A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

BACKGROUND: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance. METHODS: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate. RESULTS: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains. CONCLUSIONS: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

Reconstructing marginality: a new model of cultural diversity in nursing.

This article presents a new model of cultural diversity in nursing that critically reconstructs the concept of marginality that underpins other models. Rather than viewing the marginal as "other," marginality is redefined as the space in between the dominant cultural reality and the cultural realities of minority groups located within a society. Members of a minority cultural group who become skilled in the difficult process of negotiating this in-between space open the possibility of transformation within nursing education and practice. This model has been applied in a study of the experience of nursing students of Pacific ethnicity in New Zealand. Subsequently, an undergraduate Pacific nursing program was developed, with greatly increased success rates in registration of Pacific nurses. This model of cultural diversity can also be used to understand nursing practice involving people from minority cultures or other socially excluded categories.

DIFE: A new model in undergraduate nursing education.

This article presents a new model of nursing created in 2003 for use in an undergraduate nursing program. It reviews the drivers for the development of an innovative approach to nursing education in a New Zealand educational institution, Whitireia Community Polytechnic. After referring to the literature informing this development, the article briefly outlines the philosophy underpinning a revised curriculum for the program. The article then describes the nursing model created to realize the intention of the revised curriculum, the DIFE framework, consisting of four interrelated phases: Discovery, Interpretation, Facilitation, and Evaluation. It highlights the distinctive educational practices that use of the model in teaching the curriculum produces. In this approach, educational practice embodies a model for clinical practice. Finally, this article reflects on the value of this new model of nursing after 5 years of use.

The Australian and New Zealand dialysis workforce study in the international context.

BACKGROUND: Given increasing demand for renal replacement therapy, this study sought to identify of key workforce issues facing dialysis units, based on a "snapshot" of the current workforce. METHODS: A web-based survey of all dialysis unit managers in Australia and New Zealand, in October 2008, about their workforce. RESULTS: A significant minority of dialysis staff in most regions were not registered nurses. Many renal registered nurses worked part-time. Staff/patient ratios in dialysis units varied significantly by region, reflecting the relative prevalence of home therapies. Most dialysis units were generally adequately staffed. The proportion of registered nurses with specific renal qualifications varied significantly by region. CONCLUSION: The changing character of the workforce in the dialysis unit in the future will require clarification of the relationships between different categories of dialysis staff. Specialty education for nurses needs to be oriented to equipping staff to be effective in their changing work environment.

Solution-focused conversations: a new therapeutic strategy in well child health nursing telephone consultations.

AIM: This paper is a report of a study to explore well child nurses' perceptions of outcomes resulting from the use of solution-focused conversations in their telephone consultations with clients. BACKGROUND: Well child nurses (health visitors) in some services provide a separate telephone consultation service for parents who need immediate advice or are unable to visit the clinic. As well as purely physical issues suggesting infant pathology, these consultations address a range of other concerns relating to parenting and child behaviour. The standard problem-solving approach used to address physical issues is less effective for various non-physical concerns, where different communication strategies may be helpful. METHOD: In this qualitative, action-oriented study, a small group of well child telenurses in New Zealand was introduced to a specific communication strategy, called 'solution-focused conversations', during 2005. They applied this approach in their practice and then reflected together on their experiences in focus groups. FINDINGS: The nurses considered that the solution-focused conversations enabled clients to: recognize the nature of the parenting issue of concern that had motivated their call; identify more effective parenting practices to address specific issues with their child; increase their confidence in their own parenting capabilities. CONCLUSION: This study suggested the value of learning a specific communication strategy for the practice of a group of well child telenurses. Solution-focused conversation is a suitable approach for the single, relatively short, interactions involved in telephone nursing. Other communication strategies could be appropriate for nurses in different clinical situations.

'Doing dialysis at home': client attitudes towards renal therapy.

AIM: This paper reports a study seeking to describe characteristic attitudes towards their treatment regime among a group living on home dialysis. BACKGROUND: Although there are many papers about the problem of renal patient compliance and a number describing the experience of living on dialysis, studies have not focused on client attitudes towards their therapy. METHODS: The study used an interpretivist methodology. Twenty home dialysis clients from one renal service were interviewed for an hour each in 2004. Texts of the taped interviews were analysed to formulate a number of themes that summarize the client perspective. RESULTS: During the initial period of adjustment to treatment many participants learned their need for treatment by experimenting with the therapeutic prescription. They then used their knowledge of the therapy to alter their treatment regime to maintain their normal lifestyle. Having modified their therapeutic prescription, participants' motivation to continue meeting the continuing demands of the treatment regime was influenced by their individual life situation, including their relationships, work and personal attitudes towards life. CONCLUSION: Health professionals have interpreted renal client behaviour in relation to their therapy in terms of compliance, because effectiveness of treatment depends on their cooperation. From a client perspective their attitudes are better understood in terms of negotiation. Renal clients do not simply follow professional advice but, through a process of negotiation, seek to integrate therapy into their pattern of regular activities to maintain their normal lifestyle. Renal clients' motivation to meet the ongoing demands of treatment is not related solely to their health status, but is affected by their general life situation. RELEVANCE TO CLINICAL PRACTICE: Understanding client attitudes towards therapy enables nurses to support people living on dialysis better. Through enhancing their relationships with clients, nurses can assume a key role in service to people living with chronic conditions.

The experience of living on dialysis: a literature review.

This article reviews eight qualitative studies from the literature seeking to understand of the experience of people living on dialysis. Discussion of this group of papers suggests that the renal client experience can be comprehensively interpreted as a response to renal illness and therapy within the specialized health care context of renal replacement therapy. From a better understanding of the experience of people living on dialysis, health professionals can more adequately support them so they can live as fully as possible.

Negotiated care: a model for nursing work in the renal setting.

AIM: This article outlines a model for the nursing role in the chronic health care context of renal replacement therapy. METHODS: Materials from several streams of literature are used to conceptualize the potential for nursing work in the renal setting as negotiated care. In order to present the role of the renal nurse in this way it is contextualized by viewing the renal setting as a specialized social context constituted by a dominant professional discourse and a contrasting client discourse. DISCUSSION: While performing specific therapeutic activities in accord with the dominant discourse, renal nurses can develop a relationship with the person living on dialysis, based on responsiveness to their subjective experience reflecting the renal client discourse. In contrast to the language of noncompliance prevalent in the renal setting, nurses can, through their relationship with renal clients, facilitate their attempts to negotiate the requirements of the therapeutic regime into their own personal life situation. Nurses can mediate between the dominant and client discourses for the person living on dialysis. Care describes the quality that nurses actively seek to create in their relationships with clients, through negotiation, in order to support them to live as fully as possible while using renal replacement therapy. CONCLUSION: Within chronic health care contexts, shaped by the acute curative paradigm of biomedicine, the model of nursing work as negotiated care has the potential to humanize contemporary medical technologies by responding to clients' experiences of illness and therapy.

Living on dialysis: concerns of clients in a renal setting.

Background. This article reports a study that sought to understand the experience of a group of Caucasian men with end stage renal failure managing their own haemodialysis therapy in their homes. Methodology. The study used a critical interpretive methodology. The renal setting was critically viewed as a specialized health care context constituted by several interrelated discourses. Although established by the dominant professional discourse, it also includes a number of others, in particular an obscure client discourse that is a response to the dominant discourse. Methods. Initially participants' own interpretations of their individual experiences were outlined. These were then collectively reinterpreted by contextualizing them in terms of the critical view of the renal setting, in order to discern their own views as renal clients that were obscured by the language and ideas of the dominant discourse with which they had been enculturated. Findings. From an analysis of the set of accounts derived from interviews with six participants, four concerns of the renal client discourse were identified. Together these model their shared perspective, which underlies each of their individual accounts of their experience of illness and therapy. These concerns were: (1) suffering from continuing symptoms of end stage renal failure and dialysis; (2) limitations resulting from negotiating dialysis into their lifestyle; (3) ongoingness and uncertainty of life on dialysis; and (4) altered relationship between autonomy and dependence inherent in living on dialysis. Conclusion. One specific implication of this study is that the distinctive potential of the nursing role in renal settings lies beyond the performance of a range of technical tasks, in addressing the experience of people living on dialysis, described here as the concerns of the renal client discourse.