What do New Zealand pre-dialysis nurses believe to be effective care?
Abstract: In New Zealand, and globally, the incidence of patients developing chronic kidney disease and entering the pre-dialysis phase is increasing at approximately 6% per year. The specialist pre-dialysis nurse plays a key role in providing care to this complex group of chronically ill people, but as yet no literature indicates what constitutes effective pre- dialysis nursing care. This paper reports on qualitative research that asked a group of New Zealand specialist renal nurses what they believed comprised effective pre-dialysis nursing care. Semi-structured phone interviews were undertaken with eleven pre-dialysis nurses from throughout the country. Through inductive analysis a number of key themes were identified. These were; a strong nurse patient relationship, a comprehensive holistic nursing assessment and timely and appropriate patient education. Commonly used measurable indicators, timely initiation of dialysis and formation of dialysis access prior to treatment, were also considered important but essentially seen as out of the nurse's control. We argue that to ensure pre-dialysis care is effective it is important to not only measure quantifiable parameters but also consider the qualitative elements identified as being at the heart of effective pre-dialysis nursing practice.

Key Words: Pre-dialysis nursing, effective care, qualitative research, nurses' perceptions.
Article Type: Report
Subject: Hemodialysis (Research)
Hemodialysis (Standards)
Nurses (Surveys)
Nurses (Beliefs, opinions and attitudes)
Authors: Walker, Rachael
Abel, Sally
Meyer, Alannah
Pub Date: 08/01/2010
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: August, 2010 Source Volume: 26 Source Issue: 2
Topic: Event Code: 310 Science & research; 350 Product standards, safety, & recalls
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291701798
Full Text: Introduction

In New Zealand the incidence of patients entering renal failure programmes is increasing at a rate of 6% per annum. In 2008, 492 patients commenced renal replacement therapy, a rate of 115 per million population (Australia and New Zealand Dialysis and Transplant Registry, 2009). Patients with chronic kidney disease (CKD) who are expected to progress to end stage renal failure are classified as pre-dialysis. They need a high level of educational, social, psychological and emotional support in order to prepare them for this transition and often have a number of complex needs and complications which influence their care (Crowley, 2003). Although there is no New Zealand literature on this topic, international literature demonstrates that multi-disciplinary pre-dialysis care and education are effective in extending time to dialysis as well as improving quality of life, clinical outcomes and patient acceptance and treatment choice (Devins, Mendelssohn, Barre, & Binik, 2003; Devins, Mendelssohn, Barre, Taub, & Binik, 2005; Levin, Lewis, Mortiboy, Faber, Hare, Porter et al., 1997; Levin, 2003; White, Pilkey, Lam, & Holland, 2002). In New Zealand an estimated 350,000 people are classified as having stage three or four CKD (Rosman, 2008) thus signalling the increasing importance of appropriate and effective pre-dialysis care.

The New Zealand pre-dialysis nurse works in collaboration with the nephrologist and the multidisciplinary team to manage patients who are approaching end stage renal failure. While the international literature supports the importance of a specialist nursing role in providing pre-dialysis care (Anand & Nissenson, 2002; Compton, Provenzano, & Johnson, 2002; Constantini, Beanlands, McCay, Cattran, Hlaadunewich, & Francis, 2008), there is no current New Zealand literature focusing on pre-dialysis nursing care nor any indicating what effective pre-dialysis nursing care might comprise, let alone what this might look like from the nurses' perspective.

This article reports on findings from a study that aimed to fill that gap. It aims to describe and discuss pre-dialysis nurses' perceptions of what constitutes effective pre-dialysis care in New Zealand. It is based on a larger study that also explored the role of the pre-dialysis nurse (Walker, Abel, & Meyer, 2010) and what these nurses believe influence their ability to provide effective care (Walker, 2009). The study sought the views of the majority of pre-dialysis nurses in this country. This article begins with an explanation of the research method used for the main study, and follows with a description and discussion of key themes identified in the data relating to nurses' perceptions of effective pre-dialysis care. We conclude by discussing the implications of these findings for pre-dialysis nursing practice.

Method

This qualitative study used a descriptive exploratory methodology, an approach that takes a pragmatic or applied approach to the topic of inquiry and is becoming more common in nursing research (Schneider, Whitehead, Elliott, Lobiondo-Wood, & Haber, 2007). Qualitative research typically aims to describe and interpret social phenomena including people's experiences, beliefs and practices. Its overall purpose is to provide a description which creates an understanding greater than individuals themselves could provide (Ashworth, 1997). It was appropriate for the purposes of this study, which aimed to gather and interpret pre-dialysis nurses' perceptions about their practice.

The research was undertaken as a Master of Nursing thesis by the first author (RW), herself a pre-dialysis nurse. The sample group was defined as "any nurse working in providing pre-dialysis education and care in New Zealand". The population for this sample group consisted of thirteen nurses, as sourced from the pre-dialysis nurse annual meeting group list. Study participants were those nurses from the above group who gave their informed consent to participate in the study. Because of RW's membership of the population group, her insider status was acknowledged as part of the research approach (Walker et al., 2010). After obtaining ethical approval from the New Zealand Multiregion Ethics Committee in June 2008, an email invitation was sent to all on this list. Attached was a participant information sheet detailing what was involved in taking part in the study and an assurance of confidentiality and anonymity. Nurses interested in participating were invited to contact the researcher, submitting a consent form. Eleven consented to participate. Semi-structured audio-taped phone interviews lasting approximately one hour were undertaken with these pre-dialysis nurse key informants to gain in-depth description and discussion about their practice. Amongst the open-ended questions posed, two invited participants to discuss effectiveness in their role. These were, "Tell me how, in your role, you believe you provide effective pre-dialysis care?" and "How do you assess your care as effective?" In addition, demographic data were collected. All interviews were undertaken by RW.

Thomas's (2006) general inductive approach was used to guide a thematic analysis of the transcribed interview data. Following close and repeated examination of these data key themes were identified in the first instance by RW then checked by the two other authors. A member check (Schneider et al., 2007) was also undertaken through the presentation and discussion of preliminary findings to the participant group at an annual pre-dialysis nurses' meeting, following which some minor analytical adjustments were made. Participant anonymity was preserved through the removal of all identifying material and careful contextualising of quotes.

Findings and Discussion

The eleven participants comprised the large majority of pre-dialysis nurses in New Zealand. Apart from one newly appointed to the role, their length of time in the role ranged from two to nine years. Their nurse-patient ratio varied, although most had a pro rata caseload of 100 patients for a full time position. Many reported that this load was increasing. The level of participants' qualifications also varied. Six had some form of postgraduate qualification, with one having a Masters degree (Walker et al., 2010).

A number of themes emerged from the data identifying nurses' perceptions of the key components of effective pre dialysis nursing care. In this section these key themes are presented under the following headings: the nurse patient relationship, holistic nursing assessment, patient education and measurable indicators. In each case participants' views are described and supported by direct quotes and then discussed within the context of the relevant literature.

Nurse-Patient Relationship.

A strong relationship between the nurse and patient was described as imperative in providing effective pre-dialysis nursing care. Without this it was deemed impossible to be able to get to know the patient, assess them holistically, educate them in an appropriate way and therefore provide effective care. Participants talked of renal nursing in particular as unique in this relationship building, as not many other nurse-patient relationships continued over such a long period of time with nurses having such close knowledge of their patients' lives, families and values. A number of factors were required in order to develop a positive nurse-patient relationship. These included trust, allaying patient fear, honesty and having time. Participants described the building of trust, particularly the patient trusting the nurse, as essential to forming and maintaining a strong relationship.

What matters most? I think the essence of pre-dialysis care is developing a good relationship with the patient, and a relationship of trust, because once you get that engagement with the patient and you get them on board then the whole process of preparing them for dialysis becomes much easier. That engagement and that relationship, that building up of that relationship, it's about, you know, trusting each other really (Participant Quote).

Participants felt that breaking down barriers was essential to the building of trust and this was required before they could effectively educate patients. They believed that by building up rapport and trust they were far more likely to identify when the patient was concerned or did not understand something, therefore enabling them to make their care more effective. Allaying patients' fears with respect to their kidney disease, treatment options and the unknown was seen as important in developing the relationship and the best way of doing this was through providing good quality, targeted education and becoming familiar to the patient.

Honesty and telling patients the truth were also identified as important components in building the nurse-patient relationship. Participants believed this ensured that the patient was fully aware of the reality of renal replacement therapy and had a thorough picture of all the advantages and disadvantages of each treatment. Hence, they could be fully informed to make appropriate decisions for their future.

Building and maintaining the nurse-patient relationship was considered integral to being an effective patient advocate, which in turn was seen as key to being an effective pre-dialysis nurse. Participants described advocacy as ensuring patients received their modality choice, were provided with all services they were eligible for, saw their doctor when appropriate and understood their management. In some cases advocacy involved openly disagreeing with the doctor about the patient care. One participant said "we've got to advocate for our patient, that's really what we're here for."

Time was considered another key factor in relationship building. The majority of participants acknowledged that the more time they had to spend with patients the better, as the patient felt valued, listened to and supported and was more likely to actively participate in their care and treatment. Allowing time for interactions, making longer visits, not being rushed, giving thorough explanations and calling the patients regularly were considered positive influences on their relationships and therefore their care.

Some people like you to ... meander around very gently, which takes a long process. So you have to take your time to assess how each patient that you're dealing with will be able to receive information. You're going to have to spend the time next time to go over a little bit more of it. Otherwise, if you rush in, there is only so much they can take and, I mean, we are trying to impart information to the patients (Participant Quote).

The centrality of the nurse-patient relationship in nursing is well supported in the literature. Nurse patient relationships are the foundation for nursing practice, being a catalyst for the professionalisation of nursing (Dowling, 2006; Hagerty & Patusky, 2003), and are imperative in providing effective nursing care (Cioffi, 2006). The nurse-patient relationship is influenced by social, cultural, ethnic, economic, legal and technological influences and is crucial for all nurses regardless of their specialty as it directly influences patient outcomes (Hagerty & Patusky).

According to Bonner (2007a), knowing the patient is important in ensuring that patients are treated as individuals and it "enhances the nurse's ability to recognise subtle cues and respond much earlier to problems" (Thomas & Fothergill-Bourbonnais, 2005, as cited in Bonner, 2007a, p. 166). However, due to current pressures in health care, resources such as time are often inadequate to routinely build trust. The concept of "being there", which is relevant to the concept of time, has been previously described in nephrology nursing studies as an essential component of expert nursing care which allows the nurse to be patient focused (Bonner, 2007b; Wallace & Appleton, 1995). "Being there" was seen as "a willingness to connect and become involved" (Bonner, 2007b, p. 11).

Nursing Assessment.

Participants described the importance of a thorough holistic nursing assessment. This involves assessing all aspects of the patient's lives; their physical, mental, spiritual, cultural, family and psychosocial well-being. The majority of participants completed a holistic assessment at the initial meeting with the patient and ongoing assessments at future meetings. The importance of a thorough and holistic assessment was often described as crucial in being able to plan the patient's care as it ensured appropriate and correct choices were made for future treatment options and management.

Assessing patient needs and educational levels is fundamental to nursing. Nurses use their assessment skills each time they meet the patient (Rankin & Stallings, 2001). According to Tweed and Ceasar (2005), detailed pre-dialysis assessments enable nurses to become cognisant of their patients' beliefs, lifestyles and backgrounds. This enables them to discuss advantages and disadvantages of treatment options and implications to patients in a meaningful way. All participants in our study discussed the importance of patients understanding the different modalities and how each would affect their lives so that they were informed enough to choose the best option for themselves and their families. Research has shown that patients who do not have the freedom or ability to choose a dialysis therapy have a reduced quality of life compared to those who do (Branson, 2007).

The time required to form a trusting relationship to thoroughly assess the patient in their home environment, including their coping strategies, was significant. One participant described how nurses were able to provide more thorough assessment than doctors because they had the time.

We try and are quite holistic in our assessments, so we've sort of crossed everything off and made sure that it is going to be an appropriate treatment for them. So I think sometimes with them (doctors), it becomes difficult because they (patients) don't get that same level of assessment (Participant Quote).

The majority acknowledged that home visiting provided the best environment for assessment of the patient as it provided better familiarity with them, their lifestyles and their family/whanau, so was more likely to be effective. The importance of involving the family was a factor most participants perceived as essential in delivering effective care. As one stated, "When someone starts on dialysis it's not just the patient that's affected, it is the family and the wider community".

Patient Education.

Participants described an important indicator of effective care as ensuring the patient received timely and appropriate education. This ensured the patient and family were aware of the disease process and its potential effects on their body, what this might mean for their future and how it was going to affect their lives and the lives of their families. This was especially important for patients with kidney failure as they are a diverse complex group with varying needs, educational ability and levels of understanding.

A number of studies support their view that pre-dialysis education is effective in improving outcomes for the patient and the service (Devins et al., 2003; Devins et al., 2005; Klang, Bjorvell, Berglund, Sundstedt, & Clyne, 1998; White et al., 2002). Golper (2001) stated that

Educating patients also involved discussion around treatment options, and assisting patients to make the most appropriate modality choice. Participants saw this as being particularly important in relation to palliative care.

You have to be quite open with them and quite honest and think about things in a practical way, in a common sense way. You know, you have referrals through for 88 year olds, 90 year olds, that are only really just managing in life at the moment and adding dialysis will not be of any benefit, and we have to be quite honest with them (Participant Quote).

The style of information delivery was considered important and participants ensured this was appropriate to the patient's level of need and understanding. The majority felt that knowing the estimated time before the patient commenced dialysis and the number of planned future contacts was very important in ensuring effective education delivery. Some participants commented that time restraints forced them at times to try and deliver the majority of information and education to patients in one initial session. They were aware this was not good practice as often it inhibited factors such as relationship building, gaining informed consent and appropriate education delivery, not to mention staff satisfaction. Redman (2004) supports this, advising nurses to use short education sessions with repetition of information and ongoing assessments of knowledge to deliver the most effective education.

Nurse led clinics and group education sessions were considered effective ways to provide short and repetitive sessions. Participants felt that the benefits of nurse led clinics included allowing the nurse to review and re-educate, answer questions, clear any misconceptions and discuss any changes to the treatment plans. Group sessions were also described as providing the opportunity to meet other patients and were seen as effective in providing education to a larger group of people. Redman (2004) also supports this method of education stating that group instruction encourages 'peer-influenced learning' and also makes learning interactive and therefore more memorable to patients.

Measurable Indicators.

In line with international recommendations, the best measurable indicators that nurses currently have for determining the effectiveness of pre-dialysis care are timely initiation of dialysis and the formation of permanent dialysis access (fistula formation or peritoneal dialysis catheter insertion) prior to starting treatment. These two factors together determined and enabled what the majority of participants described as "a smooth transition to treatment". A smooth transition meant the patient being physically prepared for renal replacement therapy as well as having adequate education and information about dialysis and treatment choices, with input from the multi-disciplinary team.

A planned progression to dialysis ensured a smooth transition with minimal disruption to the patient's life and appropriate permanent dialysis access in place to commence dialysis. This was, however, dependent on a number of factors out of the nurse's control, such as theatre room and anaesthetist availability and waiting lists. Despite this, permanent dialysis access formation was the only job specific key performance indicator mentioned by participants. One felt that not meeting this requirement did not necessarily mean their predialysis care had not been effective.

Every time you put an acute line into someone to start haemo doesn't mean you've failed, because there are lots of reasons why you maybe don't get access in. It can be either a) acute presentation, b) they are just not playing ball with you. But I think it is the simplest way of measuring effectiveness (Participant Quote).

Although perhaps the simplest way to measure effectiveness in a general sense, one must ask, are these two indicators the best for assessing specifically nursing effectiveness? The indicators correspond to the general recommendations for effective pre-dialysis care and are included in the Kidney Disease Outcomes Quality Initiative (K/DOQI) and Caring for Australasians with Renal Impairment (CARI) Guidelines (Kelly, Stanley, & Harris, 2005; Levin & Stevens, 2005; Thomas, 2007). They relate, however, to the effectiveness of pre-dialysis care by the multi-disciplinary team rather than to the specific role or influence of the pre-dialysis nurse and would therefore seem an inappropriate measure of the effectiveness of this nursing role. Indeed, participants perceived that outside factors affected these measurable indicators more significantly than the holistic care they provided. Papps (1994) stated, "if nursing quality is to improve, it is important to use both the patients' views and nurses' conceptions of good nursing care to develop frameworks for evaluating care" (p.59). Frameworks using non-quantifiable parameters in addition to quantifiable parameters would allow nurses to know they were being effective in ways such as in the quality of their relationships with patients. Mueller (2006), as cited in Rabetoy (2007), stated that we should not only be measuring quantifiable parameters but also the human element and that frequent visits create an environment where trusting partnerships develop leading to better communication, more education, better adherence and better patient relations.

Limitations of the Study

Limitations of the study include that it only explored nurses' perceptions. It would also be interesting to explore doctors' as well as patients' and their families' perceptions of effective pre-dialysis care. Although also a strength, another possible limitation was RW's insider status, as this potentially affected researcher objectivity. However the risk was minimised by using peer analysis and member checking to ensure confirmability of research findings (Schneider et al., 2007).

Conclusion and Implications

With the increasing burden of chronic kidney disease globally, ensuring pre-dialysis care is effective is critical. Given the recognised importance of the specialist nurse in this field, ensuring pre-dialysis nursing care is effective is of increasing importance. However, as reported in this study, the measurable indicators commonly used (timely initiation of dialysis and formation of dialysis access prior to treatment) are influenced by a number of factors that are not within nurses' control and are not related specifically to their role. The participants in this study, who comprise almost all pre-dialysis nurses in New Zealand, identified a number of more qualitative areas that they consider are central to practising pre-dialysis nursing effectively, namely a strong nurse patient relationship, a comprehensive holistic nursing assessment and timely and appropriate patient education. We propose, therefore, that to ensure pre-dialysis care is effective it is important to not only measure quantifiable parameters but also consider the more qualitative elements, identified here as being at the heart of effective pre-dialysis nursing practice.

A clear understanding of what nurses perceive as effective pre-dialysis nursing care is important to the advancement of this challenging specialty and to the delivery of high quality patient care. The ability to measure effectiveness in a broader sense needs to be seriously engaged with to determine more creative and meaningful ways of achieving this. The components and qualities of effective pre-dialysis nursing care impact on nurses' responsibilities and functions, including within the multi-disciplinary team, and have implications for their future role. With appropriate education and skills this role can develop and progress to better meet the needs of patients and their families.

A consensus on what comprises effective predialysis nursing care also has implications for the preparation of nurses to work in this area. The need for appropriate post graduate education and clinical skills would seem to be an essential component in this process. This may require the development of competencies that pertain particularly to this area of practice.

Further implications relate to ongoing planning of pre-dialysis services in an area where demand is growing rapidly and cost is always an issue. Nurses have an integral role to play in the successful planning and resourcing to these services to ensure the best possible patient outcomes for their patients.

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Rachael Walker, RN, MN, Clinical Nurse Specialist--Pre-dialysis, Renal Department, Hawkes Bay District Health Board, Hastings

Sally Abel, PhD, Senior Lecturer, Faculty of Health and Sports Science, Eastern Institute of Technology, Hawkes Bay

Alannah Meyer, RN, MN, Senior Nurse Lecturer, Faculty of Health and Sports Science, Eastern Institute of Technology, Hawkes Bay
Education of patients early in the course of chronic
   renal insufficiency offers many potential benefits
   for patients and health care professionals, including
   improved treatment outcomes, reduced anxiety,
   greater prospect for continued employment, improved
   timing for the start of dialysis, and a greater
   opportunity for intervention to delay disease progression
   (p. 20).
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