Successful Home Hemodialysis Programs: An Exploration of Key Nursing Care Processes.

The aim of this qualitative study was to identify nursing processes of care that help keep patients successfully on home hemodialysis (HHD). A qualitative descriptive approach using appreciative inquiry was used as the framework for data collection and analysis. Four focus groups were held with HHD nursing teams in the Province of Ontario, Canada. Results suggest that successful HHD teams have highly performing nurses who work cohesively as a team, and have consistent structures and processes in place for patient education and follow up. A culture of success has the potential to keep patients successfully on HHD, improve nurse job satisfaction, and retain highly functioning and specialized nursing staff. Quality improvement initiatives aimed at improving rates of HHD are important given the benefits to patients of HHD as a treatment modality.

All-Star Quality Improvement: Keep It Simple.

An important factor for quality and safety in patient care is an environment in which quality and safety are prioritized and embedded into the culture. Quality improvement (QI) methods can be complex, with some intensive resources required and specific methods employed. However, all staff can be involved in QI if the problem is approached with curiosity and the process is kept simple, with a consistent goal of improving practices. The purpose of this article is to highlight some simple but effective QI methods authored by all-star nephrology nurses that can be easily applied by teams in various settings with minimal resources.

Mindful Self-Compassion Training and Nephrology Nurses' Self-Reported Levels of Self-Compassion, Burnout, and Resilience: A Mixed Methods Study.

Caring for people with chronic kidney disease, let alone during a pandemic, can place nurses at risk for burnout. This study explored the effects of the Mindful Self-Compassion (MSC) 8-week training on nephrology nurses' levels of self-compassion, burnout, and resilience. Twelve nurses participated. Surveys were completed before, immediately after, and three months after training. A focus group was also conducted. Results demonstrated in creased levels of self-compassion, mindfulness, and resilience while levels of burnout decreased. The central qualitative theme was enhanced resilience. Subthemes were creating a community of support, awareness and discovery, and the mastery of the techniques. The MSC training was an effective intervention to build essential skills for maintaining a healthy workforce. Implementation of such training programs within the health care environment are highly encouraged.

Resilience, Mindfulness, and Self-Compassion: Tools for Nephrology Nurses.

Nephrology nurses are not immune to the effects of a stressful work environment. As a result, their emotional and psychological health can be at risk. In addition, there has been unprecedented stress and uncertainty working as nephrology nurses during the pandemic. These stressors can have negative effects on nurses' health, resulting in burnout and/or compassion fatigue, which can lead to nurses leaving nephrology or the nursing profession. Mindfulness has been suggested as a strategy to mitigate work-related stressors and build a more resilient workforce. Our experience suggests that combining self-compassion practices with mindfulness is also effective. Mindfulness may be beneficial for nephrology nurses, but its use does not negate the need for organizations to address the structural system issues that also contribute to burnout.

Pandemic Uncertainty: Considerations for Nephrology Nurses.

The COVID-19 pandemic is a situation of great magnitude that most of us have not experienced in our lifetime. Pandemics are widespread, affecting many geographical areas, and uncertainty is inherent given the rapidly changing situations. As nurses in dialysis providing a life-sustaining therapy, we are required to provide an essential service during pandemics and need to thrive in the uncertainty. This article offers points for consideration that can assist nephrology nurses in their approach to these uncertain times.

Identifying Needs for Self-management Interventions for Adults With CKD and Their Caregivers: A Qualitative Study.

RATIONALE & OBJECTIVE: Fostering the ability of patients to self-manage their chronic kidney disease (CKD), with support from caregivers and providers, may slow disease progression and improve health outcomes. However, little is known about such patients' needs for self-management interventions. We aimed to identify and describe the needs of adults with CKD and informal caregivers for CKD self-management support. STUDY DESIGN: Descriptive qualitative study using semi-structured interviews and focus groups. SETTING & PARTICIPANTS: 6 focus groups (37 participants) and 11 telephone interviews with adults with CKD (stages 1-5, not on renal replacement therapy) and informal caregivers from across Canada. ANALYTIC APPROACH: Thematic analysis. RESULTS: 3 major themes were identified: (1) empowerment through knowledge (awareness and understanding of CKD, diet challenges, medication and alternative treatments, attuning to the body, financial implications, mental and physical health consequences, travel and transportation restrictions, and maintaining work and education), (2) activation through information sharing (access, meaningful and relevant, timing, and amount), and (3) tangible supports for the health journey (family, community, and professionals). LIMITATIONS: Participants were primarily white, educated, married, and English speaking, which limits generalizability. CONCLUSIONS: There are opportunities to enhance CKD self-management support by addressing knowledge pertinent to living well with CKD and priority areas for sharing information and providing tangible support. Future efforts may consider the development of innovative CKD self-management support interventions based on the diverse patient and caregiver needs identified in this study.

Partnering with Patients, Families, and Caregivers in Nephrology Nursing Research.

Nurses value patient- and family-centered care as one of the most important elements of nursing, and as such, these foundations are embedded into nursing practice and theory. Patient engagement in health research, as an evolution of patient- and family-centered care, has emerged as a critical new way of doing research over the last several years. However, the benefit, value, and exploration of ways in which patient partnerships can be built within the context of nephrology nursing research are still relatively new. This article describes patient-centered outcomes research, discusses how patients can be involved throughout the research process, and provides examples for effective partnerships in nephrology nursing research.

Evidence-Based Reviews: Trends in Nephrology Nursing.

Evidence-based practice (EBP) is one of the essential components of nephrology nursing. Reviews of such evidence are important as a means to synthesize research findings into one meaningful form of data. Publication trends of evidence reviews in nephrology nursing are unknown. The purpose of this systematic review was to identify trends in publications of evidence reviews in the Nephrology Nursing Journal. Titles of all publications in the Nephrology Nursing Journal from January 2003 to September/October 2018 were reviewed. A total of 23 evidence reviews were identified and formed the basis of this systematic review. Narrative analysis and concept mapping were used to synthesize data. There was a trend toward systematic reviews of quantitative studies, as well as evidence reviews that focused on the topics of quality of life and access to health services. The need for systematic rigorous reporting is recommended for EBP, as well as future reviews on identified priority areas of research.

Reaching Consensus on Outcomes for Successful Cannulation of an Arteriovenous Fistula: Patient and Healthcare Provider Perspectives.

There is a lack of consensus on what constitutes successful arteriovenous fistula (AVF) cannulation. The purpose of this study was to describe outcomes of successful cannulation of the AVF from both patient and healthcare provider perspectives. This was a mixed method study. Results reflecting the patient's description of success through interviews were reported previously. A sample of nursing and physician experts in vascular access completed a one-time survey. Results from healthcare providers suggest they consider cannulator ability to assess the AVF, knowledge of AVF anatomy, and patient-centered care as most important to cannulation success. Patient comfort, patient-centered care, and available support staff (i.e., expert cannulators) were perceived by both patients and healthcare provider groups as contributing to success. Strategies that promote patient comfort, patient-centered care, and having access to cannulation experts have the potential to improve cannulation outcomes.

Outcomes for Successful Cannulation of the Arteriovenous Fistula: Perspectives from Patients on Hemodialysis.

There is a lack of consensus in the literature on what constitutes successful arteriovenous fistula (AVF) cannulation outcomes from the patient perspective. The purpose of this study was to describe what successful cannulation means to patients on hemodialysis. A qualitative descriptive approach was used. A purposeful sample of 17 patients dialyzing with an AVF participated in one face-to-face interview. Using content analysis, four themes were identified that impact the patient experience in defining successful cannulation: 1) an emotional response - pain and anxiety, 2) a 'friendly' nurse-patient relationship, 3) nursing interventions/technical skills during cannulation, and 4) the impact of the environment. Results provide valuable insight into what patients define as successful cannulation, recognizing that it goes beyond the actual needle insertion procedure.

Cannulation Outcomes of the Arteriovenous Fistula for Hemodialysis: A Scoping Review.

The arteriovenous fistula (AVF) is the recommended access for most people requiring hemodialysis. Success or failure of cannulation of the AVF greatly impacts the patient's experience. Research suggests that skill development in this area is needed. This scoping review was conducted to review current research on cannulation of the AVF to find strategies to improve successful cannulation. Results of this scoping review (n = 36)demonstrated that most studies can be categorized under the technique of cannulation, and concerns and preferences with the AVF as a consequence of cannulation. There are large gaps in the literature, with interventions to improve cannulation and a need to understand more about cannulation from both patient and nurse perspectives.

Understanding skill acquisition among registered nurses: the 'perpetual novice' phenomenon.

AIMS AND OBJECTIVES: To determine whether the perpetual novice phenomenon exists beyond nephrology nursing where it was first described. BACKGROUND: The perpetual novice is a state in which nurses are unable to progress from a novice to an expert in one or more essential clinical skills which are used in their practice area. Maintaining clinical competence is essential to quality patient care outcomes. DESIGN: An exploratory, sequential, mixed methods design was used, comprised of a quantitative component followed by in-depth interviews. METHODS: Registered nurses employed in one of four roles were recruited from two university-affiliated hospitals in London, Ontario, Canada: Clinical Educator, Clinical Nurse Specialist, Advanced Practice Nurse and Nurse Practitioner. Participants were first asked to complete and return a survey and demographic questionnaire. Following the return of the completed surveys, ten participants were interviewed to enhance the results of the surveys. RESULTS: The results of the surveys confirmed that the perpetual novice phenomenon exists across multiple nursing care areas. Four contributing factors, both personal and structural in nature, emerged from the interviews: (1) opportunities for education, (2) the context of learning, (3) personal motivation and initiative to learn and (4) the culture of the units where nurses worked. CONCLUSION: The perpetual novice phenomenon exists due to a combination of both personal factors as well as contextual factors in the work environment. RELEVANCE TO CLINICAL PRACTICE: The results assist in directing future educational interventions and provide nursing leaders with the information necessary to create work environments that best enable practicing nurses to acquire and maintain clinical competence.

Dialysis modality decision-making for older adults with chronic kidney disease.

AIMS AND OBJECTIVES: To examine the personal and structural facilitators and barriers for home-dialysis decision-making for older adults with chronic kidney disease. BACKGROUND: Chronic illness is a global problem. Older adults with chronic kidney disease form a large and growing segment of the dialysis population in many high-income countries but are less likely to uptake home-dialysis despite its benefits. DESIGN: This qualitative ethnography framed in social theory took place in Canada and included adults with chronic kidney disease not on dialysis, older than 65 years of age. METHODS: Thirteen people (seven men and six women, aged 65-83 years of age) who received care in a team chronic kidney disease clinic took part. Persons with chronic kidney disease were interviewed and group interviews were conducted with four of their chronic kidney disease clinic healthcare professionals. Content analysis was used for data analysis. RESULTS: The factors influencing older adults' chronic kidney disease modality decisions are similar to younger adults. However, older adults with chronic kidney disease are in a precarious state with persistent uncertainty. Age imposes some limitations on modality options and transplantation. Modality decisions were influenced by health status, gender, knowledge, values, beliefs, past experience, preferences, lifestyle and resources. Support from family and healthcare professionals was the largest determinant to home-dialysis selection. CONCLUSION: The social and contextual factors associated with age influenced home-dialysis decision-making. Adequate social support, functional status and resources enabled home-dialysis selection. RELEVANCE TO CLINICAL PRACTICE: Understanding more about the decision-making processes for older adults with chronic kidney disease is important for quality interventions and the economic sustainability of dialysis services.

Shower and no-dressing technique for tunneled central venous hemodialysis catheters: a quality improvement initiative.

Self-care practices and quality-of-life nuances juxtaposed our tunneled hemodialysis central venous catheter (CVC) protocols. Despite our advice, individuals with CVCs were showering. As a quality improvement initiative, we compared the standard CVC dressing practices to the "shower and no-dressing" technique. After 1380 catheter months (n = 119) infection rates were 0.31 events per 1000 catheter days. The "shower and no-dressing" technique appears to be a safe CVC dressing option with improved quality of life, no increase in infection rates, and cost-effectiveness.

Recent Changes in Anemia Management: The Kidney Disease Improving Global Outcomes (KDIGO) Anemia Guideline versus the Canadian Society of Nephrology (CSN).

The management of anemia is important for health outcomes for people with chronic kidney disease (CKD). Global evidenced-based guidelines must be placed in the Canadian context to be relevant to guide practice. This paper summarizes the response of the Canadian Society of Nephrology to global anemia management guidelines in CKD and the implications for practice.

Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD.

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for anemia management in patients with chronic kidney disease provides the structural and evidence base for the Canadian Society of Nephrology commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 11 of the 61 KDIGO guideline statements. Specifically, we agreed that a therapeutic trial of iron is appropriate in cases in which a reduction in erythropoiesis-stimulating agent (ESA) dosage or avoidance of ESA and transfusion is desired, transferrin saturations are >30%, and ferritin concentrations are >500 µg/L. However, we concluded that there is insufficient evidence to support an upper target or threshold for ferritin and transferrin saturation levels. We agree with the initiation of ESA treatment when hemoglobin (Hb) level is 90-100 g/L; however, we specifically state that an acceptable range for Hb level is 95-115 g/L, with a target of 100-110 g/L, and add caution to individualization above this range due to concerns regarding the safety of ESAs. We agree that ESAs should be used with considerable caution in patients with active malignancy, history of stroke, or history of malignancy, and we suggest initiating ESA therapy at Hb level of 90 g/L and to aim for a Hb level in the range of 90-105 g/L. The reader is encouraged to note the level of evidence and review the entire KDIGO anemia guideline to interpret the guideline statements and commentary appropriately.

Moving beyond the "perpetual novice": understanding the experiences of novice hemodialysis nurses and cannulation of the arteriovenous fistula.

Cannulation of the arteriovenous fistula (AVF) is an essential skill for hemodialysis (HD) nurses. With declining rates of AVFs, opportunities to develop expert cannulation skills have become limited. This study explored the concept of perpetual novice and AVF cannulation from the perspective of the novice cannulator. Nine hemodialysis nurses were interviewed using ethnographic methodology. The study identified the interplay between personal and environmental/contextual factors that hindered skill acquisition. Personal attributes identified by participants included HD nurses' approach to learning and previous experience, emotional reaction to stress, and interpersonal relationships with colleagues. Environmental/contextual factors identified as impediments to cannulation skill development included limited learning opportunities, attitudes and demands from patients, unit flow and time pressures, and limitations imposed by the current model of nursing care. This study will be helpful in directing future educational, operational, and supportive interventions for novice HD nurses around cannulation skill development.

A renal nursing professional practice model: the next generation.

Professional practice models provide a structure for excellence in nursing practice. Our centre has had a long tradition of working with a professional practice model with proven nursing outcomes such as job satisfaction, empowerment and perceptions of improved patient care. Our model, in place since 1999, has provided an opportunity to discuss and articulate a vision for nursing practice based on the values of accountability, evidence-informed care and empowerment. In order for the model to effectively guide nursing practice, a revision was necessary to keep pace with the changes in the renal program and the health care environment. The revised model needed to address the enhancements in nursing roles, practice environment, corporate requirements and patient care needs. This paper describes a revised professional practice model unique to nephrology nursing.

Chronic kidney disease stressors influence choice of dialysis modality.

AIM: This article is a report of a study examining the relationships between chronic kidney disease stressors and coping strategies with dialysis modality. BACKGROUND: People with chronic kidney disease are given information to enable dialysis modality choice. This education increases awareness and may alleviate concerns and stress. Disease-related stressors and coping may affect dialysis selection. Understanding the influence of stress and coping on dialysis choices will assist in providing responsive programmes. Reducing stress and encouraging coping may increase home dialysis which, despite economic and patient benefits, remains underused. DESIGN: A prospective correlational design was used. METHODS: Information was obtained from the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 223 individuals not on dialysis between the years 2005-2007. Data were recorded with respect to modality at dialysis initiation (n = 76) from 2005-2010. The effects of stress, coping and patient parameters on modality selection were compared using bivariate and multivariate analyses. RESULTS: Individuals on home dialysis vs. in-centre haemodialysis reported significantly fewer pre-dialysis stressors. Coping was not associated with dialysis modality. Individuals on in-centre haemodialysis had a lower serum creatinine, less advanced kidney disease and weighed more than those who started on a home therapy. Physiological stressors were most common and are amenable to interventions. CONCLUSION: Pre-dialysis stress levels predicted dialysis modality. Interventional studies are recommended to address chronic kidney disease stressors with the outcome of improving home-dialysis usage.

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease.

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease This paper examines home-dialysis decision making in people with Chronic Kidney Disease (CKD) from the perspective of critical realism. CKD programmes focus on patient education for self-management to delay the progression of kidney disease and the preparation and support for renal replacement therapy e.g.) dialysis and transplantation. Home-dialysis has clear health, societal and economic benefits yet service usage is low despite efforts to realign resources and educate individuals. Current research on the determinants of modality selection is superficial and insufficient to capture the complexities embedded in the process of dialysis modality selection. Predictors of home-dialysis selection and the effect of chronic kidney disease educational programmes provide a limited explanation of this experience. A re-conceptualization of the problem is required in order to fully understand this process. The epistemology and ontology of critical realism guides our knowledge and methodology particularly suited for examination of these complexities. This approach examines the deeper mechanisms and wider determinants associated with modality decision making, specifically who chooses home dialysis and under what circumstances. Until more is known regarding dialysis modality decision making service usage of home dialysis will remain low as interventions will be based on inadequate epistemology.