In 1969, the United
Ostomy Association’s (UOA) national office had responded to 1,000 requests for
information, 75% of those requests were from physicians seeking assistance. Seven
hundred personal letters were written from that same office that year to patients
in need of help (Lenneberg, 1971). Membership of the International Association
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The Student Experience: Living the Legacy
for Enterostomal Therapy was 110 (Barer, 1972). However, even with demonstrated
need, there were considerable problems convincing other health care providers,
hospital administrators and insurance companies that a specialist in ostomy care
was essential. While progress has been made, this remains a difficult challenge
even today.
In the spring of 1972, I arrived at the Cleveland Clinic as an enterostomal
therapy student. On a larger scale, the world was in considerable turmoil with
the assassinations of Martin Luther King, Jr. and Robert F. Kennedy in 1968, the
Watergate scandal in 1972 and the Vietnam war cease-fire a year out of view
(1973). This year in the field of ostomy care, President Nixon would sign into law
HR-1, a major revision to the Social Security Act which would enact Medicare
reimbursement for ostomy equipment (Langsner, 1972). Carl Stokes was in office
and was the first black mayor of Cleveland. Racial unrest was prevalent. This was
the first time I recalled seeing security guards posted outside buildings and in
parking lots. Policemen with dogs patrolled outside the student dormitory at the
Bolton Inn. The front door of the Inn had a bullet hole in the glass window pane.
As a young woman from the quiet midwestern city of Minneapolis, I remember
vividly the fear of entering the city and viewing the results of fires and riots. I
took a handgun with me, something that would shock most people who know
me now. Resolved, I determined that the Cleveland Clinic was the first program
for educating enterostomal therapists and had a rich tradition of excellence.
Something important was about to happen in my life, and it did.
There were four students in our class: three nurses and me, a patient with a
temporary ileostomy. These were the final years of accepting non-nurses into
enterostomal therapy programs. Norma, herself, had an ileostomy and most of
the first enterostomal therapists were stoma patients or family members of a
stoma patient. This provided a high degree of commitment to the “cause” and
resulted in what we later referred to as “missionary zeal.” However, enterostomal
therapists functioned within the nursing profession and, as that profession
evolved, enterostomal therapy would logically become ET nursing, a postgraduate
education course. Requirements for entrance into ET education also stated that
each candidate had a position to practice enterostomal therapy upon graduation.
This is no longer a requirement in the programs.
Orientation was provided by the program directors, Norma and Rupert B. Turnbull,
Jr., MD. They were to become historic figures as the founders of the ET nursing
specialty, but that was not known to me then. We had breakfast in the Cleveland
Clinic cafeteria. This was to become a daily event, if we got up early enough so the
operating rooms were not yet busy. Dr. Turnbull and Norma liked to eat with the
students. I later remember checking out the cafeteria for a doctors dining room;
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Bonnie Sue Rolstad
there must have been one. Even at lunch or dinner, if he saw us, he joined us. I felt
quite welcome there.
Program goals, activities, a calendar schedule and scientific articles were provided
as we began our training. Ostomy management was primarily the focus of the
specialty. Care of patients with draining wounds or fistulas was an adjunct as
many of the same principles and equipment were adaptable to that group. The
curriculum was six weeks of intensive ostomy care. The length of stay for patients
undergoing ostomy surgery was between two to four weeks. Sigmoid colostomy
patients would be routinely instructed in irrigation procedures on the seventh
postoperative day. Therefore, we were frequently able to follow inpatients through
a period where their first posthospitalization visit would occur today.
Technical knowledge was essential and the file drawers in Norma’s office held
huge stores of products which became an almost full time project. Indications for
product use, the manufacturer’s name, order number and fitting requirements
were to be mastered during the course. As the director of the program, Norma had
scheduled lectures by an interdisciplinary faculty and discussion groups. However,
unknowing visiting professors would be sequestered by Norma for a “simple” one
hour lecture add-on for the students. We benefited from Norma’s enthusiasm as
she strove to provide a comprehensive experience. After clinic on Fridays, from
4:30–6:00 p.m., the Colon and Rectal Department Seminars were held. The weeks
were full.
Clinically, we were challenged, even by today’s standards. Students made rounds
daily with the surgeons and then to discuss ET assignments for the day. During
the program, we saw approximately 45 inhospital patients with ostomies per
day. Individual student case loads were ten to twelve patients per day with care
provided “under supervision”. My personal experience also included twenty hours
of observation in surgery and 160 patient observations and/or direct patient
care in the Outpatient Clinic. It was routine for Dr. Turnbull to have three to four
exam rooms in process at the same time. The students followed specific patients
and then provided direct consultation to patients assigned by Norma (Gill, 1972;
Rolstad, 1972).
Surgical observation was a bit foreign for a non-nurse. (There was no cable surgery
channel in those days.) However, Drs. Turnbull, Weakley and their colleagues were
most helpful and informative. Dr. Turnbull mused over the loveliness of clover
fields in my home state of Minnesota while creating a loop ostomy in an obese
patient. He explained in detail the rationale and techniques of primary maturation
of stomas. (The Atlas of Intestinal Stomas authored by Drs. Turnbull and Weakley
was already a surgical text.)
142
In the evenings, Dr. Turnbull would make rounds again around 4–6 p.m. A few of
the students would be available at these times in order to take in just a little more
information before the end of the day. One particular night, Dr. Turnbull called
our dormitory to inform us that a patient with an ileostomy and small bowel
obstruction had come into the emergency room. We hurried over to the hospital
and participated in the ileostomy lavage and teaching. Every occasion was an
opportunity for learning and that was the environment Norma and Dr. Turnbull
provided.
The list of required and selected readings provides insight into the development
of ostomy care, adaptation theory and surgical techniques during this period. Here
are just a few article titles from the bibliography.
Practice development
Stoma rehabilitation clinics (Lenneberg); History of the North American Association
of Enterostomal Therapists; Enterostomal Therapy in the Community Hospital
(McConnell, 1969).
Patient care
Post-operative care of the patient with abdominal perineal re-section of the rectum
with permanent colostomy (Smith, 1970); The process of aging and rehabilitative
nursing (Nursing Clinics of North America, 1966); Perineal wound healing (Leonard,
R., lecture abstract, date unknown); The patient has an ileal conduit (Murray et
al., 1971); I am Joe’s intestine (Ratcliff, 1971); Colostomy simplified (Marino et al.,
reference to text unknown).
Equipment
Instructions for assembling a Perry 51 model appliance; Instructions for the
Hollister appliance and belt; Colostomy irrigation/common irrigation problems
(Catheter and cone tips discussed. Routine digital dilation of the stoma discussed
and discouraged.); Peristomal skin protection with Orahesive (Kyte, Hughes,
undated); Urinary appliances and stomal care (Merrill et al., 1971).
Psychologic recovery
Helping your ostomate patient cope (Gill et al., 1972); Spotlight on behavior (NY
Times, 1971); This road can be traveled (Randall, 1972); Agnew’s blast at behaviorism
(Psychology Today, 1972).
Sheaves of original articles from well known authors at the Cleveland Clinic
including Richard Farmer, MD (Gastroenterology), Ralph Straffon, MD (Urology),
William Hawk, MD (Pathology), Rubert B Turnbull, Jr., MD and Frank Weakley, MD
(Colon and Rectal Surgery).
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Bonnie Sue Rolstad
Requirements for graduation from the program included 30 written case studies,
one indepth case study, a project paper satisfactory completion of an equipment
exam, clinical evaluation and a written final. Certification was granted upon
successful completion of the course. During the luncheon graduation ceremony
each student received an autographed copy of Atlas of Intestinal Stomas (Turnbull
& Weakley, 1969) a program pin and the enterostomal therapy badge (designed at
the Clinic).
Much discussion is heard today about fees and reimbursement. In 1972, tuition
for the course was $200 (which I paid myself ) and $660 for travel and hotel (which
was paid by my sponsoring hospital). The enterostomal therapist’s position was
located within the Department of Surgery at the Cleveland Clinic. In 1971, charges
for independent ET visits were approximately $25.00 for first hospital call, $10.00
for each hospital visit thereafter and $15.00 for an outpatient visit (Rolstad, 1972).
Medicare did not directly reimburse for enterostomal therapy visits and this has
not changed.
Throughout the 23 years I have practiced ET nursing, each position I have filled
has been that of Director. I have applied many of the approaches and zeal for the
mission I saw reflected in Norma’s work. (Not including the massive file drawers
with product!) Later, as a CoDirector of the ET Nursing Education Program at Abbott
Northwestern Hospital in Minneapolis, Minnesota, I participated in curriculum
development and implementation. Scheduling patient rounds, lectures and
special events were all part of the responsibility which I recognized from observing
Norma’s skills and my own experience.
While teaching in our course, I frequently reflected upon the unique opportunity I
had in Cleveland for intensive education in one focused area. The management of
stoma patients, particularly identification and treatment of stoma complications,
requires experienced practitioners. There are no short-cuts to mastery. Experienced
ET nurses currently have an important mentoring role of assisting newly graduated
ET nurses as they gain experience in this aspect of practice. The ET nursing scope
of practice now includes wounds and incontinence within an eight-week course.
Some of Norma’s greatest attributes were hospitality and networking. During our
program, Norma invited students to her home on select weekends. She lived in
Akron, so we stayed the weekend. In the basement, were the now infamous shelves
of ostomy supplies. Dinner, relaxing and meeting her colleagues was the norm.
Presidents of ostomy product manufacturing companies or visiting nurses and
surgeons dropped by for dinner. Always present was the drumbeat of the mission.
On one weekend at Norma’s, the students thought a show and dinner would
be great … instead we headed to Youngstown for a United Ostomy Association
regional meeting! It was a wonderful time of positive energy and learning. I have
144
tried to bring these feelings to my students as they have negotiated the stresses
of ET nursing education.
Later, I searched my notes from the program (yes, I still have them all) for indications
of boredom or disinterest. They were absent. Each day was a new opportunity in
a safe environment that nurtured exploring. Another change occurred for me as
well. Norma provided guidance on social activities in Cleveland and encouraged
us to get out and relax. By the time I left Cleveland, this hesitant young woman had
taken the train downtown to shop, rented a car to tour and shop in Shaker Heights
and taken a tour of historic places in Cleveland. My perspective had changed.
Our breakfast in Yokohama comes to a close. My son Josh joins Bob Turnbull (Dr.
Turnbull’s son) and his two sons to explore Chinatown, Herb strolls off to read the
paper, while Gwen Turnbull (Dr. Turnbull’s daughter-in-law), Norma and I begin
the day of conference. I glance over at Norma and see the still enthusiastic, direct
woman twenty-some years older. She has cleared a path we will never be fully able
to travel and has made our journey easier. A prayer from Meister Eckhart comes to
mind, “If the only prayer you say in your life is ‘thank you’ that will suffice.” Thank
you, Norma.
REFERENCES
Barer, A. (Fall, 1972). Report of San Francisco Conference, First Impression. ET Quarterly, 6–8.
Commission of Professional and Hospital Activities. (April, 1970). Certain Operations on
Digestive and Urinary System: Projected Patient Counts for Stoma Rehabilitation Clinics.
Unpublished paper. Ann Arbor, MI.
Gill, N. (1971). For those students we are coming to Enterostomal Therapy Training.
Correspondence.
Langsner, J. (Fall, 1972). Medicare. ET Quarterly,. 17.
Lenneberg, E. (July 1971). Role of enterostomal therapists and stoma rehabilitation clinics.
Cancer, 226-229.
Rolstad, B. (1972). Enterostomal therapy training course, Cleveland Clinic; summary of
activities. Unpublished paper.
Rolstad, B. (Fall, 1972). Should an enterostomal therapist be a member of a hospital staff?
Part II. Unpublished paper.
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Marilyn Spencer and Fran Anderson-Ciambor
Enterocutaneous Fistulas
T
he patient with an enterocutaneous fistula poses significant problems in
management and in a potentially high mortality rate. These fistulas are
unanticipated and require thorough assessment of the patient in order to
determine the appropriate course of treatment and care. The ET nurse is a vital
contributor to the management of a patient with an enterocutaneous fistula,
recommending treatment modalities that protect the patient’s skin in the face of
potentially corrosive output and that contain the fluid. In a study of 23 patients,
Hugh and Cohen (1986) found that nutritional support and adequate local care of
the fistula site allow spontaneous closure in about one-third of the patients.
The development of advanced nutritional support, such as elemental diets in the
1960s and total parenteral nutrition (TPN), were the greatest advances in medical
technology that decreased the morbidity and mortality of patients who developed
these fistulas. Prior to the introduction of advanced nutritional support, mortality
rates were reported varying from 20% to 80% depending on the cases reviewed.
Deitel (1983) reported a decrease in mortality rate from 40% prior to 1969 to
less than 10% in 1983 that was directly related to the combination of nutritional
support, skin protection and judicious surgery; Fischer (1983) reported mortality
rates as high as 6% to 20% despite modern techniques and improved surgical
intervention.
ETIOLOGY
Pathologic factors, such as cancer, inflammatory bowel disease, trauma and distal
bowel obstruction contribute to the development of an enterocutaneous fistula.
Most often, these fistulas occur as a complication of abdominal surgery.
The specific cause of an enterocutaneous fistula following an abdominal operation
is obscure and difficult to diagnose, however distal obstruction promotes suture-
line breakdown. Hugh and Cohen (1986) postulated that distal obstruction
associated with peritoneal adhesions or abscess is the critical determinant of fistula
persistence. Definitive diagnosis (Irving, 1977) is best accomplished by doing
fistulography through the external openings and conventional barium studies.
In 1978, Sternquist et al., found that in a group of thirty-four patients with 38 fistulas,
25 were associated with inflammatory processes (diverticular disease, Crohn’s
146
disease, ulcerative colitis, appendectomy, necrotizing enterocolitis, infected

pseudocyst, lysis of adhesions, perforating cecal carcinoma), the remaining were
all complications of abdominal surgical procedures. In a retrospective study of
38 patients, Doglietto et al. (1989), found that 35 fistulas resulted from surgical
complications, two from Crohn’s disease and one from pancreatic blunt trauma.
The causative factor must be fully assessed and a treatment plan instituted that
manages the drainage until the fistula heals spontaneously (about one-third of the
patients will heal) or until surgical intervention is warranted. Each patient must be
assessed individually before surgical intervention is undertaken to ensure stability
and improve the patient’s nutritional and metabolic states. Resection and bypass
procedures are most commonly used as surgical intervention. Most recently,
Lange et al. (1990) were able to achieve endoscopic occlusion of eleven out of 17
gastrointestinal fistulas using fistuloscopy (use of a flexible endoscope advanced
percutaneously along the fistula tract) and a fibrin tissue sealant.
FACTORS IN FISTULA MANAGEMENT

The complications of enterocutaneous fistulas present a formidable task in medical
management. Fischer 1983 delineated the major factors to be considered: fluid
and electrolyte imbalance, malnutrition and sepsis.
Fluid and electrolyte imbalance is a common complication of enterocutaneous
fistulas. The potentially high volume, corrosive output can quickly denude the
skin. Early attention should be given to maintaining fluid and electrolyte balance in
order to minimize complications. Accurate intake and output provides the basis for
volume replacement, electrolyte balance and nutritional supplementation. Medical
textbooks provide in depth information on expected volumes and composition
of gastrointestinal tract secretions. Dunavant (1982) effectively summarized the
major characteristics of these secretions:
1. Gastric juice: 2000 to 2500 ml/day; pH 1.0 to 3.5; contains pepsin, hydrochloric
acid, and electrolytes (per liter) — 60.4 mEq of sodium, 9.2 mEq of potassium,
84 mEq of chloride, and 0 to 14 mEq of bicarbonate.
2. Pancreatic juice: 700 to 1200 ml/day; pH 8.0 to 8.3; contains proteolytic
enzymes (trypsin, chymotrypsin, carboxypolypeptidase, ribonuclease and
deoxyribonuclease), a glycohtic enzyme (pancreatic lipase), and electrolytes
(per liter) — 141.1 mEq of sodium, 4.6 mEq of potassium, 76.6 mEq of
chloride and 121 mEq of bicarbonate.
3. Bile: 500 to 700 ml/day; pH 7.8; contains bile salts, bilirubin, cholesterol, fatty
acids, lecithin and electrolytes (per liter) — 148.9 mEq of sodium, 4.98 mEq
of potassium, 100.6 mEq of chloride and 40 mEq of bicarbonate.
147
4. Succus entericus (intestinal juices secreted by minute glands lining the small
intestine): 2000 to 3000 ml/day; pH 7.8 to 8.0; contains proteolytic enzymes
(peptidases), glycolitic enzymes (sucrase, maltase, isomaltose and lactase),
a lipolytic enzyme (intestinal lipase) and electrolytes (per liter) — 111.3
mEq of sodium, 4.6 mEq of potassium, 104.2 mEq of chloride and 31 mEq of
bicarbonate.
Fischer (1983) described malnutrition as a problem in patients with enterocutaneous
fistulas even in light of nutritional support via elemental diets and identified three
sources of malnutrition in these patients:
• lack of proper food intake (solid food increases the output of small bowel
fistulas);
• the hypercatabolism of associated sepsis (sepsis is almost always part of
the fistula syndrome and is associated with rapid breakdown of lean body
mass); and
• loss of protein-rich energy-requiring secretion from the fistula (small bowel
secretions contain about 75 g of protein in 24 hours).
Deitel (1983) described the effective use of elemental diets for malnourished
patients with enterocutaneous fistulas when these compositions are delivered
distally to proximal gut fistulas or with low intestinal fistulas. The chemical
composition of elemental diets does not stimulate enzyme secretion and is ready
for intestinal absorption. When the patient is still not a candidate for the elemental
diet, total parenteral nutrition (TPN) is indicated.
Sepsis is almost always associated with enterocutaneous fistulas and is the major
cause of mortality. Fischer (1983) described the nature of the septic process being a
result of a combination of factors: post-surgical disruption, abscess formation, and
necrotic and devitalized tissue act as a culture medium for a variety of organisms
(most commonly, coliform, bacteroides, enterococci and staphylococci). In
addition to antibiotics, drainage of the infected area is indicated and surgery may
be necessary.
MANAGEMENT TECHNIQUES
Care of the patient with an enterocutaneous fistula is a nursing as well as a medical
challenge. Gilsdorf, Laing and Myklethun (1977) outlined stages of the care of a
patient with an enterocutaneous fistula as:
1. Stabilization: manage sepsis, manage fluid and electrolytes.
2. Diagnostic evaluation: observation of the fistula and wound,
roentgenographic study, documentation of fistula location and pathway.
3. Establish plan of care based on diagnosis.
148
4. Support: educational, financial, nutritional.

5. Closure: spontaneous or surgical.
Protecting the patient’s skin, containing drainage, controlling odor and providing
emotional support are key factors in the nursing management. The ET nurse has
an arsenal of products at her disposal to accomplish these tasks. Denuding of
the skin from the corrosive nature of the fluid output has always been a primary
concern. However, with the advent of skin barriers and plastics in the 1950s, skin
breakdown, skin protection and drainage collection has become manageable.
Sterile technique is unnecessary since the drainage from the gastrointestinal tract
is not sterile. However, skin protection is critical and may be difficult if the fistula is
located in a crease or in an open wound.
The successful use of a silicone cast was described by Laing (1977). The cast
incorporated Dow Corning #3110 RTV (room temperature vulcanizing) silicone
rubber and RTV catalyst #4. The mixture was poured onto the patient around a
“shank” placed into the fistula. The mold was sculpted to fit the patient’s individual
body contour and a collection device was attached to the mold.
The advent of skin barrier pastes has eased the techniques used in the process of
skin protection. Skin barrier pastes that do not contain alcohol should be used to
fill in skin depressions around the fistula and provide a smooth surface for a skin
barrier sheet. A drainable pouch should be applied over the skin barrier sheet and
the pouch connected to a bedside gravity drainage system.
CONCLUSION
The ET nurse plays a vital, multi-faceted role in the care and management of a
patient with an enterocutaneous fistula. Using the vast resources, knowledge and
talents of the specialty of ET nursing practice, appropriate treatment modalities
can be recommended which may contribute to spontaneous closure of the fistula.
Critical factors in the ET nursing management of these patients that lead to positive
outcomes are: skin protection with products that both conform to body contours
and act as a barrier between the skin and the corrosive effluent; containment
and collection of the effluent with equipment that can be connected to gravity
drainage systems (accurate intake and output provides the basis for volume
replacement, electrolyte balance and nutritional support); controlling the odor
of the drainage through containment of the effluent. Through the benefit of ET
nursing services, the challenge of time-consuming nursing care problems, such as
frequent dressing and linen changes, are eliminated.
The unanticipated development of an enterocutaneous fistula is distressing to the
patient: odor from the drainage contributes to feelings of isolation; the continuous,
irritating drainage causes discomfort and pain; the necessity for frequent dressing
149
and linen changes disturbs the need for rest, and; anorexia and immobility may
occur in reaction to the condition. Intervention by ET nursing services contributes
significantly to the patient’s rehabilitation through management of the key
physical factors vital to recovery. Administering to the physical factors in this
nursing management results in improved patient psychological well-being by
eliminating odor and drainage problems that contribute to feelings of isolation.
With secure collection and containment of the drainage, the patient is much more
amenable to mobility and ambulation.
Adequate, appropriate care of the local fistula site, as provided by ET nurses, is
a critical factor in the management of enterocutaneous fistulas and, as found in
previous studies, is a key issue in spontaneous closure of the fistula in about one-
third of patients.
REFERENCES
Bryant, R. (1992). Acute and Chronic Wounds: Nursing Management, pp. 248–281. St. Louis:
Mosby Year Book.
Deitel, M. (1983, July). Elemental diet and enterocutaneous fistula. World Journal of Surgery,
7(4), 451–4.
Doglietto, G., & Crucitti, F., et al. (1989). Enterocutaneous fistulas: Effect of nutritional
management and surgery. Italian Journal of Surgical Sciences, 19(4), 375–80.
Dunavant, M. (1982). Wound and fistula management. In D. Broadwell, & B. Jackson (Eds).
Principles of Ostomy Care (pp. 658–686). St. Louis: C. V. Mosby.
Fischer, J. (1983, July). The pathophysiology of enterocutaneous fistulas. World Journal of
Surgery, 7(4), 446–50.
Gilsdorf, R., Laing, B.J., & Myklethun, A. (1977). The ETs role in managing post-operative
enterocutaneous fistulas. ET Journal, 4(4), 7–9.
Hugh, T., & Cohen, A. (1986, December). Persistent postoperative enterocutaneous fistula:
Pathophysiology and treatment. Australian and New Zealand Journal of Surgery, 56(12),
901–-906.
Irving, M. (1977, October). Local and surgical management of enterocutaneous fistulas.
British Journal of Surgery, 64(10), 690–4.
Jeter, K., Tintle, T., & Chariker, M. (1990). Managing draining wounds and fistulae: New and
established methods. In D. Kras-ner, Chronic Wound Care (pp. 240–246). King of Prussia,
PA Health Management Publications.
Laing, B. (1977). Making silicone casts for enterocutaneous fistulas. ET Journal, 4(4), 11–12.
Lange.V., & Schildberg, F., et al. (1990). Fistuloscopy — an adjuvant technique for sealing
gastrointestinal fistulae. Surgical Endoscopy, 4(4), 212–216.
Sternquist, J., & Hitchcock, C, et al. (1978 November-December). Enterocutaneous fistula.
Diseases of the Colon and Rectum, 21(8), 578–81.
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Living with a Legend

W
hile watching a TV miniseries (A Woman of Independent Means) recently, I
realized one could probably call my mother “a woman of independence,”
or “a woman of independent energy,” or even “a woman of independent
spirit,” as she has always been an independent woman with a high energy level and
a spirit of iron. These adjectives all exemplify her.
The “woman of independence” most likely came from her background of the same
type of women. Mom’s grandmother, Lillie Mullennax, was quite a lady, yet one of
“independence.” She decided to learn to drive at age 65, purchasing a car of her
own and hiring someone to teach her to drive. This was the grandmother who
had a colostomy in the earlier years of 1940. The woman of “independent spirit”
probably came from Mom’s mother, Esther Nottingham Day, married three times
before finding the “love of her life” (and those weren’t the days to be known as a
“divorcee”). Grandma Esther also owned and operated the first reducing studio in
our hometown of Akron, Ohio.
Mom married when she was just 18 into an Irish-Catholic family — quite a change
for someone who at age twelve experienced, as an only child, separation of her
parents and family (as she knew it). But she loved the camaraderie of such a family.
Since I am the youngest child, I remember little about the illness my mom endured.
However, I have heard the stories from my father, Edward (Ted) Gill (deceased
1974), my sister Marilyn, and my brother, David, as well as relatives and friends
of the family. Just recently Mom entertained the “St. Rita Study Club,” a Catholic
women’s group she has been a member of for 50 years. The ladies still recall and
discuss the time Mom was so close to death that they all gathered at a member’s
home and prayed the rosary. They never thought she would make it. Who had ever
heard of “Ulcerative Colitis” in 1948? Did it mean death?
To quote Mom’s writing (in part) “My Five Years of Ulcerative Colitis”:
The first indication that I was having a problem occurred in 1948. I was 28
years old at the time with two small children, one 7 years old and one 5 years
old. It was in May when I suddenly started having diarrhea. I [attributed] this
to a touch of intestinal flu. But after several weeks of diarrhea, I consulted a
physician, who gave me a bottle of medicine and sent me home assuming that
could cure me! But this did not happen. After consulting him several times with
no results, I decided to consult another doctor.
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Sally J. Thompson
This doctor, Paul E. Cheek, M.D., of Akron, Ohio, was only a year older than me
and fresh out of medical school. The first time I walked into his office he told me
I had ulcerative colitis. This really did not mean anything to me. I figured a few
medications and that would take care of it. I am sure if we both knew what we
were to go through together we would have been horrified.
It is hard to remember the whole sequence of events in the next two years,
medication, diet, trying to cook for the family, constant bowel movements, and
being unable to get to the bathroom in time. I remember going to a company
picnic with my family and having to come home because of soiling myself. It
was one step forward and two steps backward. The doctor constantly asked
me if I wanted to go to someone else and would have consulting physicians
come in. I knew they really did not know what to do either. Money became a
big problem. I was finally started on ACTH and cortisone, since it was new. The
doctor could only guess what dosage to give me; he did reason out I should
not have just cortisone because of the side effect of shutting down the adrenal
glands. I only progressed into more trouble even though he also gave me ACTH
at intervals. He did not know. My red blood count started to go down, and I
found myself spending hours in the emergency ward of the hospital getting
blood transfusions. My blood count on my return from a trip to Arizona had
been so low that I ended up having a total of 28 pints. Money used for cortisone
tablets was eating us up. The tablets sold for $36 for 40, and I took 6 a day.
ACTH was not even available except through the hospitals. I finally had to
accept help through community funds. Have you ever had to sit in a hospital
where an intern or resident used you for a guinea pig? I was given type A blood
transfusions, and later they found out my blood type was A negative.
Although I had been terribly ill off and on for several years, I was married and
had a good husband. We had intercourse only once that month, and my periods
had practically stopped. Shortly before this occurred, another problem had
started. My entire hands and part of my arms developed large water blisters.
Also my hands were swollen, my hair became very dull looking, but since I had
not had a period, I felt I should have a pregnancy test.
On the day I was to get my results of the pregnancy test, my husband was
patiently waiting for me outside the emergency exit of the hospital. My own
physician, Doctor Cheek, met me in the emergency ward where he informed me
that I was pregnant, and he really thought I should have a therapeutic abortion!
I was stunned. I walked out to the car and got in. I turned to my husband and
told him. It’s strange what you will do or how you will react under stressful
conditions. He was so shocked, horrified and stunned that I burst out laughing!
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Although I have not brought this aspect into this story until now, I am in many
ways a deeply religious person. I had not grown up with a basic religious
background. My parents did not go to church on a full-time basis at that time,
but I had experienced some deep insights or vision in my early teens. I spent my
summers at my grandmother’s home (who had the colostomy) where they were
firm Baptist. I had sought out religion of different kinds during my teenage
years and had finally decided to convert to Catholic. Surprisingly, I was already
planning to join the Catholic church when I met my husband, a Catholic. I
subsequently turned Catholic.
By 1951, when I became pregnant, I had spent many years in church work
forming study groups, working with the Ladies Guild, belonging to an Inter-city
Catholic study group, active in ‘The Negro Questions’ and starting of a church to
convert the blacks. So in this time of this major crisis of being pregnant, I had to
make some large decisions! The Catholic church does not believe in abortions;
I first was a Protestant. I was not fully convinced of the theory of the Catholic
church [which does] not believe in abortions. But something firmly told me that
I was pregnant for a reason, and that I was not to have an abortion.
It was not an easy nine months. Illness was playing a huge part. The water
blisters did dry up. Blood transfusions were increasing.
One of my children’s fond memories was getting to hear the baby’s heart beat
at the doctor’s office and feeling the baby move. They were 9 and 11 years old
at the time.
I had finally decided I no longer could go to the hospital in order to get free
medication. My mother decided to help us out and we eventually borrowed
money on our home.
Finally, on May 31, 1952, my water broke, two weeks early, and I was taken to
the hospital to have the baby. It is hard to express the next 24 hours, since I was
so ill and they did not think I would live. I was left alone except an occassional
nurse coming in during the night. I was in labor 18 hours, and to top it off,
Doctor Cheek who had taken care of me was out of town. I had predicted he
would be, but he had been smart in having another obstetrician see me several
months before in case anything did come up.
The time came for delivery, and basically all I can remember was them saying
the baby was born and my reply was, ‘yes, it’s a girl and she’s a redhead.’ They
were shocked, for it was true. When they asked me how I knew, I told them I had
ordered her.
That’s my Sally.
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Sally J. Thompson
I was so sick I got the chills, and had to have blood, etc. right then. More agony
came later, for I was put in a 12 bed ward. Then the diarrhea started. I could not
control it. The nurse would force me to get out of bed — go to the community
bathroom, where I left a trail of stool all the way. (Did I think I was the only one
in her ward?) In despair, they did move me to a private room. I went home in
about a week still horribly ill. I had to stay in bed most of the time, but because
my mother could not stay at night and my husband worked at night, I was forced
to often crawl on my hands and knees to the baby’s bed to take care of her. My
other daughter (11 years old) would often get out of bed to help me with her.
Before she went to school she would make the baby’s formula and give her a
bath. My son then came down with the measles and had to be confined to his
bedroom for fear the rest of us would get it. Thank goodness we did not.
After Sally was born, this unleashed all the ‘fury’ of the disease the pregnancy
had held back. Some months later, and in the next year and a half, I started to
see five little areas on my legs become ulcerated. In less than three weeks’ time
the flesh fell off my legs clear down to the bone. Nerves were exposed, and the
pain was agonizing. Pain medication was not even giving relief. The ulcers even
came on my face, my abdominal area, and my legs were now ulcerated. I could
only crawl up and down steps in the morning and evening.
Now my legs were so bad that I would wrap towels around them at night to
collect the fluid running out from them and it was terribly painful. I would have
tears running down my face when I tried to remove them in the morning. The
flesh being dead had a horrible smell which made even me sick at my stomach.
So I turned to God for help and believe it or not, I learned what is now called
‘Transcendental Meditation.’ I could separate my mind from the pain fairly well,
but I was positive there was no help in Akron for me, for the doctors called in
for consultation would only shake their heads. I recall the priests who came
to see me, and when I would ask them to pray for me, they would reply, ‘you
pray for me’. The St. Rita Group was of immense help and support too, as was
my husband, children, my wonderful mother, stepfather and friends. I was very
fortunate in this respect.
Then in December 1953, my medication was changed to synthetic cortisone. It
was new and would be cheaper, but my adrenal glands had been beat too long
and I started to have vomiting and diarrhea. Whether this was started by the
‘flu’ or the change of drug, I am not sure.
By afternoon I knew that I was terribly ill and the doctor was called. I was in
complete collapse, without pulse, and cyanotic (from AMA Archives of General
Medicine, August 1954, Vol. 8E, pp. 326–327). All I can remember is that I was
conscious and my poor family was watching the ambulance drivers take me
154
out with a stricken look on their faces and their crying and my reassuring them
I was not going to die. They worked on me all night long. At the hospital I can
remember a wonderful nurse patiently rubbing my feet for me and a resident
who stayed with me all night long. This was December 20th, I arrived home the
day before Christmas.
So 1954 ushered in a New Year, but for me it meant being a semi-invalid. I was
too sick to sit in a doctor’s office. I had to be driven to the office and they would
come to the car to give me shots (ACTH-Iron).
I knew I was dying if something was not done and so did Dr. Cheek. He started
to look beyond Akron to the Mayo Clinic, to Cleveland, wherever. He consulted
with the head gastroenterologist at CCF [Cleveland Clinic Foundation] at that
time, whose name was Charles H. Brown, M.D. Arrangements were made for
me to come directly into the hospital. I remember Doctor Cheek stating that
he thought we should start here, but he did not know whether they could help
or not, or whether I could survive the needed treatments and examinations. A
couple of days before I left home, I recall looking out at the fall leaves (October
1954) that were falling off a dogwood tree across the street and wondering if I
would ever see fall leaves again.
I cried out to the priest who came to see me before I left and asked what was
going to happen to me. There was this desperate look in his eyes as to the right
answer to give me. Suddenly he blurted out, ‘read the book of Job,’ and it did
comfort me.
So I entered the Cleveland Clinic Hospital — what a shock I was to the nursing
staff and physicians. They never had seen anything like me. By now, I was on
morphine tablets because of the severe pain. My legs and ankles were so swollen
I could not wear shoes. I had a moon face from the cortisone and my body was
swollen. I had iritis and bone problems, an enlarged liver and the ulcers on my
body. Doctor Cheek was right! The tests were agonizing. Try having a procto
when your abdomen is full of scabs, your bed is full of scabs each morning, the
tests such as a bone marrow test is taken, a biopsy of the liver where it took
three times to obtain it, and then having stomach pains all night long. After
four weeks, I already looked and felt like a different person. Then Doctor Brown
told me he was going to have a surgeon see me, but not to be frightened. To
quote him, ‘All surgeons talk as though they will operate right away.’
By this time I really did not know if I would live or not. I conditioned myself to
just living one day at a time for whatever it was worth.
Dr. Turnbull and I finally met. After discussing all my problems, I looked at him
and inquired as to how he could give me an ileostomy. Pulling up my night
gown, I showed him all the ulcers, scabs, etc. on my abdominal area. He was
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Sally J. Thompson
floored. He finally said, ‘Let me think it over and get back to you!’ When he did,
he proceeded to say they would anesthetize me in the room and when they
operated they would cut through the scarred tissue. Believe it, it’s a very hot
and cold feeling to know you have to go to surgery. One minute you will be fine
and next you are sure you are not going to make it. On Dr. Cheek’s last visit to
see me, I asked him if I was going to come out of it all right, and he answered ‘Of
course, fine, if you survive the surgery.’ It was agonizing to not see my children
very often, especially the baby (2 years old) for she had been so careful when I
was home to not bump me in my legs. We loved each other so much.
The remark made by Doctor Cheek on my survival had really made me think I
might not make it. I had had a marvelous chief resident with me clear through
this ordeal. I rushed out the night before surgery and proceeded to tell him that
if I were going to go to surgery and die I might as well go on home. He bravely
assured me that I would be all right, but he admitted afterward he sure was not
positive I would survive.
The anesthetist came to see me the day before to check me; the surgery day
came! I was anesthetized before I left the room. The next thing I knew, I awoke
while they were finishing suturing me, and unbelieveable to all, I heard and
repeated their conversation later. I was in terrific pain for 24 hours. My skin
had been so soft, that Doctor Turnbull was concerned whether I would hold
together at the suture line. After 24 hours, he changed my medication and
I began to feel better. In order for me to not pull apart, they would pull me
straight out of bed and then I would sit in a chair. I remember the anesthetist
coming in and not seeing me in bed — the look on his face seemed to say ‘she
didn’t make it’ until I spoke to him from the chair.
The suture line was full of pus and each morning these areas had to be cleaned
out. Painful, oh yes! The tears would roll down my cheeks. But slowly, I started
to get better. They advised me to eat rich protein foods to help build myself
up. Because there was no hyperalimentation then, I did eat and eat. I wanted
to get well.
Christmas was approaching so I addressed cards and prayed I would get home
for the holidays. The abdominal area and all the ulcers were healing, but not fast
enough. The postoperative pouch I had then was cemented on (the Furr bag)
with Karaya powder inside. This was better than what Grandma had though!
When they tried cementing on the permanent one (the thin new Marlen white
neoprene), my skin would not take it! Not knowing I probably would have to
come back in the day after Christmas, they said I could go home. I spent one day
at home, then could not keep a pouch on and had to come back. Tearfully, after
seeing my baby and my family, it was worse than not going home at all! Luckily
156
I got the same room that I had before I left, but I was devasted especially when
I was told I had to be put on a Dempsey Mattress with a hole in it. I then laid on
my stomach so that the effluent would drain into a pan so that the skin could
heal. I was only allowed up to eat, and I had to stay this way for two weeks. After
this I was given a Perry Model 51, which I went home with. I remember on New
Year’s Day Dr. Turnbull made rounds as usual. He came to see me and stayed a
while to watch the Rose Bowl Parade with me. Many years ago he used to march
in this same parade.
I had spent nine weeks at Cleveland Clinic — Thanksgiving, Christmas, and
New Years. When I finally returned home, I recall some funny things such as the
screen doors still on (it was January), cookies in the desk drawers, and Sally’s
hair curly and bushy. My Mom had tried to hold down two places.
During this time my stepfather had a heart attack, and Ted had come up
everyday to see me. It was a happy reunion for us all, even though I had some
more surgeries to go through still that year. My ulcers still were not healed
and the rectum had to be removed. So on Easter Sunday I came in again to
Cleveland Clinic and had the rectum removed. I then had some plastic surgery
in July on my face, and Fall brought a repair of a surgical hernia.
But a new life began, and having my health again was so wonderful. To be able
to cook, work and play with the children had given me a whole new outlook
on life.
This was a beginning of a new life for me. Slowly, I began to resume housework,
caring for my children and getting back into a home-life with Ted, my husband.
It was strange, but even more after I had surgery, I knew I wanted to help my
fellow man. All through my illness this was a burning desire. Unconsciously, I
vowed to do the best I could, if I survived. Where it seemed an impossibility, I
only needed to ask the ‘man up above’ to decide if this were my goal in life or
not. It was his decision.
Along these lines, I first volunteered at Akron (Ohio) City Hospital to help pass
out mail, along with other tasks thinking this might be the way. I learned a great
deal about hospitals, the emergency ward, x-rays, protocols, but nothing in the
line of helping the ostomate.
One afternoon I decided to drop into the office of the dermatologist who
referred me to the Cleveland Clinic when I was ill. His name was William Dorner,
M.D., of Akron. After chatting a while with him, I related this desire of mine to
help. He offered me the first opportunity to open this door. He decided that
he would contact some young surgeons he knew, and suggested that I should
go and see them, then ask who else might be interested. I was not a nurse or I
would probably not have had the nerve that I did to face these surgeons.
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Sally J. Thompson
I eventually went to 28 physician offices and told them what my intentions

were. I guess I was convincing. The surgeons started to call me. When I visited
them, I would return home and would piece together parts of any equipment
I had.
Then in May of 1958,1 returned to the Clinic to have a check-up by Dr. Charles
Brown. Everything was fine, and he asked me if I had seen Dr. Turnbull lately. I
told him no. He suggested I stop and say hello, so I did. When he asked me what
I was doing with my time now, I told him I was getting into ‘his line of work.’
An amazement came over his face and he discussed the growth of ostomy
surgery at the Clinic and the problems of rehabilitating the patients. In August,
to my surprise a telephone call came from Dr. Turnbull asking if I would come
to the Clinic to work as a stoma technician. I almost fell off the chair. At home I
had one child starting the first grade, one in high school, and one in college. I
was 38 years old, but I could only say ‘yes.’
There were many difficulties because of a growing family, of course, but a fire
that could not be put out to help others burned inside of me.
Although I became a widow in 1974, life for me since this unusual beginning
of a career has been very exciting. Much hard work and effort was part of the
ensuing years, and today there are over 2,000 Enterostomal Therapists in the
world.
In October, 1983, I married a former classmate of mine from in high school, a
widower. I met him at a class reunion. ‘Truly, life has rewarded me for my illness
of previous years.’
On October 1, 1958, Mom started her career at Cleveland Clinic. I had problems
with going to school after she began working, so much so that Mom & Dad had to
pull me out of the Catholic School and put me back in the public school where I
attended kindergarten. There I was closer to home and had a very understanding
principal and teacher. I think they knew what I didn’t realize for years — there
was a separation anxiety there. Mom was going to not be home — the Mom I was
separated from so much when I was an infant because of her hospitalizations.
I never felt Mom was any different from other moms — I can’t even remember
when I learned she had an ileostomy. It was just “her” and so was her work. It was
hard explaining to my friends what she did and why she did it. At young ages
“poop” is not something you talk about without giggling.
I remember going to the early UOA meetings (Cleveland Chapter). My girlfriend,
Mary, would go with us and she and I would play Barbie dolls in the lobby while the
meeting went on. (By this time my brother and sister were “on their own!”)
158
I remember the ET school formation at Cleveland Clinic for which Dr. Turnbull and
Mom had the vision. Early ET trainees stayed at our home due to lack of funds and
housing facilities. It was fun having ladies from other states and countries (Canada
was the only “other country” in those days!) 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!
I remember attending the early national UOA conferences, where the ostomates
really weren’t sure where the “E.T.” fit in. I remember seeing Mom cry over this.
Suddenly she was somewhat of an “outcast.” So she then had another vision, a
separate organization for the ETs which Dr. Turnbull again helped her organize.
I remember the early manufacturers of ostomy products, many of whom would
come to our house and discuss with Mom just what the needs of the ostomy
patients were.
My father was a rubber worker in a supervisory position at General Tire. He would
attend every meeting with Mom. He was very supportive of her mission in life, after
all, he came so close to losing her. Yet through their long days, up at 5 am, up late
at night so Mom could go visit patients at the Akron hospitals after coming home
from Cleveland Clinic, they would go dancing with their friends on the weekends,
or just “get together” with them.
As time went on, and they did more traveling, some of those “friends” became
distant. But the true friends have been there, through Dad’s death in 1974 and
Mom’s second marriage in 1983 to Herbert G. Thompson, Sr., whom she met at a
class reunion. Mom has a way of finding “jewels,” my dad was one and Herb is, too.
Herb has also supported her endeavors and travels with her to all the meetings she
still attends.
My decision to become an ET was in 1971, while I was in college. While Mom had
pursued her career at Cleveland Clinic, she also saw patients in Akron hospitals in
the evenings. A business developed from the needs of these patients for products,
which they asked Mom to provide. People came to our house for ostomy products,
evenings, weekends, holidays — you name it — whenever they needed their
supplies.
When I asked Mom if she could train me as an ET, she said (I’ll never forget it),
“Honey, you don’t know how long I’ve waited for you to ask me that question.” Six
weeks of riding to work on that Greyhound bus from Akron to Cleveland and back
again darn near killed me at 19 years of age. I’ll never know how Mom did it for 21
plus years.
So I became an ET, and Mom’s patients in Akron had a hard time adjusting to a
young “snot” like me. After several years, instead of being known as “Norma Gill’s
daughter”, I began introducing my patients to Mom, and subsequently (in Akron,
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Sally J. Thompson
Ohio), she became known as “Sally Thompson’s Mom”! (I specified “Akron, Ohio”,
because to this day, Mom is known throughout the world, yet not well known in
her own home town).
Some quotes from Dr. Turnbull in Mom’s honor at the then IAET (now WOCN)
Vancouver meeting in 1979:
Norma Gill truly came up from the ashes of defeat... Norma is not an average
human... she has one objective — to get the job done... She quickly intruded
herself on the nurses with her quickly made up specialties... (a housewife who
knew virtually nothing about hospital work), but the nurses began to respect
her and her skills since it made their job easier... I personally have the highest
regard for our relationship.
Some quotes from her daughter (my sister) Marilyn, at the meeting in Mom’s honor
in Vancouver, in 1979:
... We (the family) have seen her elated, disappointed, saddened, determined
and visionary in her effort to enhance the cause of Enterostomal Therapy.
... Her determination did not stop with her recovery.
... She did not know what she could accomplish with her limited education, yet
she knew she had a mission in life.
... an asset may have been her limited education since she did not have what
many more educated people have — tunnel vision — which prohibits some
from being able to see what can be done by others outside the field.
... worked with many manufacturers in developing new products and improving
older products.. encouraged manufacturers to go international as she saw the
need in other countries for products.
... she managed to find time for the family through all this and maybe that’s why
I admire her more than any person I’ve ever known.
I never tried, and will never try, to equal my mother. She has achieved in her lifetime
an immense reward for her suffering. She “took lemons and made lemonade.” At
age 75, she still is spreading the word of Enterostomal Therapy throughout the
world.
As I said when she was honored in Vancouver by the (then) IAET in 1979, I’m proud
of her, I love her, and I hope I never outgrow the honor of being known as “Norma
Gill’s daughter.”
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Enterostomal Therapy: the Personification of a Philosophy of Care
Enterostomal Therapy: the

Personification of a Philosophy
of Care
L
ittle Tony needs our help right now — he’s pretty sick, you know. After all, we
have a big house with some rooms we’re not even using. Your mother can fix
up the third floor for him — there’s a bed and a bathroom up here, so he’ll
have some privacy but still feel like he’s a part of the family. You kids will need to
be special friends for him.
So said my father, Rupert B. Turnbull, Jr., M.D., as he knelt in front of the old, footed,
cast-iron bathtub filled with hot soapy water, on the third floor of our rambling
home in Shaker Heights, Ohio. He had removed his tie, rolled up the sleeves on his
white dress shirt, and was busy bathing a naked, emaciated, son of an immigrant
farmer — a wide-eyed, olive-skinned, foul-smelling nine year old boy named Tony
— one of his patients. Tony’s mother was still in Italy and his father didn’t have
the time or ability to care for an ailing son and earn enough income so he could
reunite the family, so my father brought Tony home. He lived with us for several
weeks and each evening, my father personally attended to his bath.
Tony was only one of a series of patients my father brought into our home for
“closer attention,” some tender loving care, extra time to recuperate after surgery,
or a home away from home. Tony’s grateful father made sure that there was fresh
produce on our back doorstep for years to come. Caring for sick people was a way
of life for our entire family.
My wife recalls my father’s inability to harm any living creature, no matter how
small. She caught him letting a mouse back into the house through the basement
window after my mother’s many attempts to get rid of it. Dad’s explanation? “It’s
cold outside and there’s nothing to eat out there. It’s warm in here — it’s a big
house — there’s room for everyone. Besides, we have plenty to eat.”
My mother even had an extra long extension cord placed on the telephone in the
dining room. The phone was set on the table near my father at mealtime — almost
as part of his place setting — so that he could take calls during dinner from the
patients to whom he had given his home phone number.
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Robert W. Turnbull and Gwen B. Turnbull
The 1950s and 1960s predated pagers, beepers, portable and cellular phones, so
Dad had a telephone installed on the piling next to our boat dock and used his
ship-to-shore radio to check in with the hospital during his “leisure time” on our
family boat.
I was only twelve when I made the first of many home visits I was to make with my
father. One particular patient, Walter, remains in my memory as the epitome of why
my father must have chosen this profession. Dad explained that Walter was dying
from rectal cancer and that he was having difficulty with his rubber colostomy
pouch. We arrived at Walter’s home in the early evening and were greeted by his
wife and escorted into the bedroom. Walter’s home seemed very dark and ominous
to me — perhaps it was a child’s impression of what death should feel like. There
was a drawn, strained look on the faces of Walter and his wife which generated a
sense of dread in my young sensibilities. Walter’s face brightened somewhat when
Dad walked into the room, and after chatting for a few moments, Dad changed
Walter’s colostomy pouch. In a little while, the room seemed brighter to me, the
mood lighter, and Walter’s face calmer. I don’t remember much of the dialogue
after the pouch was changed, but I do remember feeling that my Dad’s visit had
made an incredible difference in the atmosphere in that house.
My wife and I have been asked to contribute a chapter to this Festschrift addressing
my father’s vision for Enterostomal Therapy. While it may appear to be a simple
task, it is not. Children are frequently unable to fully comprehend the role their
parents play outside the home. Each day, the parent leaves for work and returns
in the evening, and the child has little understanding of what has transpired in
the interim I knew that he worked hard and long hours as a surgeon, but because
he never boasted about his accomplishments, we were totaUy unaware of the
global impact he had on colorectal surgery, cancer research, patient rehabilitation,
and enterostomal therapy, until we were adults. At home, he was disorganized
affectionate, funny messy, clumsy, and addicted to “Star Trek”. How were we to
know that this lover of nature, our ring leader for mischief, the first one in the pool,
was also an internationally known researcher, pioneer, and writer?
As a result, we are now forced to speculate about his initial vision and purpose
as he began the development of Enterostomal Therapy as a profession, and base
our opinions on retrospection, our adult observations, our own experiences
with ostomy patients, discussions with Rupe and his professional peers during
the later years of their lives, and his own words from his prolific pen. We have
arrived at the conclusion that Dr. Turnbull’s vision of Enterostomal Therapy was
that trained health care professionals would serve as a personification of his own
philosophies and style for the delivery of care. Archie Vinitsky, co-founder of the
United Ostomy Association and the International Ostomy Association, has stated,
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“I observed closely the support Dr. Rupert Turnbull [gave to] the ET idea through
the organizing skills and [the] dedication of Norma Gill as an indirect emissary of
his vision” (Vinitsky 1994). Edith Lenneberg confirms our belief when she stated
that Rupe needed someone who would be “an extension of himself during the
post-operative period” (Lenneberg, 1994). Prillie Stevens believed that Dr. Turnbull
envisioned “an expanding role with no limitations”(Stevens, 1994).
In order to put this theory into perspective, one must first analyze the characteristics
which made him unique and which became interwoven into the fabric of what was
to become Enterostomal Therapy: empathy, leadership, innovation, research, the
ability to simplify complicated information and communicate clearly, education, the
proficiency of technical expertise and state-of-the-art care, the gift of emanating a
sense of security, stability, confidence, advocacy, and hope, and finally, a sense of
humor which bridges a gamut of human emotions.
We believe that one of the greatest attributes Rupe wished to impart was empathy
— a sense of knowing that there were those who truly understood the impact the
creation of a stoma made on one’s life.
He helped me into my bed and told me not to be embarrassed in the slightest,
that rear ends were his specialty and he had seen it all before. He said, in some
genteel way, that everybody was leaking by the time he got to them, that it was
no big deal (Skilken, 1982).
Ostomy patients had long been misunderstood, shunned, and left to find solutions
to their own overwhelming problems. Even as late as the mid 1950s, ostomy surgery
was considered only as a last resort and until surgical techniques were improved
by the discoveries of my father and Professor Brian Brooke in Great Britain, many
of the patients did, in fact, die as a result of the surgery.
Dr. Turnbull and Norma Gill exhibited great leadership, and firmly believed that
ostomy surgery should be a stepping stone to an improved quality of life rather
than a sentence to a life of depression, isolation, rejection, and shame. Warren
Bennis, author of On Becoming a Leader (Addison-Wesley Publishing) believes
that leaders with deep convictions which coincide with and meet the needs of
a group, provide great leadership. The patients were out there, for sure, but, as
Prillie Stevens stated, “the paucity of people interested in addressing them must
have concerned Rupe” (Stevens, 1994). They were waiting for a leader with vision,
creativity, and innovation — forging the way for those who would follow. Edith
Lenneberg remembers: “We met many times in years to come. He was always
cordial, shared ideas freely, and encouraged the impossible” (Lenneberg, 1994).
Since the inception of the specialty, ETs have been recognized as exceptional
leaders and pioneers all around the world.
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Dr. Turnbull continually searched for a better way and urged those around him
to do the same. A remarkably original thinker, his was not a tunnel vision, but a
macroscopic view toward the total care of his patients, characterized by innovation
and research. As his dear friend and colleague, Dr. George Crile, Jr., stated, “not
content with solving the physician’s problem with ileostomy, Turnbull proceeded
to solve the patients’ part of the problem. He founded the School of Enterostomal
Therapy” (Crile, 1989).
Taking the “road less traveled” is always difficult, but Turnbull faced the challenge with
his characteristic energy, excitement, and a sense of adventure, whether it was: (1)
improving surgical techniques (solving ileostomy dysfunction, “no-touch technique”
for rectal cancer, “blow hole” colonic decompression); (2) reducing morbidity and
mortality (a lifelong search for the etiology of, improved treatment, and cure for
inflammatory bowel disease, endocavitary irradiation); (3) enriching the quality
of patient life (the use of karaya, collaborative efforts with ostomy manufacturers,
coordination with patient advocacy groups); (4) efforts to expand general knowledge
about stomas and acceptance of ostomy patients (Norma Gill, UOA, LAET, multiple
professional affiliations); or (5) seeking global partners (Georges Gillemin, M.D. and
Jean Papillon, M.D. in France; E.S.R. Hughes, M.D. of Australia; Brian Brooke, M.D. and
John C. Goligher, M.D. of London; Taiso Tamura, M.D., E.T. in Japan, and many others).
Throughout the years, ETs continue to serve as innovators and conduct research
within the scope of their professional practice. Through the untiring efforts of the
WCET, this quest has been taken forth around the world.
Another early function of Enterostomal Therapy was to simplify the complicated,
thereby insuring that information was shared and communication assured, whether
it is teaching a patient or family, or educating other health care professionals. As
my wife struggled with her first professional manuscript, Rupe advised, “use simple
language, one word instead of two... people need to understand what you are
talking about, so don’t try to impress them with language they will not understand.”
Edith Lenneberg writes: “It never ceased to amaze me how Dr. Turnbull spoke to
patients and lay people. He disclosed fully what he knew and thought. He showed
‘professional’ slides to membership of the ostomy associations and talked about
them as he would colleagues, with the distinction that he used comprehensible
language. This kind of respect for all human beings was profoundly inspiring to
me” (Lenneberg, 1994). In 1952, Rupe wrote:
To withhold information about a cancer from a patient who wants it is to start
an elaborate amateur ‘cat and mouse’ production. The patient realizes he is
not well and will frequently go from one doctor to another to have his illness
diagnosed. He begins to distrust both family and physician and, in the end,
there is bitter resentment from all sides. (Turnbull & Michaels, 1952).
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With the publication of the Atlas of Intestinal Stomas (Turnbull & Weakley, 1967)
in conjunction with his colleague Frank L. Weakley, M.D., nearly fifteen years later,
Rupe once again proved that simplicity and practicality are the best teachers.
Over the years, I have been repeatedly reminded of the impact of this publication
by surgeons who have shared with me that they have taken the Atlas into the
operating room with them simply because Robert M. Reed’s illustrations are so
clear and easily understood, and the text is simple, easy-to-read, and to the point.
If this is the way the publication has been used — as a “handbook” — it is safe to
surmise that my father attained his goal for publishing it.
The effort to “spread the word” so to speak, was achieved through education. Both
Norma and Dr. Turnbull wrote prolifically and managed a schedule of speaking
engagements which would exhaust most people. Educational pamphlets for the
patient as well as the professional were created and distributed by the Cleveland
Clinic Foundation. Articles on every facet of ostomy patient rehabilitation began
appearing in medical and surgical textbooks, newspapers, and professional
journals. The idea that others were welcome to come, contribute, learn and share,
was quickly spread across the country and around the world.
As with other major events, chance played a significant role in the international
dissemination of the vision of Enterostomal Therapy. Jan Langstone, a young
British woman, had been secretary to J. Alexander Williams, a consultant surgeon
at Birmingham General Hospital, prior to coming to the U.S. to serve as Dr.
Turnbull’s secretary. She believed that British colorectal surgeons and patients
would benefit from what was happening at the Cleveland Clinic. During one of her
early visits back to visit her family, Jan somehow managed to orchestrate Norma’s
first international trip, arranging for Norma and her husband to stay with Jan’s
father during their visit to Birmingham General Hospital. Norma and Dr. Turnbull
continued this international networking by providing educational seminars
through Europe, Asia, South America, and Australia. In 1973, Rupe proudly writes:
At this time there are 135 therapists at work in hospitals and doctors’ office
in the United States (119), Canada (11), New Zealand (1), Hawaii (1), England
(1), and Australia (2). Some states and teaching centers are not yet staffed
with therapists, but it is predicted that by 1980, all major centers in the United
States and Canada will have enterostomal therapists available... because of the
expertise of the trained therapist, it seems expedient for the surgeon to transfer
stomal care of his patient to the therapist, supporting her with his specialized
counsel and advise (Turnbull, 1973).
Today, such actions might be called “marketing.” As Frank Weakley said, “He
[Dr. Turnbull] recognized that marketing was beneficial and that sometimes,
self-marketing was indicated. He said, ‘Who says we are good at this? WE do!’
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(Weakley, 1993, 1994). Whatever it is called, the desired outcomes were achieved
and the end result was that an expanded number of patients and health care
professionals demonstrated an increased understanding about ostomy surgery
and the rehabilitative needs of stomal patients. This knowledge translated into an
improved quality of life and decreased mortality and morbidity. The “kick start” in
this process was education.
National and international educational efforts have been carried forward by the
Wound Ostomy Continence Nurses Society (formerly the International Association
of Enterostomal Therapists for which Dr. Turnbull served as a founding father),
the United Ostomy Association, the World Council of Enterostomal Therapists, the
International Ostomy Association and the American Cancer Society.
My father never missed an opportunity to convey a message or espouse a
philosophy to eager surgical residents and even to several of my boyhood friends
who would accompany us on vacations to Canada, Cape Cod and the “Knob,” a
mountain retreat owned by the Crile family. My father could walk through the
woods and verbally dissect each plant and tree by genus and species, as he did
when I observed him operating on his patients in front of a room full of medical
or ET students, explaining layer by layer why, how and what he was going to do
to resolve the patient’s condition. Dr. Peter Wilk, one of Rupe’s students, wrote my
mother after hearing of my dad’s death:
My first day as a doctor as an intern back in 1968 was on his service. I’d heard
about him but knew nothing of him. I wasn’t prepared. He was a giant then. He
knew everything. He could operate better than anyone ever could — the blade
sang. He knew all his patients and loved them... the patients, one after another
after another, would come in desperately ill... and almost all, two weeks later,
one after another after another, would leave well. I remember working so hard
then, being so tired, but being so excited by the ‘miracles’ …
Rupert was always teaching and those around him became mirror images of his
academic insights. Ralph Straffon, M.D. of the Cleveland Clinic reflects that Rupert:
... in his prime was a superb surgeon and a great showman. He loved an operating
room full of visiting surgeons. He would show them what he was doing and
talk continuously during the procedure and the visitors loved it. There were
a great many prominent surgeons from all over the world who would come
to watch Dr. Turnbull work. I remember when I arrived here (Cleveland) from
University Hospital in Ann Arbor (Michigan), I was astounded to see that Dr.
Turnbull had five abdominal perineal resections on the surgical schedule for
one day. This procedure in Ann Arbor took the surgeon four or five hours and
this would represent almost one week’s work. Much to my surprise, Dr. Turnbull
had mastered this operation and could do it in a much shorter time.
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Indeed, my father performed over 6,000 surgeries on the colon and rectum during
his twenty-seven years in practice. Frank Weakley (1993, 1994) surmised that Rupe
believed that it was only natural to specialize, and that being busier in a narrow
field made mistakes occur closer together, so that they were easier to remember
and correct. Rupe said: “Greatness is bestowed upon a person not so much because
he or she is better than anyone else, but just because he or she lived longer or saw
more cases than anyone else” (Weakley, 1993, 1994).
Rupert Turnbull’s proficiency in technical expertise and attention to state-of-the-art
care was cloned by Norma Gill. One of Norma’s patients, Patricia Stout Skilken in
her book Never Apologize, Always Explain remembers Norma as:
... a tall, attractive woman in, I would guess, her thirties. I assumed she was just
another nurse, but it soon became clear that Norma was more of a specialist.
She changed my dressing and the post-op bag, working faster than the nurses,
and with more self-assurance. She had apparently done a lot of this, and knew
a lot about it... Norma was an upper. She continually told me how good I was
going to feel, how marvelous it would be to be free of pain and be able to do
anything I wanted again (Skilken, 1982).
In most of the surveys conducted over recent years which have attempted to
identify the effectiveness of Enterostomal Therapy Nursing, one common thread
surfaces: ET Nurses exude a sense of security, stability, confidence, advocacy, and
hope.
‘Oh, I’ll take care of all that tomorrow morning,’ he said with a wave of his hand,
supremely confident that he could fix what no other doctor could even figure
out. Boy, did I like his style! I believed him and adored him from then on. I knew
he would take care of me. It is not often that I completely relinquish control
over a situation that affects me personally, and give myself up into the hands of
someone else. I used to do it with Daddy, I do it with (my husband) when I need
to, and I did it then with Dr. Turnbull, with the greatest sense of being in good
hands (Skilken, 1982).
Norma didn’t come to visit me during my stay at the clinic; I was past needing
ostomy therapy by then. I did see her in the hall one day, though. I was shuffling
along, holding onto my stomach and pushing my I.V. stand, and she went past
me at a near run and yelled over her shoulder, ‘Piece of cake, isn’t it?’ and I
replied sweetly, ‘Shut up.’ She giggled and kept on going, and later I giggled
too. It was nice that Norma didn’t have to baby me anymore. I was an old pro
(Skilken, 1982).
Dr. Turnbull’s youthful sense of fun and humor spilled over into his work and served
as the salve to ease difficult situations and the antidote for daily tedium. Marilyn
Spencer writes: “He was well known to write physician orders on the patients’
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linens, sheets or pillow cases as he made his daily rounds. So staff had to check the
linen before changing the bedding so as not to miss MD orders” (Spencer, 1994).
My wife and I believe that the essence — the heart of Enterostomal Therapy
Nursing — is found in the distinctive attributes exhibited by my father during his
career. Throughout the years, since the inception of the specialty, dedicated ET
Nurses have distinguished themselves among their peers and won the lifelong
affection and respect of their patients.
After my examination, Turnbull pretty much turned me loose. He said it wouldn’t
be a bad idea if I came back in a year, and once a year after that, just to keep in
touch with any new developments in ostomy care, but he also said that I didn’t
have to come back. He exact words were, “As long as you feel okay, you are
okay,” and I resolved, at all costs, always to feel okay... I had my instructions: ‘Feel
okay.’ I had spent most of my life doing so, and so I pronounced myself cured
and imagined that it had been Dr. Turnbull who had done the pronouncing...
As it turned out, he was 100 percent right about everything. But then, I never
doubted him for a minute; I’d learned not to. I hate to think how I might have
felt about all this without Dr. Turnbull and Norma Gill (Skilken, 1982).
We conclude with this quote from Denise O’Donnell, a former patient, who wrote
our family in 1981: “Hopefully, we all have integrated a part of his knowledge into
our lives and will use it ….”
REFERENCES
Crile, G., Jr. (1989). The process of discovery. The Turnbull Memorial Lecture, St. Louis.
Lenneberg, E. (1994, October 14). Personal communication.
Skilken, P.S. (1982). Never Apologize, Always Explain. New York: Everest House.
Spencer, M.B. (1994, October). Personal communication.
Stevens, P. (1994, November 11). Personal communication.
Turnbull, R.B., Jr., & Michaels, A. (1952). The management of the patient with the permanent
colostomy. Cleveland Clinic Quarterly, 19(1).
Turnbull, R.B., Jr., & Weakley, F.L. (1967). Atlas of Intestinal Stomas. St. Louis: C V Mosby.
Turnbull, R.B., Jr. (1973). Rehabilitation of the stomal patient. Seventh National Cancer
Conference Proceedings. The American Cancer Society.
Vinitsky, A. (1994, October 27). Personal communication. [Archie Vinitsky was co-founder of
the United Ostomy Association and the Interational Ostomy Association].
Weakley, F.L. (1993, July 7 & 1994, October 14). Personal communication. [Dr. Weakley is
Clinical Emeritus, Department of Colorectal Surgery, The Cleveland Clinic Foundation].
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Norma Keeps Going and Going and Going …
Norma Keeps Going and Going

and Going …
T
here were folks who had surgery resulting in an ostomy long before there
was a dignified way of living with the results. Sometimes the surgery resulted
in the return of good health, sometimes it did not. Some of us remember
what it was like in the days before there was Enterostomal Therapy and Norma
Gill-Thompson. Those of us who survived struggled alone trying to manage our
lack of control of body waste with homemade devices... some with success. Many
with failure. It was not unusual to be sent home from the hospital with diaper-like
material to absorb the unpredictable output. Cellucotton was less expensive than
surgical dressings. It could be purchased by the bale and cut to an appropriate
size. Binders of a washable cotton fabric would hold the cellucotton in place so
the person could roam from the bathroom facilities for short periods of time.
There was no odor containment. Denuded skin was the expectation. Sometimes
aluminum paste or lanolin would soothe the pain.
Some surgeons knew of places where special pouches could be ordered and
offered the addresses to their patients. These pouches were placed over the stoma
and held in place with a belt. A pad of absorbant material between the pouch and
the skin added a level of comfort. The pouch was removed several times a day,
washed, rinsed and used again. Odor was still a problem. It was not easy to conceal
these early pouches under clothing. Denuded skin remained.
Conquering a life threatening illness is one thing — living with the results quite
another. Ostomy surgery could result in one’s becoming a bathroom recluse.
Others rose from the ashes of disease and used their success as an opportunity to
help others.
Norma Gill was one who shared with others her own success in conquering the
technical problems of living with an ostomy. Self help groups were the major source
of assistance to persons who survived ostomy surgery. Norma participated. Most
physicians did not know what equipment was available and did not understand
the burdens of the day-to-day living of the ostomate. Norma did.
Rupert Turnbull recognized that Norma, a former patient, had the knowledge
and enthusiasm that was needed to help his recovering patients resume a
socially acceptable life style after ostomy surgery. She was recruited to serve in
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Cheryl Van Horn
this capacity at the Cleveland Clinic Foundation and soon the title Enterostomal
Therapist was coined. No matter that she wasn’t a nurse. No matter that she did not
have a medical background. She got results. This consumer-generated specialty
came into being because patients needed help and Norma could deliver it.
Her success with patient rehabilitation soon became evident to the surgical
community and before long she was involved in developing a school of
enterostomal therapy. The school grew. The profession grew. Other schools were
formed. A national association came into being. The technical aspects blended with
the medical and nursing aspects of patient care. Enterostomal therapy became an
international nursing specialty.
Not only did Norma provide the practical assistance and emotional support
patients needed, she communicated the need of the patients to the manufacturers
to advance the research and development of better equipment for ostomy care.
The results of her efforts are seen in the odor containment, skin protection and
inconspicuous pouches readily available today. There is variety for special needs.
There are manufacturers of ostomy supplies who market their goods worldwide
and their success is based on input from the pioneer Norma Gill-Thompson, whose
vision has helped many people with ostomies continue to live in a dignified
manner as productive, socially-acceptable citizens of the world.
Thanks Norma. I speak as one of many who have reaped the benefits of your efforts.
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Pioneer Years
Pioneer Years
Frank L. Weakley, M.D.
P
erhaps the most significant pioneering work in stomal surgery was the
solution of the problem of “ileostomy dysfunction.” Fifty years ago the
ileostomy and colostomy were formed by placing the stomal end of the
bowel outside of the body protruding above the skin approximately two inches.
The exposed serosa was in an unfriendly environment and underwent a process
of severe thickening and contracture. The longitudinal contracture shortened
during the progression of serositis and eventually pulled the end of the bowel to
the edge of the skin in an everting motion, resulting finally in complete covering
of the serosa and resolution of the serositis. This process took six weeks, and
during its evolution the thickened bowel wall for the length of the serositis caused
obstruction due to narrowing and lack of peristalsis. Overcompensation by the
activity of the upstream, unaffected bowel caused the loss of enormous amounts
of fluid and electrolytes (approaching sometimes 24 liters a day) forced through
the serositis-affected bowel sufficient to make adequate intravenous replacement
extremely difficult. This extensive loss stopped and normul succus entericus began
passing after completion of the bowel end eversion, marking the resolution of the
serositis.
This production of health-threatening amounts of liquid output was called “stomal
dysfunction,” or in the instance of ileostomy — ”ileostomy dysfunction.” In the case
of colostomy, the consequences were distinctly less severe. The stomal eversion
process was called “maturation” of the stoma.
In the 1950s surgeons sought a solution to this “dysfunction” problem. Dr. Rupert
Turnbull and Dr. George Crile, Jr. in Cleveland recognized the problem to be
obstruction of the stomal bowel. Dr. Turnbull solved it by placing a split thickness
skin graft on the serosa at the time of the initial operation, thus preventing serositis.
But after awhile the “dysfunction” occurred because the skin graft strictured and
caused stomal obstruction. Longitudinal incisions in the strictured graft gave relief,
but again only temporarily. Dr. Crile (1954) suggested the removal of the serosa
and muscle and eversion of the mucosa and submucosa at the initial operation,
which avoided “dysfunction” entirely and instantly. But this maneuver was time-
consuming and sometimes too damaging to the bowel wall. When it could be
effected, however, it was successful in producing a “dysfunction-free” ileostomy.
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Frank L. Weakley
They called it the “mucosal grafted” ileostomy, and it could be constructed in most
instances.
Dr. Bryan Brooke in England noted that the original “dysfunction” stopped after
completion of natural eversion; so he suggested manual eversion of the stomal end
of the bowel and suture of it to the skin edges at the time of the initial operation,
reducing the “maturation” process from six weeks to a few minutes (Brooke, 1952).
Serositis and obstruction did not occur; so “dysfunction” did not occur. Dr. Turnbull
feared that instant, manual eversion would produce obstruction and encourage
retraction due to the opposing peristaltic forces at the eversion, but Bryan Brookes
showed such fear to be unwarranted.
The initial work of these two surgeons and their persistent work in stomal surgery
has been recognized by the naming of the end ileostomy constructed today as the
Brooke-Turnbull ileostomy. They applied the principle to colostomy construction
also, thus improving this aspect of the rehabilitation of all stomal patients.
“Ileostomy dysfunction” — originally proposed by Warren and McKittrick (1951) —
is now a term that should be relegated to historical reference, because it was the
result of the extremely voluminous watery output caused by serositis obstruction.
Increased watery output occurring today in the presence of partial food bolus
obstruction, or adhesions, or recurrent Crohn’s disease as “pre-stomal ileitis”
does not reach the magnitude of the fluid and electrolyte loss produced by the
serositis of natural stomal maturation and, therefore, does not deserve the same
designation. Also, reserving the original term to the condition eventually solved by
Brooke and Turnbull enhances the importance of the work done by both of them
for the benefit of the thousands of patients who have been rehabilitated by the
Brooke-Turnbull ileostomy.
Pioneering stomal surgery then became involved in the solution of other problems
resulting from surgical intervention, stomal management, and recurrent bowel
disease. After prevention of serositis proper stomal siting was recognized as
the first determinant in trouble-free management. Abdominal wall muscular
and subcutaneous contours, surgical scars, and obesity considerations became
recognized as being more important factors than vector distances defined by
relationships between topographical points, such as umbilicus, anterior-superior
spine of the iliac bone, and symphysis pubis as had been traditionally employed.
The advantage of the loop-end ileostomy in providing more protrusion in obesity
than the end ileostomy was demonstrated. It was also learned that the ileostomy
mural blood supply could be assured by the use of the loop ileostomy, or the loop-
end ileostomy, in contradistinction to the occasional blood supply compromise
resulting from removal of the mesentery at the bowel end done to achieve
symmetry of the end ileostomy. The management tragedies of stoma siting lateral
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Pioneer Years
to the rectus muscle and in the inguinal region became recognized. Also seen
was the wisdom of siting a stoma in the epigastrium in instances of advanced
abdominal protuberance. Transplantation of an established ileostomy to another
favorable site in instances of peristomal herniation or massive prolapse as a more
long-lasting solution than peristomal herniorrhaphy was demonstrated. Relief of
skin level stricture under local anesthesia; cure of prolapse of the downstream end
of a loop stoma; demonstration that a skin level loop colostomy is totally diverting;
and demonstration of the effectiveness and trouble-free performance of a loop
ileostomy — all were surgical developments of the pioneering years of stomal
surgery. All this and more was established by the mid-nineteen sixties (Turnbull &
Weakley, 1967).
Also, generally known by then as a result of the pioneering years of stomal surgery,
were the prevention and treatment of problems that were the result of imperfect
stomal management. Since the results of bad stomal siting became apparent early
after surgery, the problems were recognized quickly and were subject to early
solution. Unfavorable surface contours, skin scars, body deformities, and advanced
obesity changes were especially considered at the time of initial surgery and thus
usually eliminated as contributory management problems.
The day to day and week by week management errors resulted in problems
that eventually worsened to the extent of demanding resolution. The author
remembers Norma Gill and Dr. Turnbull creatively discussing the reasons for
stomal management problems as if they were detectives trying to solve a crime.
Stomal mucosal ulceration could be due to faceplate inner rim pressure, because
of sizing errors, or from misapplication or from offending pressures from postural
encroachments. Ileostomy canal ulceration can be caused by overfastidious
rubbing and cleansing — especially with the use of a cotton applicator. Mucosal
destruction from heat-lamp application was seen; peristomal skin ulceration from
belt pressure was seen, diagnosed, and corrected. Undermining skin ulceration
from follicular inflammation needed cure by debridement and the temporary use
of a non-adhering pouch.
When non-disposable pouches were used in cases of urinary diversion and
proper cleaning was not followed, urinary crystals formed on the inside wall of
the pouch, creating a sandpaper-like surface, that abraded the mucosa at the
end of the stoma. The advent of disposable pouches saw the end of this problem.
Centered application of the faceplate around the ileostomy was assured by the
employment of a water-soluble paper strip placed to define the rim of the hole
in the faceplate. Karaya powder washers, sheets, and integral inclusion of Karaya
washers in the pouch manufacture made stomal management easier. Elimination
of cement, employment of double-sided adhesive disks, and variations of general
173
Frank L. Weakley
pouch characteristics brought more freedom of choice, and further contributions

to trouble-free stomal management.
New disease in the prestomal ileum even years after the initial stomal surgery
brought its own special problems due to stomal retraction and increased watery
consistency to the ileostomy output. When sufficiently severe, resection of the
involved ileum was found to be necessary for the rehabilitation of the patient.
The pioneering work in ostomy surgery was devoted to the development of proper
stomal surgery, proper stomal management, and proper management of recurrent
disease. By the mid 1960s these problems and solutions were defined. Since that
time, refinements have been made and prevention of problems by education of
new patients and new health care personnel has been ongoing. So problems in
all three of these areas are progressively less severe and less frequent. Arrival at
the solutions we have, however, could not have taken place if it were not for the
innovative skill and response of the industry supplying the stomal management
hardware. The patients defined the problems; the E.T. and the surgeon validated
the solutions; and the equipment industry provided the materials to simplify
solutions and help avoid problems.
We have gone from before 1960 when patients met together to share stomal
problems and practical solutions unsolved by the medical profession to that time;
through the time approximating the turn from the 1950s to the 1960s when Norma
Gill, after her own health recovery, and Dr. Turnbull turned their attention to these
problems with the enlisted aid of product manufacturers; to the mid 1960s by
which time the pioneering or discovery period of stomal surgery and management
was largely accomplished leaving the challenge largely to ongoing education.
The key to this education being effective and the standards achieved by the
pioneers being maintained or surpassed lies in the effectiveness of the system
established in the past to function as it should. The surgeon and the ET, the
manufacturers and the patient should function respectfully — each with the other
— to identify problems and to discover new solutions. The “self help” groups need
no longer struggle alone with problems unaddressed by health care professionals
as was true in the past, but now they can enjoy an existence as an educational
forum propagating established solutions.
Development over the years of hardware employed in the management of
stomas has spawned its usefulness in wound management, fistula problems,
and in urinary and fecal incontinence. Reservoir surgery today has sharply
curtailed some stomal surgery, and if the etiology of inflammatory bowel disease
becomes known, other operations may be found to be unnecessary. Due to
their knowledge of gastrointestinal physiology and with their demonstrated
educational skills, ETs may see new involvement in education of patients and
174
Pioneer Years
other health care professionals in important non-surgical disorders of the

gastrointestinal system.
Until those Utopian times, thorough knowledge of the contributions of the pioneer
surgeons and ETs and manufacturers will remain challenge enough for all of us and
will keep us better prepared to deal with the problems we may see now and in
the future in making our own contribution for the retrocession of the horizons of
ignorance.
REFERENCES
Brooke, B. N. (1952). The management of ileostomy including its complications. Lancet,
2,102–104.
Crile, G., & Turnbull, R. B. (1954). Mechanism and prevention of ileostomy dysfunction.
Annals of Surgery, 140, 459–466.
Turnbull, R. B., & Weakley, F. L. (1967). Atlas of Intestinal Stomas. St. Louis: CV Mosby Co.
Warren, R., & McKittrick, L. S. (1951). Ileostomy for ulcerative colitis: Technique, complications,
and management. Surgery, Gynecology and Obstetrics, 93, 555–567.
175
Commemorating the 100th Birthday of WCET® Founder,
First President and First Journal Editor
Norma N. Gill-Thompson 26 June 1920- 25 October 1998
Norma N. Gill gave ‘birth’ in 1978 to the WCET®, loved and nurtured it and passionately believed in the importance
of its mission to provide education to nurses throughout the world so all persons would benefit from specialised
care in ostomy, wound or continence care. She loved the WCET® and considered it like her child.
The WCET® continues the work Norma and other pioneers began over 40 years ago. As a global association,
translation of our education materials into other languages is so important. This includes our WCET Journal and
guidebooks on stoma siting and stoma complications. Please visit the WCET® Online Store for more information
at https://wcet-online-store.myshopify WCET® continues to explore new ways of delivering education, including
our very popular webinars.
As Norma believed in the importance of our members exchanging and gaining information, the WCET® bullETin,
the official magazine of WCET®, enables our members to have their practice stories, thoughts and events shared
among our members in over 65 countries. The twinning projects of WCET®, which bring educational programs to
‘emerging’ countries (focused on stoma, wound and continence care), have been very successful and have made
a huge difference in countries such as Indonesia, China and Kenya.
In honour of Norma, this is indeed the year to join WCET® in our global mission. The price of membership is
£25 annually with discounts for multiple year memberships. Membership scholarships through the Norma N. Gill
Foundation® (NNGF®) are available if you cannot afford the cost. Go to our website, www.wcetn.org for more
information and to join us in our world mission.
WCET® membership Includes:
• WCET® Journal quarterly (ISSN 0819-4610) in English (print) and other languages (electronic)
• WCET® bullETin (ISSN 2652-1695) published three times a year (electronic)
• Biennial Congress registration discount
• Educational materials
• Free access to members only webinars
• Twinning Project participation opportunities
• Access to NNGF® Scholarships
• Access to global communities of practice
• Opportunities to participate in WCET® leadership roles
• Excelsior College online nursing programs reduced tuition
• Exclusive members-only rates for an online subscription to Advances in Skin & Wound Care
• Ongoing professional development
The NNGF® was created in her honour under the auspices of the WCET® to recognise Norma’s life work in the field
of Enterostomal Therapy (ET) and her dedication to helping others. The mission of the NNGF® is to raise funds for
nursing scholarships to further ET nursing education throughout the world and to help establish Enterostomal
Therapy Nursing care where services are non-existent.
All proceeds from the sale of this book go to the NNGF®.

Proceeds from this copy of Enterostomal Therapy Nursing Growth & Evolution of
a Nursing Specialty Worldwide, A Festschrift for Norma N. Gill-Thompson, ET,
2020 Commemorative Edition, enables the WCET® Norma N. Gill Foundation®
(NNGF®) to provide scholarships to enable nurses to attain specialised education in
order to help fulfill Norma’s vision of specialised nursing care for all patient’s with
ostomy, wound or continence needs worldwide.
The mission of the World Council of Enterostomal Therapists® is to lead the

global advancement of specialised professional nursing care for people
with ostomy, wound or continence needs.
www.wcetn.org

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Enterostomal Therapy Nursing

Growth & Evolution of a

Commemorating the 100th Birthday of

Edited by Paula Erwin-Toth

WCET Journal WCET 杂志 Journal du WCET Revista do WCET

News and views 编者按 Éditorial de collaboration spéciale Editorial Editorial

Original article Artigo original Artículo original

Un monde de professionnels experts spécialisés dans les soins infirmiers aux

Congratulations to the WCET® Journal on Achieving this 40 th anniversary milestone.

A 2020 commemorative update to the

Library of Congress Cataloging-in-Publication Data

This commemorative edition published by

on behalf of the World Council of Enterostomal Therapists

Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN

Paula Erwin-Toth, MSN, RN, CWOCN, CNS

Louise Forest-Lalande, RN, M.Ed. ET

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN

Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN

Into the 21th Century – The World Council of Enterostomal

The WCET Journal in the 21st century* - “So far … so good” 16

History of the Journal of WOCN 25

Product Innovations: An Industry Update by our Sponsors 32

Preface (to the First Edition) 46

Future Trends in ET Nursing Internationally 47

History of the World Council of Enterostomal Therapists Journal 55

Care of the Adolescent with an Ostomy 60

The Evolution of the Urinary Diversion 67

Development of Enterostomal Therapy as an International Nursing Specialty 75

Childhood Ostomy Surgery: A Developmental View 95

ET Nursing Education: A Global Perspective 103

Current Trends in Ostomy Surgery 110

History of the Journal of WOCN 119

ET Nursing and Continence Care: History and Perspective 124

ET Nursing and Wound Care: Embracing the Challenge 132

Manufacturers’ Role in the Development of the W.C.E.T. 138

The Student Experience: Living the Legacy 140

Enterocutaneous Fistulas 146

Living with a Legend 151

Enterostomal Therapy: the Personification of a Philosophy of Care 161

Norma Keeps Going and Going and Going … 169

Pioneer Years 171

Paula Erwin-Toth, Deerfield, Ohio, USA

Diane L. Krasner, York, Pennsylvania, USA

Paula and Diane

Picture 1. Norma N Gill-Thompson with daughter Sally.

Photos courtesy of Sally J. Gill-Thompson. © WCET 2012, used with permission

Into the 21th Century – The

3: Strengthen Existing Services

scientific articles. The BullETin is a newsletter which provides information about ET

A relevant example of a successful Twinning Project is between Hong Kong and

COLLABORATION WITH OTHER ORGANISATIONS AND INDUSTRY

NEXT STEPS: MOVING FORWARD!

The WCET Journal in the 21st

THE JOURNAL PUBLISHER

INDUSTRY PARTNERS AND THE WCET JOURNAL

1998 — A PIVOTAL YEAR FOR THE WCET JOURNAL

2004 TILL NOW

9 Odobašić, A. The beginnings of Enterostomal therapy in Bosnia and Herzegovina. WCET

Box 1- First WCET Journal Editorial

©WCET 1982, reprinted with permission

Box 2 — The WCET announcement of the passing of Norma N Gill-Thompson

Vale Norma N Gill-Thompson 26.6.1920 — 25.10.1998

Box 3 — Eulogy from Norma’s Funeral