Evaluating Renal Nursing Practices

CHAPTER ONE

Introduction

This chapter has detailed the reason for the author’s choice of practice scope for evaluation. The aims and objectives have been listed together with the search and evaluation strategies utilised in this research. There is also a description of the structure used in this research and a conclusion of the chapter

Reason for the choice of practise scope for evaluation

A study conducted recently to examine strategies to attract trainee physicians to the renal medicine identified that complexity of the speciality and heavy workloads were some of the factors contributing to the global decline in the number of physicians with career interest in renal medicine (Hill & Arnold, 2020). In addition to this, the results of the recent friction between the government and the junior doctors over the changes effected on their contracts and working hours have contributed to the short fall of junior doctors within the speciality (Brand and McGoran 2018). As such, staff in this unit have combined their nursing and technical roles to compensate for the dwindling short fall of junior doctors despite their significantly reduced numbers brought about by retirements and nurses leaving the profession before retirement (Ellis and Jenkins 2016). They staff are involved in reviewing patient’s blood results, adjusting dialysis prescriptions, managing immediate adverse effects of dialysis including hypotension, administering medications as well as educating the patients. Although the unit is nurse-led (giving care, coordinating and managing access to other health and social Care providers), expert practitioners in this area of renal nursing have constantly strived to promote excellence in the application of nursing care and evidence-based practice (Kleinpell et al., 2014). Standard Operating Procedure (SOP), the UK Renal Association Clinical Practice Guidelines (CPG), NICE guidelines, National Service Framework (NSF), principles of clinical governance, NMC standards, Knowledge and Skills Framework (KSF), networking, service users, and other government documents and initiatives have been the framework through which high-quality nursing care have been provided. CPG are statement recommendations informed by systematic review of evidence and an assessment of the benefits and harms of the alternative care options to optimise patients care (Sandlin et al., 2013). As a senior staff in the unit, my role is to plan, implement and evaluate the care of the dialysis patients. According to Parry & Parry (2018), medical professional, nurses and allied health professionals have been afforded a high status in societies due to the specialised knowledge base, specific skills in delivering health care, and a commitment to serve patients and stay in touch with new and emerging evidence about health, illness and ways of helping people to achieve optimal health. This dissertation gives me the opportunity to assess, evaluate and appraise my practice environment in relation to personal and professional development in order to help HD patients to achieve optimal health. Having worked in the renal unit for more than 15 years, the evaluation will help me in identifying the learning opportunities within my area of practice to develop my role as a renal nurse.

Registered nurses are expected to make sound decisions about their ongoing personal and professional development, practice within the scope of their personal and professional competence, while extending the scope where appropriate, working harmoniously and effectively with colleagues, patients, clients and their families (Department of Health 2010). Meeting the objectives of this evaluation will aid in extending my role while working effectively with colleagues, patients and their families. This evaluation took place in a busy 30 stationed dialysis unit of an acute hospital providing care for up to 140 patients who are undergoing chronic maintenance HD. It is a very complex environment with patients coming and going, preparation of dialysis machines, connection and disconnection of patients from the dialysis machines, and the constant reuse of the dialysis machines for renal patients.

Aims and objectives of the study

This study aims at evaluating the extent to which renal nurses are fulfilling their roles. Putting into consideration the core dimensions of health evaluation. These are: effectiveness, which describes the benefits of health services measured by improvements in health of a population; efficiency, which relates to the cost of an intervention in relation to the benefits obtained; humanity, which refers to social, psychological and ethical accountability of the treatment that people receive from health care interventions; and equity, which refers to the fair distribution of health services among groups or individuals (Volk et al., 2013)

The objectives of this evaluation therefore, are:

To evaluate the effectiveness of the renal nurse in patient-centred care,

To assess personal growth of the renal nurse in the providence of patient centred care,

To evaluate professional advancement in the role of the renal nurse in providing patient centred care

The search strategy and evaluation strategy

Methods used in an evaluation can range from simple intuition to rigorous science (Erickson, 2012). Scientific methods including quantitative and qualitative techniques aim at providing high quality evidence that minimizes bias and confounding factors. This section has identified and presented the search strategies used to obtain qualitative evidence of areas of the role renal nurse and where greater knowledge is required to improve health and reduce care burden which will be detailed in chapter three. This research has utilised a systematic literature review to gain information with regards to renal nursing. The purpose of a systematic literature review is to identify, integrate and critically evaluate relevant studies that address a specified research question (Munn et al., 2018). Systematic reviews use rigorous research methodology to try and limit bias in all aspects of the review (Khan et al 2011). To make sense of scientific evidence in order to follow an evidence-based approach to practice, Munn et al (2018), suggested that clinicians should turn problems of their clinical practice into focused questions and to comprehensively search for literature to address the questions. The truthfulness of a systematic literature review is directly related to the thoroughness of the search to identify all the relevant studies and a comprehensive literature search does not only help to identify the current knowledge with regard to relevant concepts and context, but also helps to identify what is known and unknown in a particular field (Walliman, 2017). The scientific databases used in this study are CINAHL, Applied Social Sciences Index and Abstracts (ASSIA), Cochrane library, Medline and the National Institutes of Health (NIH) to generate data that is relevant to this research. Other electronic search engines such as Semantic scholar and Google scholar have also been used to identify research studies highlighted in other literature as essential to ensure valuable information has not been left out. These databases were selected because they provide reliable information that is especially useful in a qualitative research in health care. The databases also give medical information, the articles are authoritative, peer reviewed and easily accessible (Rogers et al., 2018). NIH has a wider range of coverage of medical topics and provides systematic reviews of medical work (NIH) To identify the research question, the PICO framework was used. PICO is a framework utilised in qualitative research to frame a research question. The elements of the framework are: Population, Intervention, Comparison and Outcome and is shown in table 1.

The search period placed was between 2010 to 2020 and Studies detailing the positive and negative results of the role of the renal nurse will be included to identify areas where the nurse is doing well and identify areas where he/she is not doing very well to develop their role. Bruce et al (2008) and Egger et al (1997) found publication, language and geographical bias where positive results are published more frequently than negative results, statistically significant results in RCTs are more likely to be published in English-language journals, and some journals and databases tend to publish articles primarily originating from certain countries (e.g. 52% of the 10 million references published in MEDLINE database are from United States) alone (Bruce et al 2008). There was utilisation of Keywords, phrases and acronyms related to the research question. Boolean operators (AND, OR) were also adopted to combine the keywords and expand the significance of the study in the databases named above. Table 2 shows the keywords used during the search.

The inclusion and exclusion criteria was utilised to narrow the search. Filtration was according to the period, language used in the articles, published and unpublished work, and the population of interest as shown in table 3.

To appraise the search findings, a critical appraisal tool was utilised. By definition, critical appraisal is the process of allocating merit to a study by careful scrutinization of the work. The tool utilised for this process usually has a set criteria by which the work is compared against to determine how trusted the findings are (Moult et al., 2018) The Critical Appraisal Skills Programme (CASP) was used to examine the quality of the findings from the search. CASP has a number of appraisal tools that are tailor made to suit different research studies, systematic reviews included (CASP, 2018)

Structure of the research

Evaluation is a systematic data-based inquiry of whatever is being evaluated (Husereau, 2013).

To ensure a systematic approach, the dissertation is organised in chapters as outlined in the Northumbria University module handbook (2019/20) with chapter one focusing on the introduction. Chapter two focuses on the literature review to articulate the role of the renal nurse from the available evidence (how the role affects the practice). Chapter three is a critical evaluation of the role of the nurse as discussed in chapter 2, the identification of gaps in order to enhance the experience of a patient. This leads to chapter four, which is the role development to seal the identified gap. Chapter 5 is a summary of the issues considered and emerging from the discussion including a summary of personal reflection of what has been learned about the topic. There is also an identification of the future projects and recommendations.

Conclusion

This evaluation will put into consideration the learning objectives of the module. These include: a theoretically deconstructed role of the specialty and obligatory practice, in-depth analysis and reflection on examples derived from practise experience to develop personal contribution, professional knowledge formation, practice theory and research biology, case studies clinical and community-based exercises to gain the capacity building strategies and identification of support needed, as well as a proposal for future resource development that includes understanding of the impact of the new role, service development models and the change analysis strategies.

CHAPTER TWO REVIEW

Introduction

This chapter has detailed and critically analysed the practise sphere, which is renal nursing, and the professional roles within it. The analysis has placed renal nursing within the context of the extensive driving forces such as consultative practise, clinical administration, health policies, and accountability among others.

Literature Review

Health care, according to Evans & Stoddart (2017), is any activity that is intended to improve the state of physical, mental or social function of one or more people and it includes a range of activities such as improvement of health, preventative medicine, curative health services, recuperation, extended care and end of life care. The main goal of healthcare is to promote, within an individual, the longest life possible with the least amount of pain and discomfort (Toon, 2015) Renal nursing is a health care activity which focuses on improving the physical, mental and social well-being of patients with Established Renal Failure (ERF). This also entails enlightening the patients and the family members about the treatment and management procedures of the condition (Gomez et al., 2012). The renal nursing specialty has been in existence for approximately 45 years. In 1973, treatment for kidney disease (ESRD) by haemodialysis, peritoneal dialysis, or transplantation was funded by the federal government through the Social Security program (Ellis et al., 2012). ESRD was made the only disease-related disability and therefore treatment was readily available. Due to this, the role of the renal nurse expanded fast and the number of professions in the field increased rapidly (MacLellan et al., 2014) The role of the renal nurse currently cuts across clinical care and administration. On the clinical part, the renal nurse should be equipped with knowledge about every organ of the body, and be highly skilled and motivated in order to provide a holistic approach to renal treatment and management (Schober & Affara, 2006) On the administrative part, the renal nurse should be able to coordinate a renal team, ensure that every aspect of patient care is well looked into and also motivate the team members (Ellis & Abbott, 2009). They also act as a link between the nurses and the management of the medical facility. At times the responsibility of business and financial management is placed on them. But generally, the renal nurse leader should ensure optimal health care is provided to the patient suffering from renal failure (MacLellan et al., 2014) According to Mantzoukas & Watkinson (2006), the limited availability of resources for healthcare should require health care activities to be evaluated in order to match the care provided to the needs of the people, which is, choosing only the interventions with the greatest gains at the lowest cost. Schober & Affara (2006), also argued that healthcare evaluation is a critical assessment on, as scientifically rigorous basis as possible, the degree to which health services fulfilled the stated objectives. Improved patient’s outcomes and reducing mortality is at the core of healthcare professional practice and nurses as the main care givers within the unit are at the core of this initiative (Mantzoukas & Watkinson, 2006). The objective of renal nursing is to provide a holistic patient- centred care for ERF patients. Murray et al (2013), suggested that for already established health care, it may only be necessary to evaluate the dimension for which there is uncertainty about the outcome. Therefore, this evaluation will focus on the ability of the renal nurse to provide patient-centred care. Renal nursing is faced with numerous uncertainties with regards to the providence of quality health care in a technological filled environment (Bergjan & Schaepe, 2016). Husereau (2013), suggested that a properly carried out evaluation does not only tell us whether a role works, but also tells ‘why’ and ‘how’ it works. This enables the acquisition of knowledge, the spreading of successful interventions and the development of new ones (Rhoades & Rhoades, 2014).

Through Equality and Excellence: Liberating the NHS (2010), doctors and nurses have been encouraged to use their professional judgment to determine what is right for the patients. Also, through the issue of accountability, renal nurses have a duty to patients, programs, funders, policy makers and the profession to ensure the delivery of the best health care possible to achieve the promised benefits while making the optimal use of resources (McCormack et al., 2011). The future of the NHS will depend on the most talented, important, and accountable staff to work within their care delivery model of thinking and innovation to contribute towards the health, happiness and well-being of its people (England N.H.S, 2017)

Practice environment

Established Renal Failure (ERF) is irreversible kidney damage characterised by (stage 5) Estimated Glomerular Filtration Rate (eGFR) 15ml/min/1.73m2 (NICE 2013). It is believed to affect 1.8 million people in England with an additional more than 1 million who are believed to have the condition but have not been diagnosed (NHS Kidney care 2017). 24.9% of the disease is believed to be caused by diabetes. The National Kidney Foundation’s kidney disease outcomes quality initiative (NKF-KDOQI) classified ERF into stages. These are stages one to four. Stage 1 is a mild chronic kidney disease (CKD) that is characterised by an estimated Glomerular Filtration Rate (eGFR) of 60-90ml/min/1.73m2. There is mild to moderate CKD in stage 2, with an eGFR of 45-59ml/min/1.73m2. In stage 3 the patient experiences moderate to severe CKD with an eGFR of 30-44ml/min/1.73m2 and has to visit a CKD General Practitioner (GP). Stage 4 has an eGFR of less than 30ml/min/1.73m2 (Gilbert & Weiner, 2013). The stages 1 to 3 of CKD are managed in the community whereas stage 4 CKD is referred to the hospital for Renal Replacement Therapy (RRT) preparation. The median age of starting RRT is 65years with a normal eGFR = or > than 90ml/min/1.73m2 (Renal Registry 2017). When dealing with people who have long-term conditions, it was studied that person-centred care aids in promoting the health of people and minimizing the strain on health services (Ellis et al., 2012). As a nurse caring for patients with a long-term condition, the evaluation seeks to identify areas within the renal nursing role to develop greater knowledge and skills. This will promote health and decrease the strain on the health services. Fundamentally, there are four treatment options for ERF. These are: Haemodialysis (HD), Peritoneal Dialysis (PD), Kidney Transplantation (KTX), and conservative management (Walker et al., 2014). Haemodialysis can be done at the hospital by the nurses or at home by the patient. Hospital -based haemodialysis is often the only option for frail and the elderly and involves hospital attendance by the patient for 3-4 sessions each week. These sessions last for about 4-5 hours (Selman et al., 2019). Peritoneal dialysis is home based and is carried out by the patient. Conservative management applies to people who choose not to have dialysis and are followed up by nephrologist in the clinic for symptoms control. According to the 21st UK Renal Registry Report (2017), there were more than 44,512 ERF patients undergoing Haemodialysis (ICHD) in the United Kingdom alone. This incidence is highly expected to rise due to the increasing incidences of diabetes and hypertension. Despite major advances in technology, the prognosis for the renal patients undergoing dialysis is still worse than the prognosis of some types of cancer (Ayeigbusi et al., 2017).

Dialysis aims at clearing away from the body waste products, retained fluid, and electrolytes when the kidneys have failed, are not present or have been impaired. This is done in order to sustain the life of the patient up to death or until a kidney transplant is obtained (Kantor et al., 2018). This medical intervention utilises a dialysis machine which works as an artificial kidney. There are two types of dialysis: haemodialysis and peritoneal dialysis. Haemodialysis occurs externally whereby the patient’s blood undergoes filtration, cleaning and goes back to the body of the patient (Harwood et al., 2003). Peritoneal dialysis occurs internally whereby the abdomen is utilised as a filtration membrane. A catheter is inserted through which the cleansing solution passes, the blood is cleansed and waste products eliminated out of the abdomen and are disposed of (Ding & Lo, 2016). The haemodialyser utilises the principles of diffusion, convention, ultrafiltration and hydrostatic pressure (Selman et al., 2019). Diffusion is the transfer of solutes from a region of high concentration of the solutes to a region of low concentration of the solutes. In the dialysis machine, there is a dialyser in which blood mixes with a saline fluid known as the dialysate (Moissl & Wupper, 2013). Convention involves the transfer of solutes along with the movement of fluid during dialysis, and ultrafiltration and hydrostatic pressure occur as a result of pressure exerted by the blood as it passes through the dialyzer forcing the movement of fluid and small solutes (Maierhofer et al., 2018). Ideally, the dialysis prescription should resemble the physiology of the normal kidney that maintains the body homeostasis (Ellis & Abbott, 2009). Despite these relatively convenient methods, the process of caring for these patients is complex as the nurse must stay up to date with the constant changes in technology. The renal nurse should also engage with the patient for prolonged periods of time, to help them to adapt to the lifestyle changes brought about by a chronic illness and the treatment (Kantor et al., 2018). Other concerns commonly raised by patients include disruptions of lifestyle, experience of continuing symptoms, stress and the uncertainty of life, hospitalisation, and poor quality of life. All these concerns lead to higher demands on the health care systems (Selman et al., 2019). Expert practitioners in this area of renal nursing have constantly strived to promote excellence in the application of nursing care and evidence-based practice (Harwood et al., 2003). The management of renal patients requires a multidisciplinary team approach including medical staff, nurses, dieticians and social workers to share skills and transfer competencies across professional boundaries to optimise clinical outcomes and enhance quality of life (Ellis & Abbott, 2009). Renal named nurse is the key link professional to the other health care systems provided by the multidisciplinary teams (Walker et al., 2014).

Evolution of the role of the renal nurse

Since 1915, renal nursing has been undergoing constant evolution. In the past, the role of the renal nurse involved recording of patients’ intake and output and control the diet of the patient. The nurses were also responsible for stimulating the elimination of waste through the gastrointestinal tract, providing rest to the renal patient and prevent infection to the patient (Gorham et al., 2018). In order to reduce the production of metabolic wastes it was mandatory to decrease muscle activity of the patient, keeping the patient comfortable at the same time (conservative management of CRF), and this was the responsibility of the renal nurse (Millar, 2016). However, after the revolutionary creation of Quinton-Scribner Arterial Venous (AV) shunt (the first chronic vascular access) in 1960, the role of the nurse changed gradually. The nurses were now responsible for the preservation of the access and preventing medical complications such as infections, clotting and disconnection or dislodgement. Educating patients and their families to care for the vascular access, as well as giving nursing care during dialysis were also included in the roles of the renal nurse (Gorham et al., 2018). During this time the chronic vascular access (AV shunt) also meant that haemodialysis could be instituted as a long-term treatment for CKD. Therefore, as the number of patients continued to grow steadily, so did the need for the dialysis. It was no longer economically feasible for the physicians to be in attendance for the entire treatment and still attend to other patients. The procedure was therefore delegated to the nurses (Ayeigbusi et al., 2017). For the chronic dialysis patients, nursing care meant going beyond the provision of patient comfort. It also entailed being involved in the treatment of the patient, assessment and monitoring of the patient, keeping records, administering medicine, fluid control and providing education to the family members and the patient (Kantor et al., 2018). These skills have remained important today although some researchers within the field have highlighted tensions between technological caring and nursing (Schober & Affara, 2006). The evaluation will demonstrate the ability of the renal nurse to humanise the process, preserve the patient dignity while still working in a technological field. Dialysis nurses should be confident in acknowledging the technology as one aspect of person- centred care in order to provide quality care (Bennett 2011).Person-centred care is about doing things with people and not to them (HIN2014). Advanced level nursing is more needed today, with the constantly increasing population. The demand for quality health care services has risen and there is a major constrain in finances. Therefore, it is crucial for any medical facility to have qualified medical workers who are well educated, capable and provide optimum care at any given time (Kleinpell et al., 2014). This is where advanced level nursing comes in. it encompasses four main aspects of clinical practice, administration/ management, educating others and able to learn at the same time and research development (East et al., 2015). Advanced level nurses have the capability of decision making in the diagnosis and treatment of patients (Cooney et al., 2013).

Over the years several government documents and initiatives such as: the Lord Darzi’s report: High Quality care for all (2008), the Equality Act (2010), Equity and Excellence: Liberating the NHS (2010), and the NICE Quality standards for patient experience in adult NHS services have outlined the significance of patient’s experience and the necessity of focusing on advancing patient experience where possible. Among the reports, the Lord Darzi’s (2008) report signalled the need to consider patient experience alongside safety and quality while the National Institute for Health and Care Excellence (2012) has produced quality standards to improve the patient’s experience recommending individualised approach to health services to enhance patient experience. Patient experience is the process of illness within an individual and how treatment is accorded to that patient (Evans et al., 2017). The experience incorporates a wide range of activities that affect the patient. Right from the health care structure in a medical facility, to the health plans and care from medical doctors and other hospital staff. It is important to provide good patient experience as it is one of the contributing factors to good health outcomes of the patient and gives peace of mind to the family members of the patient (Cooney et al., 2013)

Conclusion

The NHS England’s five year forward view (2014) recognised the challenges faced by people with Long-Term Conditions (LTC) and recommended that their carers should be well coordinated between those who are involved to reduce duplication, fragmentation and create ownership. Although dialysis patients have the most frequent contact with health services in the context of their dialysis (4-5 times a week) they are less able to access other services located away from their place of dialysis (Brand et al 2016). Developing knowledge and skills will help identify their needs and manage them better. Godwin et al (2010) argued that care of patients with LTC should be proactive, rather than reactive focusing on supporting patients to self- manage (Goodwin et al 2010). The key themes of renal nursing have been discussed in chapter three together with issues emerging from this evaluation. Future needs in renal nursing and its direction have also been outlined in the chapter.

CHAPTER THREE EVALUATION

Introduction

This section has focused on the results obtained from the search conducted. It has also outlined major themes and issues that have emerged from the evaluation.

The results

The first search for the role of the renal nurse in haemodialysis care returned more than 1424 articles. After narrowing the search to adult outpatient haemodialysis nursing care 627 articles were selected. The inclusion and exclusion criteria was applied to this findings and the results were as follows: 6 articles from CINAHL, 3 through the Medline, 2 from Cochrane library, 2 from the NIH, 3 from semantic scholar, 3 from Google scholar through Springer Link, and 2 from Springer Link open access. This gave a total of 19 articles to be used for the main literature review as they were relevant to the research question and had passed the critical appraisal stage. This data is presented in table 4.

The Prisma Table

All the other literature has aided in the evidence -base to support the argument. Despite some countries having a private health care system, this project is looking at the role, so it is easily transferable to the UK practice. Clinicians must ensure that the literature is critically appraised for its usefulness and scientific validity before applying the results to their practice (Taylor et al 2004). While a variety of approaches including publication of numerous critical checklists and Critical Appraisal Skills (CAS) teaching in undergraduate and post graduate education to enhance critical appraisal skills, in the UK and Abroad, the Critical Appraisal Skills Programme (CASP) is the most widely disseminated form of CAS training (Taylor et al 2004). Since study designs are subject to a number of variables that introduce bias, the use of standardised checklist presented by CASP to determine the quality of the study, identify strengths and weaknesses of a study to enhance the usefulness of the findings, assess study design and applicability to a local perspective in the most economic manner is recommended (Singh 2016). When appraising the literature, the Critical Appraisal Skills Programme (2019) checklist including tools for systematic reviews, cohort studies and qualitative studies will be utilized with some modifications due to the nature of the research. This will ensure all papers are critiqued with equal rigor as it is a complex process (Aveyard, 2010). Depending on how well the literature is meeting the recommendations of CASP tool, the literature will be rated as low, medium or high. A data extraction form will then be compiled highlighting the evidence found and present the emerging themes in order to be identified easily throughout the project. The data extraction phase is perhaps the most challenging aspect of the methodology as it involves going back to the primary articles to highlight the relevant information to answer the research question. The use of a data extraction form is to standardise the process and improve the validity of the results (Bettany-Saltivo 2012). This section will review the 19 articles of literature highlighting the key point to be discussed further in the next chapter.

Major themes arising from the Findings

Reducing depression among patients on dialysis

Tsai et al (2015), conducted a research to examine the efficacy of a Nurse-Led breathing training program in reducing depressive symptoms in patients on Haemodialysis as the primary outcome. Recruiting 64 patients for the study (32 in the study group and 32 in the control group), the nurse administered an audio-device guided breathing in a quiet room at the dialysis centre through individualised coaching and practice. The intervention did not only alleviate depressive symptoms on the Beck Depression Inventory II (BDI-II) but also had positive effects on patient’s perceived health-related quality of life in role -emotion domains on the Medical Outcome Studies 36-Item Short Form Health Survey (SF-36). Even though the validity of the results may have been affected by the small sample size and high attrition rate in the control group, RCT are high quality evidence to study the effects of treatment or medical interventions on real people and the depressive symptoms in the study population are similar to those in the local dialysis centre therefore the results can be applied locally (Kleinpell et al., 2014). A study was conducted by Idieret et al., (2011), to examine the impact of Therapeutic Patient Education (TPE) for patients on Haemodialysis. It was argued that with the development of TPE programs increasing in the field of ESRD, the focus was to understand their impact on haemodialysis, patient’s physiological and psychosocial well-being. Using the World Health organization (WHO 1996) definition of TPE as “a set of structured and diversified activities organized by one of the several health professionals to improve knowledge, self-care skills, adherence, medical and biological state, psychosocial and life skills, quality of life and well-being” 22 studies were reviewed. Out of the reviewed studies, 18 dealt with the physiological outcomes while 4 dealt with the psychosocial outcomes. Although the study only included published articles from human and social science written in English, it was discovered that there was a positive impact of TPE on patient’ physiological well-being. This was demonstrated by decrease in phosphorous, calcium and calcium phosphorous product level, decrease in inter dialytic weight gain, and improved physical activity due to adherence to diet and fluid recommendations. The intervention also had positive outcomes on the patient’s psychosocial well-being including decreased depressive effects, perceived stress, and improved self-efficacy and improved mental quality of life. Renal nurses are encouraged to stimulate the development of TPE programs for dialysis patients within their multidisciplinary teams to promote the commitment of all for the global management of patients in the TPE process. While most of the interventions were performed by a nurse (11), others were performed by the dietician (6), psychologist (1), and nurse with a psychologist (1) or multidisciplinary team (2). While the methodology and theoretical content of some interventions was strictly educational (16), other studies associated educational content with Cognitive behavioural therapies (6), transactional theory of stress, empowerment or self-efficacy which requires communicational, educational, animation and assessment skills to support.

Diet restrictions and patient adherence to medication

Cheng et al., (2016) conducted a quantitative study to investigate the effectiveness of systematic nursing instruction on low phosphorous diet, serum phosphorous level and pruritus of HD patients. 94 patients were involved in the research, 47 in the experimental group and 47 in the control group. While the participants in the control group received regular care including individual health education, those in the experimental group received individualised systematic nursing instructions through pamphlets with instructions on low phosphorous diet and use of phosphate binders, medication reminder cards and self-recording of their diets in addition to regular care. From the study, it was demonstrated that patients who received systematic nursing instructions had significantly reduced phosphorous dietary intake (967mg from 1196mg after 28 days, reduced serum phosphorous level (4.37mg/dl from 4.99mg/dl in the experimental group as opposed to 4.80mg/dl from 4.46 mg/dl in the control group), and mild pruritus severity (2.57 from 5.81) than the control group which had moderate pruritus (5.34 from 5.68). Sandlin et al., (2013), conducted a descriptive study with a paired pre and post intervention survey to examine the impact of nurse-led education on phosphate binder medications adherence in Australia. Using a convenient sample of 70 patients on dialysis at the time, patients were asked to bring their phosphate binder medications into the dialysis centre and self-administer them while the nurses explored the patient’s habits when taking phosphate binders and assessed if they took them correctly. Nurses then tailored education according to individual patient’s needs while allocating points for bringing the phosphate binders to each dialysis session, taking the medication with a meal on dialysis, achieving the recommended serum phosphate level each month and issued certificates to those with the most points at the end of the 12 weeks. Although the sample size was small, in the context of a single centre, 40% of the patients were assisted by the nurse to complete the survey verbally, and a non-validated questionnaire was used. The results identified significant improvements in the proportion of patients who took their phosphate binders correctly (at the start of their meal) (44% pre survey to 72% post survey). 50% of patients had agreed in the pre-intervention that they needed help to understand how to take their phosphate binders correctly as opposed to 29% post intervention survey. Similarly, 72% of patients in the post intervention survey disagreed that they should still take a phosphate binder without a meal as opposed to 50% before the intervention suggesting increased awareness of the importance of taking phosphate binders with food. Although there were no significant changes in the three bone disorder minerals (phosphate, calcium and parathyroid hormone), and there was considerable variation in phosphate binders prescribed and whether they were used alone or in combination, HD patients have a high pill burden (up to 25 tablets per day) and nurses have a vital role to promote HD patient’s medications knowledge and adherence to prevent complications.

Promotion of patient fluid adherence by renal nurses

A pilot study to test if nurses can improve fluid adherence in patients on haemodialysis with adherence issues in Spain using solution focus communication was conducted by Beyebach, et al., (2018). Knowing the difficulties of compliance with fluid restrictions among HD patients, congratulations were accorded to patients who improved their Intra Dialytic Weight Gain (IDWG) and explore in detail how they had accomplished the weight reduction. The Patients were complimented on their achievement and were invited them to keep track of anything else they might find useful to control their fluid intake over the next days. The research validated the difficulties of those who failed to control their IDWG and empathized with their predicaments. Through solution-focused communication (language based, collaborative practice requiring a shift of attention from a problem-oriented, deficit perspective to focus on solutions and behaviour change), patient’s monthly IDWG shifted from >2.53kg pre-intervention to 2.23kg post intervention and this was kept at follow-up. Though the sample was small, a controlled randomized study would help to gain patient-reported adherence measures to gain a clearer picture on how solution-focused communication promotes fluid adherence. Otherwise the results from this study cannot be generalised.

Role of the renal nurse in guiding decisions regarding the End of Life Care

A case study to navigate the role of the nurse in guiding decisions about the End of Life care (EOL) was used by Stilos and Diane (2010). The study involved an 87 year old long-term dialysis female patient with several comorbidities. These were congestive heart failure, grade 3-4 left ventricular failure, myocardial infarction, peripheral vascular disease and right leg below knee amputation. The patient had been admitted to hospital for gall bladder problems, on discussion with the patient’s daughter, the nurse learned that the patient had expressed a wish to have everything possible done before coming into the hospital. The nurse then provided the patient’s daughter with an opportunity to share her mother’s perspectives and goals of care. While ensuring that the daughter had a good understanding of her mother’s current status of health, she then communicated with the physician to clarify the patient’s goals of care with the daughter including Do Not Resuscitate (DNR), continue dialysis, and assess and manage symptoms of discomfort. The discussion was documented so that all those involved could be informed. In this case the role of the renal nurse was to review patient’s goals of care and to facilitate communication regarding the End of Life care plan with the family and multidisciplinary teams using local guidelines.

Management of Chronic Kidney Failure by the renal nurse

Shi et al., (2013), conducted a study to prospectively evaluate the effectiveness of a nurse-led intensive educational program on the management of Chronic Kidney failure Patients with hyper phosphatemia. Using randomly selected patients of 2 hospitals dialysing on Monday, Wednesday and Friday as the experimental group and the Tuesday, Thursday, Saturday patients as the control group, the nurses offered individual 20-30minutes patient education 2-3 times a week for 6 months. Power point lectures were used to generally educate about phosphorous, phosphate binders and methods of maintaining phosphorous balance. The power points included colourful pictures of high phosphorous foods as educational materials. The participants also received individualised diet education and comprehensive knowledge instruction of medication and hyper phosphatemia. Patients in the experimental group were advised to use clock reminders or put medication bottles on the table to remind them to take them. The control group received the usual medical and social care until after all data had been collected. 80 participants were recruited, and the outcome measures included serum phosphorous, calcium phosphorous products, serum calcium, Parathyroid hormone (PTH), and calcium level and knowledge test. Over time, the experimental group was associated with significantly reduced levels of serum phosphorous, and calcium phosphorous products (-0.35 after 3 months and -0.72 after 6 months) than the control group which had no significant change while the knowledge scores was enhanced in the experimental group (+12.38 after 3 months and +13.75 after 6 months) than the control group (+5.52 and =6.00 after 3 and 6 months respectively). There were no significant changes in serum albumin levels in the experimental group. This signified that limitations of phosphorous diet did not impose malnutrition risk. The patients took phosphate binders correctly with food and separate from vitamin D analogues so there was no change with serum calcium level and there was proper balance between serum phosphorous and calcium levels. Therefore, the PTH was unchanged. Although the study was done in China where food habits may be different, the socio-demographic and relevant clinical characteristics were comparable to those in my area of practice (deranged biochemical markers of phosphate, calcium, albumin and PTH, on dialysis three times a week, taking phosphate binders). The results can, hence, be applied locally to identify the role of the nurse in the management of hyper phosphatemia of CKD

Role of the renal nurse in providing sexual care to patients on dialysis

Ek et al., (2017), studied the role of the nurse in providing sexual care to patients receiving haemodialysis in Netherlands. Using nurses working in the dialysis units across the country, they used a 38 item locally designed questionnaire with multiple choice and open-end questions based on literature and experience due to lack of validated questionnaire. The purpose of the research was to know which health care professional was accountable for discussing sexual dysfunction with the patients. Although a considerable number of nurses felt responsible for discussing sexuality with the patients (360 nurses) and had the time to do so, majority of them felt held back by barriers such as language and ethnicity, religion and culture, and older age. It was recommended that additional training had to be done to the nurses. Organizational adjustments to include information brochures, provide more privacy, posters in the waiting room, presence of agreements and guidelines, and referral systems to nephrologist or sexologist as the tools to discuss sexuality were also part of the recommendations. The study was the first to explore the perspective of dialysis nurses on sexual care for dialysis patients with limited formal comparison with other studies. In addition to this, only 552 of the 1211 distributed questionnaires were returned creating a response bias and the use of no-validated questionnaire may have created a social desirability bias. However, a pilot study had been conducted with 23 nurses before the study to validate the questionnaire and the results can be transferred locally to identify the role of the nurse in the management of complications of HD.

Role of the renal nurse in providing nutritional support for dialysis patients

Bennett et al., (2013), conducted an assessment to improve the referral rates by nurses for nutritional support, reduce mortality rates and improve quality of life of haemodialysis patients in Australia. The primary outcome was referrals to the dietician and secondary outcomes were Quality of Life (QOL), mortality and nutritional biochemistry. Four metropolitan haemodialysis units were used 2 for the intervention and 2 for the control. 96 participants were recruited although 15 dropped out (3 from intervention group and 12 from the control group) creating a bias to the results as there were less participants in the control group than in the intervention group. Using a four-item nutritional screening tool, they found that nurses were able to identify haemodialysis patients nutritionally at risk and refer to the dietician for support (there were more than three times dietetic referrals in the intervention group than in the control group). No changes were observed in the SF-36 quality of life scores although there was significant decrease in the dialysis-specific QOL assessment scores and socio-economic QOL among the referred compared with non-referred. Although none of the referred patients died compared to 5 of the non- referred, there was no significant difference in death rates between referred and non-referred patients after adjustment for age, gender, and number of dialysis hour’s treatment per week. The study was in Australia coupled with limitations of high unexpected drop out rates (16%), lack of capacity to measure the quality of nutritional intervention of those who were referred or whether they attended the dietician appointments or not. However, the results are transferrable locally where there is limited access to dietetic services (128 patients per dietician in the United Kingdom), regular nephrologist outpatient appointments do not include on-going dietetic input, and dietetic services are prioritised for new and seriously ill patients. Nevertheless, given the correct tools, the study has identified the role of the renal nurse to assess and identify nutritionally at-risk patients and refer to multidisciplinary teams for support to reduce morbidity and improve dialysis patient’s quality of life.

Role of the renal nurse in the management of Secondary Hyperparathyroidism in patients

An overview of the management of Secondary Hyperparathyroidism (SHPT) by nurses was conducted by Barbieri et al., (2015) to establish the common practices being used by renal nurses in the management of SHPT and identify training and educational needs to improve patient’s care. Descriptive study design of online survey of multiple choice and closed questions completed by nurses from 4 European countries including Spain, Italy, France and the Netherlands was used. The findings of the study revealed that a third of 111 nurses who completed the survey lacked confidence in explaining the SHPT disorder and therapies to the patients, managing side effects of drugs and appreciating the significance of controlling biochemical targets, despite their substantial nursing experience of 13 years and above. Despite these findings, it was concluded that role of renal nurses is very critical in assessing and monitoring any physical or psychological consequences of SHPT (muscle weakness, pruritus, paraesthesia, osteomalacia, calciphylaxis and ulceration). The renal nurse is also important in controlling biochemical targets, providing individualised patient education and supporting those with poor treatment adherence i.e. those on phosphate binding therapies or tolerance issues, to adhere to treatment. Although the survey was a snapshot of what was happening in the 4 countries at the time, the nurses involved in it were specialist’s nurses with substantial experience of managing patients with SHPT. Together with an experience of many years i.e. 13 years and above, the nurses represented the clinical practice of renal nurses. Therefore, the overview of the study can be transferred locally.

The renal nurse in the care of vascular access

Cowan et al., (2016), did a research to explore the factors influencing the care of vascular access. In the research, descriptive theory was utilised to synthesise what was already known about the subject. This was done to allow for the emergence of new understandings. The literature search and thematic analysis was guided by Bio-ecological theory of human development whose key factors are person, process, context and time. The key words used were haemodialysis, vascular access of Arterial-Venous Fistula/Graft (AV/AVG), and patient experience and empowerment. From the systematic search, 35 articles were utilised in the study along with 3 VA management guidelines. The findings of the articles were that there are several bio-ecological factors influencing the care of VA access of a patient. These factors are: patient experience, empowerment and shared decision making, health care environment, time and quality of life as an outcome. It was concluded that the current management of VA is predominantly centred on planning, annulation techniques, and surgical construction and revival interventions. Other aspects such as mapping and putting into consideration the significance of time throughout the journey of the patients, right from CKD to ERF, may also help to provide a more empowering and supportive culture within the dialysis environment. In addition to this, the care of the patient will be enhanced. The research yielded important information but it is not certain whether the papers included might have been biased or not.

Role of the renal nurse in palliative care

A study by Watson & Yeboah (2013), explored the importance of renal palliative care by Clinical Nurse Specialist (CNS) in the renal unit currently. Using expert opinion, it was observed that the creation of the role was to bridge the gap between renal specialities and specialist palliative care. Nurses who take on the role have expertise in both specialities to meet specific renal needs and palliative care. It was also observed that patients with palliative care needs can be identified and referred to CNS for formulation of care and management plan by any member of the multidisciplinary professional. There are various benefits of having a renal CNS. These include: easy access as these nurses see the patients earlier in their disease trajectory and before the symptoms to explore their preferences and make plans for the future. Doing this helps in avoiding unnecessary admissions, medications, increased patient satisfaction and ensure the effective use of resources. The CNS also have good links with psychological, social, GPs, spiritual and community palliative care providers. This can result in patient and staff knowledge of support services available and how to access them. Although this is an expert opinion, a basic role of the renal nurse is to connect patients with other health care systems. Therefore, doing referrals to CNS would link patients to specialist palliative care services.

The renal nurse in Intra-Dialytic Fluid Removal (UFR)

Ldvigsen et al., (2014), conducted a survey to evaluate the quality of nephrology nursing during Intra-Dialytic Fluid Removal (UFR) in patients who are undergoing haemodialysis using Ultrafiltration Rate (UFR) as a nursing- sensitive quality measure. It was argued that the goal in HD is to ensure adequate fluid removal without causing Intra-dialytic Hypotension (IH) and adjusting UFR is a common nursing intervention to prevent IH. Data was obtained regarding pre dialysis weight, pre and post dialysis blood pressure, serum sodium, dialysate sodium, temperature and relative blood volume of 140 patients who were undergoing HD from a single Scandinavian centre. The data was then used to estimate Dry Weight (DWT), ultrafiltration volume and dialysis time to calculate the UFR. Information on dialysis occurrences including syncope defined as loss of consciousness, cramping defined as involuntary muscle contraction, IH defined as decrease in systolic blood pressure by >20mmhg or decrease in Mean Arterial Pressure (MAP) by 10mmhg and single pool Kt/V was also collected. Although only a single site was used the survey identified that nurses were using higher than the recommended UFR of 10ml/kg/hr in 4/10 patients ranging between 3.7-18.5ml/kg/hr resulting in too rapid fluid removal and low relative blood volume. The researchers concluded that the quality of nephrology nursing care needed to be improved especially in the younger and low body weight patients as they tend to be the most exposed to excess UFR during dialysis. In this case, a systematic literature review could have been used to identify other patient characteristic predisposing the dialysis patients to IH.

Role of the renal nurse in Share Dialysis Care

A small-scale survey to explore the experience of dialysis patients of Shared Dialysis Care (SCD) was carried out by Walker et al., (2014). The research argued that a lot of studies had reported on findings of better health-related quality of life with SCD and that support for this type of dialysis modality was seen as a core component of the management of Long-Term Conditions (LTC). Using questionnaires, the researchers explored the experiences of support and those learning of 22 patients who had been doing SCD for 2-36 months. Although this was carried out in a small service where staffing resources were able to cope with one-to-one support for patients learning to self-care, it yielded significant results. 60% of the patients reported high levels of experiences of support and learning from the nursing staff with 17 of the participants reporting that there was nothing that could be improved. However, 5 patients felt the service could do better with ensuring dialysis equipment (concentrates, self-care machines) were in place before they arrived, having a dedicated nurse to support them while they dialysed to prevent isolation, and re-housing so that they could dialyse at home. The findings of this study were important, it is however recommendable that a larger scale survey be undertaken in future in order to identify how large and busy dialysis would cope with supporting SCD.

The role of the renal nurse in the patient’s emotional burden regarding End of Life

A qualitative study to describe the inner thoughts and feelings relating to death and dying when living with HD approaching End of Life (EOL) was conducted by Axelsson et al ., (2012). In the research, it was asserted that nurses in dialysis cared for patients with several chronic progressive and life-threatening illness. These patients suffer from high symptom burden and rely on medical technology that raises existential issues. It was added that it is important to have knowledge concerning the experiences of severely ill patient in order to improve patient care. The research utilised 8 severely ill HD patients (presence of comorbidities, malnutrition and other complications) of 4 men and 3 women 66-87years living at home alone or with family. Although it may be difficult to know when EOL begins in chronic illness the narratives showed the patients were aware of the approaching death based on signs and inferences rather than communication with health care professionals. There was a feeling of lack of interest, avoidance and attention to other priorities by the health care professionals other than communication about existential issues. Furthermore, the participants felt a lack of understanding of their situation by the health care professionals. Professionals in the dialysis unit should combine technical care with opportunities to talk about death and dying (Axelsson et al 2012).

Conclusion

From the chapter, there were several themes that arose from the literature search. The main ones were the role of the nurse in: the end of life care; palliative care; diet restrictions and adherence to medication; dealing with hyper phosphatemia and Vascular Access care, among others. The next chapter will major on the advancement of these key themes.

CHAPTER FOUR ADVANCEMENTS

Introduction

This chapter has focused on the lessons learnt from the key themes obtained after the literature search and the steps that will be taken towards the advancement of the role of the renal nurse.

Lessons learnt

Historically, nephrology nurses have worked with ever improving technology to provide Renal Replacement Therapy (RRT). This promotes the best possible quality of life for patient with End Stage Kidney Disease (ESKD) an endeavour which has seen these patients live longer with a good quality of life (Selman et al., 2019). However, prolonged dialysis is associated with lifestyle changes as well as multiple stressors which may impact on physical, psychosocial and social functioning of the person (Tsai et al., 2015). Additionally, increasing numbers of patients on dialysis along with the increasing ability of renal technology to keep them alive for longer while on dialysis is likely to see the prevalence of long-term dialysis complications increase (Kantor et al., 2018). This means that the nurse will need to be well equipped with knowledge to deal with the increasing numbers and life-style changes occurring with the patients. Nurses, medical practitioners and other allied health professionals have been given a higher status in societies due to the specialised knowledge and skills they possess in delivering health care, their commitment to serve patients, and keeping in touch with new and emerging evidence about health, illness and ways of helping people to achieve optimal health (Toon, 2015). It is apparent from the reviewed literature that the role of the renal nurse is comprised of many elements. This enables the renal nurses to strengthen the coping resources of the dialysis patients and their improved knowledge of the causes, effects and management of complications. It is also important in supporting the patients to overcome the sometimes daunting and overwhelming difficulties of dialysis. While the nephrology nurse’s technical expertise is well recognised and accepted, the roles of the care giver, educator, advocate, facilitator, and mentor and referral agent are not clearly identified or acknowledged. The evaluation will not only demonstrate their ability to deliver personalised care but will also articulate their role and identify personal and professional developments strategies to advance the role. A change in one aspect may impact on some or all of the other aspects of care as all aspects of the care of a patient are interrelated.

Future advancements in the role of the renal nurse

The first aim is to evaluate the role of the renal nurse in promoting person-centred care. According to the Health Foundation (2014), there are several components of person-centred care. These components are: getting to know the patient as an individual, seeing the patient as the expert about their health care, sharing power and responsibility and taking holistic approach to assessing people’s needs and providing care, including families where appropriate. The medical institutions should also make sure that services are accessible, flexible and easy to navigate. Medical workers have to look at people’s whole experience of care to promote coordination and continuity, making sure that the physical, cultural and psychosocial environments of health services support person-centred care. It is important that the staff of the hospital are supportive, well trained in communication and strive to put people at the centre of their care (Schober & Affara, 2006). Haemodialysis is the routine treatment for ESRF involving the patient to attend the unit for 3 to 5 hours, thrice a week. During this procedure the nurse is the main health care giver in a highly technological environment. The renal nurse prepares the patient for the treatment, commences the treatment and monitors the patients and the equipment. When dialysis is complete, the nurse identifies and manages any intra-dialytic problems (Bennett et al., 2013). Management of intra-dialytic problems entails checking for hypotension, and muscle cramps, maintaining vascular access, preventing infections, administering medications along with general knowledge of renal disease, anaemia, cardiovascular disease and diabetes (Walker et al., 2014). It is possible sometimes when working in such an environment to overlook patient care, not by choice but due to the demands placed by the practice environment. Cooney et al (2013), reported there may be instances where patients may express feelings of despair and concern regarding the diminished quality of life experienced on HD. Shi et al., (2013), also observed that there is the possibility of the nurse becoming ‘enframed’ (enslaved) by the technology of dialysis resulting in the focus of the nursing work shifting away from caring for the patient to operate the machine and the associated technology. Although the latest Patient Renal Experience Survey (PREM 2019) reported good patient experience of care, there is a risk of gravitating towards technology as the renal nurse focuses on the ‘ get them on, get them off, go home’ model of care. The literature reviewed in chapter 3 has demonstrated the commitment that the renal nurse has to adopt in order to promote person centred. The key emerging themes which will be discussed in this chapter in the context of personal and professional development include identification, management and prevention of complications, adherence, self-care, care coordination and guiding decisions.

Complications- Hyper phosphatemia

Shi et al., (2013), identified hyper-phosphatemia defined as high serum phosphorous level >1.78 mmol/l as the first major secondary complication presenting in 40-60% of HD patients. NICE (2013) also agreed that this is a common comorbidity of advanced kidney dysfunction due to insufficient filtering of phosphorous from the blood by the poorly functioning kidney resulting in large amounts of phosphate remaining in the body other than leaving in urine. Left with no management, hyper phosphatemia can directly and indirectly increase Parathyroid Hormone (PTH) secretion which can lead to the development of Secondary Hyperparathyroidism (SHPT). This in turn can increase morbidity and mortality, renal bone disease, bone and muscular pain, high risk of bone fractures, abnormal bone and joint structure, and vascular and soft tissue calcification. For CKD stage 5 adults on dialysis serum phosphate should be maintained at 1.1 and 1.7mmol/l due to improved removal through dialysis (NICE, 2013). The standard management of hyper-phosphatemia should include the use of pharmacological and non-pharmacological interventions, and patient education and support. Shi et al., (2013), identified these as phosphate binding medications, dialysis and low phosphate diet. Although it was argued that the conventional three times a week dialysis and the traditional phosphate binding medications used in the treatment of hyper-phosphatemia may not be effective in controlling phosphorous due to its distribution in the body, high rate of post dialysis rebound and the risk of introducing other complications including hyper-calcaemia, NICE (2013), recommended the approach to prevent complications. Given that phosphorous is widely distributed in food particularly those rich in protein and dialysis patients usually find it difficult to adhere to the phosphorous binding medication regimes. Sandlin et al., (2013), also argued that dialysis can remove a third of the phosphorous from the body while the remaining part can be controlled with phosphate binders and diet restrictions which has implications for the renal nurse to implement the approach. As set out in the NHS constitution for England, patients and health care professionals have rights and responsibilities and NICE guidelines are set to reflect these (NICE, 2013). To be able to manage hyper-phosphatemia effectively it was recommended that one must not only consider the pharmacological and non-pharmacological treatment options but also should review the underlying physiological pathways involved in phosphorous homeostasis (Shi et al., 2013). Phosphorus is the second most abundant element in the body after calcium, it is found in the bones, teeth, body cells and in the vascular space. The role of phosphorus is to signal the cells, synthesis nucleic acid, help in energy metabolism, membrane function, bone mineralisation, and production of blood cells. While the average person consumes about 20mg/kg/day of phosphate in a normal diet, about 13mg/kg/day is absorbed in the gut, 3mg/kg/day is secreted back and the remaining 7mg/kg/day of unabsorbed amount is excreted via the faecal route (Kantor et al., 2018). The kidney plays a major role in excretion of the total net of absorbed phosphorous (13mg/kg/day) through the process of filtration at the glomerulus. Due to the effects of PTH, Vitamin D, phosphatonins like Fibroblast Growth Factor (FGF-23) and in healthy adults the overall intake and excretion is determined by the net balance of ingested and absorbed phosphorous from the food and the amount excreted through bowel and urine. In addition, the plasma concentration is influenced by the rate of bone formation, reabsorption (Gilbert & Weiner, 2013).

The diet in relation to the kidney

The dietary intake of phosphate depends on the consumption of protein rich foods like meat, dairy products, eggs, cereals, whole grains like nuts and beans, as well as phosphorous added to the food like sausages, processed turkey, ham and fizzy drinks. According to Walker et al., (2014), this should be reduced in proportion to the Glomerular filtration Rate (GFR) and should be up to around 600mg/day which they said can be challenging due to incompatibilities with the recommended daily intake of proteins of 1.0-1.2mg/kg/day. In addition to this, the extensive patient education required, complexity of dietary tables and books and the variability of phosphorous contents in foods from the same category can complicate the intervention (Gilbert & Weiner, 2013). However, NICE (2013) recommended patients should be advised to control the intake of phosphorous rich foods particularly those with high phosphorous content per gram of protein as well as those with high levels of phosphorous additives to control serum phosphate while avoiding malnutrition. In dialysis patients, dialysate loss of protein should also be considered, and dietary protein intake maintained at 1.2mg/kg/day (NICE 2013). Although Shi et al., (2013), attributed hyper phosphatemia to patient lack of knowledge of phosphorous, it was recommended that health care professionals with necessary skills and competencies should carry out patient’s dietary assessment and give personalised information and advice on dietary phosphorous management tailored to individual learning needs and preferences. Information of general knowledge of phosphorous, how to maintain phosphorous balance, and giving pictures of high phosphorous foods and drinks to be avoided was studied to be useful (Harwood et al., 2013). By educating patients on how to identify high phosphorus using colourful pictures of high phosphorous foods and telling them to avoid consuming processed foods Kantor et al., (2018), examined that the patients had enhanced knowledge of phosphorous which led to improvement of their serum phosphorous and calcium phosphorous products. Even with increased knowledge diet control alone is insufficient to maintain Phosphorous concentration within the target range and combination with other strategies is required. Dialysis is the cornerstone of homeostatic management of electrolytes in ERF (Schober & Affara, 2006). The Renal Association Clinical guidelines (2019), recommended 4 hours thrice weekly as the standard dialysis schedule to achieve target dialysis adequacy of Kt/V of 1.2 where K stands for the dialyzer clearance, t is for the dialysis time and V is for the volume of urea distribution in the body. The larger the dialysis surface area the better the clearance, the longer the dialysis time the better the clearance and the higher the volume of urea distribution the lower the clearance (Tsai et al., 2015). According to the Renal Association Clinical Guidelines, urea is the most recognised as a surrogate uremic toxin and is the most clinically valid small solute measure of dialysis dose, and dialysis adequacy should be monitored on a monthly basis to detect any complications. A conventional 4 hours dialysis can remove 600-1200mg of phosphorous from the body with rapid reduction being seen in the first 60-90minutes of HD treatment. However, the rate is slowed as the concentration gradient between plasma and dialysate fluid falls after 2-2.5 hours into dialysis and the level does not decline further or may even rise slightly during the second half of the treatment (Gilbert & Weiner, 2013).Significant rebound usually occurs after dialysis with potential for plasma concentration to return to the same pre-dialysis level (Shaman and Kowalski 2014). Modifying the dialyzer surface area, increasing the dialysis time, blood or dialysate flow, physical activity or augmented dialysis schedule could improve the efficiency. Increasing blood flow from 300-500mil/min and dialysate flow up to 800ml/min can increase dialysis phosphate removal by 10% and intra-dialysis exercise can increase this by 9% (Bergjan & Schaepe, 2016).

Intra dialytic exercise is recommended for all patients with no contraindications to enhance patient’s physical functioning improve quality of life while patients augmented dialysis schedule is recommended for patients unable to achieve adequate dialysis target (Selman et al., 2019). High-flux dialysers are highly permeable and should be used for clearance of mid-molecule solutes like phosphorous. Even with combined dietary restriction and dialysis treatment, Shaman & Kowalski (2014), argued that some patients may be unable to control their serum phosphorous and therefore, the patient will require a phosphate binder.

The phosphate binding medication

Phosphate binding medications including calcium acetate and calcium carbonate are used in 95% of dialysis patients to inhibit the absorption of phosphorous in the gut (Shi et al 2013). NICE (2013) recommend these should be given in addition to dietary control if diet alone and dialysis fails to maintain serum phosphorous concentration to the target level. Taken with food, phosphate binders have the ability to bind with phosphate in the gut to facilitate its excretion through the bowel and control the serum level (Shi et al 2013). According to Kuhlmann (2006), the drugs are cheap, well tolerated by the renal patients and have inhibitory effect on Parathyroid Hormone (PTH) secretion which is a risk factor for SHPT. However, large doses amounting up to 13 tablets a day to achieve adequate phosphorous control is required contributing to medication non-adherence (Shi et al., 2013). In addition to this, the phosphate binding medication are associated with severe side effects including hypercalcemia, calcification of vascular tissues, constipation, aluminium or magnesium toxicity, dialysis induced dementia and renal osteodystrophy. Although they are expensive it has been observed that switching to non-calcium- based phosphate binders like sevelamer hydrochloride or lanthanum carbonate if other binders are not tolerated, patient finds them unpalatable, calcium level goes up or PHT level is reduced. Other medications affecting serum phosphorous concentration include calcitriol, alfacalcidol, and cinacalcet. Calcium and PTH levels in HD patients are maintained between 2.2-2.5mmol/l and between 2 and 9 times the upper limit of normal for the assay used respectively (Renal Association 2019). Access to better information is required to support patient’s participation and enable them to make choices in their own health care (Gorham et al., 2018). HD patients are not only treated for complications associated with HD as the hyper phosphatemia condition discussed above but also for those affecting their self-perception (Alkari ET 2018). A complication as depressive symptoms. According to the researchers the preference of the depressive symptoms is 25 to 50% more common in HD patients. It is the common psychological complication presenting in 40% of the patients dialysing within the UK. Compared to the general population, this is 20-30% higher than the 16% in general population and refers to the presence of depressive symptoms like the absence of a positive effect, low mood, and a range of associated emotional, cognitive, physical and behavioural symptom without fulfilling the diagnostic criteria of a depressive disorder (Dobbels et al 2010). The rigors of thrice weekly dialysis schedule, metabolic derangement associated with ERF, presence of multiple comorbidities, the need to adhere to a complex therapeutic regime, psychosocial and vocational impact and reduced physical competence are the main contributing factors to depressive symptoms in HD patients (Tsai et al 2015). A study by Walker et al., (2014), examined that any absence of psychological care in hospitals can sometimes undermine medical and nursing efforts to provide effective treatment, cause patient and family distress and should therefore be a concern for all health care professionals providing a health care service. The effects of depressive symptoms in HD patients as non-compliance with dialysis and medication regimes, alterations of immune systems, poor sleep quality, reduced quality of life, poor nutrition and high rates of hospitalization. To prevent these effects, lessen the burden and improve clinical outcomes, management of depressive symptoms in HD patients is essential (Ellis & Abbott, 2009). NICE (2009) recommends that all interventions for depression should be delivered by competent practitioners like psychologists or psychiatrists and should be based on the relevant manuals. However, Tsai et al (2015) acknowledged that in the general population, pharmacotherapy is usually the mainstay of treatment for depressive symptoms but in HD patients, medication safety is of great concern due to the loss of kidney function. They are noted that non-pharmacological interventions including individual or group Cognitive Behavioural Therapy (CBT) interventions can improve depressive symptoms in HD patients and improve outcomes. Dobbels et al., (2010) argued that the CBT is best administered in outpatient settings requiring regular attendance which may be undermined to attend additional treatment appointments at other facilities. Beyebach et al., (2018), studied that patient’s screening for depressive symptoms through well-known diagnostic interviews including the National Institute of Mental Health Diagnostic Interview Schedule (DIS), the Composite International Diagnostic Interview (CIDI) of World Health Organization and the United States Alcohol; Drug abuse and Mental Health Administration. However, NICE (2009) recommended that this should be reserved for psychologists and psychiatrists with trained interview skills and extensive knowledge of depressive disorders and its appearance in the context of the medical disease. Although the best screening tools for depression in dialysis population is uncertain ,the role of the renal nurse is to screen and refer and the most valuable screening option for nurses are self-report instruments like the Beck Depression Inventory (BDI), the Centre for Epidemiology Studies Depression Scale (CESD) and the Hospital Anxiety and Depression Scale (HADS) (Dobbels et al 2010).

While BDI consists of 21 items each item receiving a score of 0 to 3 to yield a total of 0 to 63 on the presence and severity of depressive symptoms, CESD consists of 20 items each item receiving a score of 0 to 3 to yield a score of 0 to 60 and HADS consists of 14 items, 7 items assessing anxiety and 7 items for depressive symptoms. A score above 14-16mon BDI is suggestive of depressive symptoms and should be referred for screening and intervention by psychologist or psychiatrist, a score of 18 or higher on CESD mandate a referral while a score above 10 on the HADS is suggestive of depression and also should be referred (Dobbels et al 2010). However, Van et al., (2018), argued that apart from being expensive, screening questions are helpful supplements but should never replace talking to patients to make personal, supportive contact. Self- report instruments are only useful if screening will lead to better treatment options.

Physiochologial state of the patient

The aim of psychological care should be to monitor the patient’s psychological state in a systematic manner, to provide or arrange for the preventative interventions to deal with psychological issues (Nichols 2003). It was also added that renal nurses are the ‘psychological eyes and ears’ of the HD patients and their role is to monitor the patient’s psychological state through patient-centred communication and active listening, provide information and education and refer patients for immediate psychological therapy. Although reducing the disease burden and improving the clinical outcomes of the HD patients can be challenging, renal nurses can also help in the management of psychological issues in HD patients. This is done by ensuring there is adequate dialysis done to control factors like anaemia, uraemia, SHPT which are known to affect physical functioning and tolerance, promote aerobic and resistance exercises. This especially applies to patients with relieve depression; arranging social support for the patient, developing tele-nursing programmes, organizing network support groups and providing patient with education and information to encourage active participation in self care and adoption of holistic approach for earlier detection and treatment of depression (Beyeback et al., 2018). It was added that dialysis patients diagnosed with depression should best be managed by a multidisciplinary team and dialysis nurses are part of that team. Although there is evidence to support that a failure to address the psychological and emotional wellbeing of HD patients risks to undermine their physical wellbeing, psychological support services within the UK are patchy and without the recommended Whole Time Equivalent (WTE) clinical psychologist, social workers and renal counselling workforce to support the psychological needs of renal patients (Seekles et al., 2018). Some units are left without this important workforce which has implications for the renal nurse to develop their awareness of depressive symptoms in HD patients through good interpersonal relationship skills, listening skills and assessment of knowledge, monitoring for common side-effects of antidepressants including hypotension, hypokalaemia, hypocalcaemia, sedation, dry mouth and cardiac arrhythmias caused by commonly used antidepressants like fluoxetine, paroxetine, sertraline and amitriptyline (Gorham et al., 2018).

Sexual dysfunction

Sexual dysfunction in HD patients is another complication identified in the literature to impact on the renal nurse’s role (Ek et al 2018). Although this is common throughout all stages of CKD, the prevalence is higher in HD patients with 70% of both men and women experiencing the dysfunction due to disturbances including uraemia, neuropathy, vascular disease and psychosocial components including depression, anxiety and social withdrawal, (Palmer et al., (2017). Although sexual health defined by WHO (2014) as a ‘state of physical, mental and social well-being in relation to sexuality’, should be part of renal care, providers are un aware of the issue, and in most cases it not provided and even where it is provided, little is known about its format and quality (Van et al., 2018). NICE (2018) guidelines on RRT and conservative management recommend that patients should receive balanced, accurate information regarding how treatment may affect them including sexual function, fertility and family planning. Given that the health and social care roles have received attention with current policies supporting increased workforce flexibility through skills escalation and inter-professional working , dialysis nurses caring for patients with CKD need a good understanding of potential problems and complications they are dealing with and help in their management (Ellis 2012). Sexual dysfunction presents with erectile dysfunction, premature ejaculation, reduced libido, and pain in men. In women, this may present with reduced libido and lubrication, difficulties in achieving orgasm and pain during intercourse (Georges et al., 2017). Although it was not clear regarding which professional should be accountable for providing sexual care for HD patients, (Gorham et al., 2018) studied that developing an understanding of other professional roles is important to avoid feelings of threat, enhance confidence in own areas of expertise, optimise patient care and staff resources in an inter professional working environments. In addition, nurses are important contributors to holistic patient care of which sexuality is an important component and their close contact with the patients during regular treatment regime places them in a better position to discuss SD (Ek et al., 2017). Although providing extensive sexual care of dialysis patients can be difficult, health care services within the UK are under significant pressure to provide innovative, effective and timely services to meet the population health needs and current policies are supporting increased workforce flexibility, skills escalation, and inter professional working. Nursing has received the greatest attention with regards to this (King et al., 2015). Advanced level nurses are constantly working to improve the quality of patient’s services through productive relationships with numerous stakeholders to influence the strategic direction of services (Department of Health, 2010). It is important for patients to be referred for more specialised sexual care if SD is found to impose on their well-being and nurses are responsible for the referrals. However, a lack of clear guidelines for referrals, insufficient knowledge, competence and training, cultural diversities among patients and care providers and lack of privacy in treatment facilities may hinder the discussions around this important subject (Ek et al., 2017).

Secondary Hyperparathyroidism (SHPT)

Secondary Hyperparathyroidism (SHPT) is another complication impacting on the role of the renal nurse (Hyder & Sprague, 2020). According to the authors, the complication is closely linked to a reduction in phosphorous clearance as a result of reduced Glomerular Filtration Rate (GFR) which is responsible for hyper-phosphatemia which leads to phosphorous induced Parathyroid Hormone (PTH) secretion which intern stimulates bone reabsorption, raised serum concentrations of calcium and phosphorous (Bishop et al., 2018). They added that hyper-phosphatemia also stimulates the kidney to activate Vitamin-D (Vit-D) to enhance intestinal absorption of calcium and phosphorous hence increasing their serum levels. However, the result of ESKD is reduced level of active Vit-D leading to low serum calcium levels which leads to over stimulation of the PTH to stimulate reabsorption of calcium from the bone to raise serum levels resulting in SHPT (Kalantar-Zader et al., 2020). The Renal Association guidelines for diagnosis, evaluation, prevention and treatment (2018) recommended the use of calcium, phosphate and PTH, non-calcium- based phosphate binders like phosex and renacet, personalised diet restrictions of phosphate, Vit-D, calcimimentic, and parathyroidectomy as the management of SHPT. The nurses in this case were aware of their roles which included: monitoring biochemical markers of calcium, phosphate, and PTH for early diagnosis, assessment of the consequences of SHPT including muscle weakness, pruritus, paraesthesia, and increased risk of bone fractures, deformities, pain calciphylaxis, and ulcerations to prevent complications. The nurses also provided education to patients regarding dietary restrictions of phosphorous and the use of prescribed medications including phosphate binders, Vit D, and calcimimetics to prevent complications. Majority of the nurses believed patients were uncompliant with their prescribed therapies including phosphate binders due to a lack of understanding of the importance of taking the prescribed therapy and the importance of dietary restriction but did not monitor in their everyday practice the side effects of the prescribed therapy as a cause of non-compliance. Further education on pathophysiology and clinical management of SHPT is important to prevent complications (Bishop et al., 2018).

Inter- Dialysis Hypotension (IDH)

Haemodialysis is a medical procedure done to remove retained fluids, electrolytes, and waste products in ERF. The main focus of the procedure is to do it without any complications (Futaro et al., 2017). However, according to the authors, Inter- Dialysis Hypotension (IDH) defined as a decrease in systolic blood pressure by >20mmhg or a decrease in Mean Arterial Pressure (MAP) by 10mmhg from the baseline is a common complication occurring in one out of four patients during dialysis. Although this highly depends on the condition of the patient, including comorbidities such as diabetes and long dialysis vintage, IDH occurs due to removal of large volumes of water, and solutes over a short period of time resulting in reduced plasma refill and reduced venous capacity (Van Der Sande et al., 2018). According to the renal association clinical guidelines (2019) this can be prevented by maintaining UFR at 10ml/kg/hr. Other strategies would include use of an asymptomatic hypotension pathway algorithm to reduce the UF rate on recognition of systolic or MAP drop, reducing dialysate temperature to 36 centigrade, addressing patient’s inter-dialysis fluid gains, accepting staged target weight achievement, arranging additional UF sessions, prompt nursing intervention to restore haemodynamic stability as well as monthly clinical assessment of fluid status, target weight and dietetic assessment (Hajal et al., 2019). Pre-dialysis nursing assessment is therefore an important role of the nurse to prevent IDH and ensure adequate dialysis (Bradshaw et al., 2017). Other short-term intra-dialysis complications include cramps, pyrogenic reactions, undetected blood loss, incorrect dialysate concentration and long-term complications of IDH include cardiac stunning, cardiac arrhythmia, stroke, thrombus formation and sudden death (Van Der Sande et al., 2018). Since patients are coming for dialysis 3-4 times a week, nurses tend to know them very well and are able to monitor them regularly to prevent hypotension and ensure adequate dialysis which according to NICE (2012), it is good for their experience. Having a prescribed fluid restriction measured as Inter-Dialysis Weight Gain (IDWG) which renal clinical guidelines (2019) suggests should not be exceeding 2-2.5kg (calculated as previous post-dialysis weight minus the current weight), the use of pre-dialysis blood pressure measurement is to have a baseline reading and to diagnose hypotension during dialysis which Bradshaw et al., (2015) suggested that it can be diagnosed with a drop of 20mmhg or more systolic blood pressure or a drop of 10mmhg or more on the MAP from the baseline. The pulse is to measure the peripheral resistance which might have an impact on the peripheral resistance and the blood flow. This in turn can affect the blood pressure and adequacy of the dialysis, and a change in patient condition or circumstance is to determine any condition which may cause deviations from the dialysis prescription. A deviations such as a recent surgery would affect the anticoagulation which can result in clotting during dialysis and the dialysis adequacy (Hajal et al., 2019). Dialysis patients are also at risk of malnutrition associated with low protein intake, comorbidities, metabolic and hormonal derangement, increased resting energy expenditure, inadequate dialysis dose, and dialysis -associated catabolism (Bennett et al 2012).

Adherence to medical prescriptions, fluid and diet by the renal patient

Adherence is another theme emerging from the literature to impact on the role of the renal nurse (Cheng et al., 2016), Sandlin et al., (2013), and Beyebach et al., (2018). While Cheng et al., (2016) investigated the effects of systematic nursing instruction on low phosphate diet adherence, Sandlin et al., (2013) investigated the impact of nurse-led education on phosphate binder medication adherence. Beyebach et al., (2018) investigated the impact of solution-focused communication on the fluid adherence in adult haemodialysis patients. Cheng et al., (2016) argued that failure of a patient to comply to low phosphate diet is associated with hyperphosphatemia which is a risk factor for pruritus, renal osteodystrophy, SHPT, calcification of the heart and blood vessels and increased mortality. Sandlin (2013), argued that medications in particular phosphate binders taken with food to bind with phosphate in the gut and facilitate its excretion through the bowel is central to the major strategies used to maintain serum phosphate level. Beyebach et al., (2018) studied that although adequate dietary behaviour is crucial for better prognosis in HD patients, excessive fluid intake in between dialysis sessions can lead to large inter dialytic weight gain which may lead to medical complications and reduced patient survival. Although they all used different methods to educate their participants including education pamphlets and illustrated books for phosphorous contents in the food (Cheng et al., 2016), asking patients to identify their phosphate binding medication by bringing them to dialysis so nurse could observe how they were being taken with or without food (Sandlin et al., 2013) or complimenting patients for achieving their interdialytic weight gain targets and inviting them to share the things they found useful to control fluid intake, the recurring theme was non-adherence to either diet or diet and fluids is a common phenomenon in the HD patients. This has implications for the renal nurse to identify strategies to promote adherence. Although is no gold standard of measurement for adherence to one’s dietary and fluid restriction, compliance in HD patients reflects the extent to which their behaviour is corresponding with the health team’s treatment advise (Barnett et al 2007). Patient empowerment and shared decision making is another theme emerging from the literature. While patients have the ability to make decisions on their own, they should do so with the guidance of a qualified medical work (Sepucha et al., 2017). Nurses are usually the closest medical personnel to patients and therefore have an impact on the kind of decisions that the patient might make. It is advisable for medical workers in the dialysis centre, especially the renal nurses to constantly educate the patient on the renal failure, dialysis and the effects thereof. This will empower the renal patients even in making informed decisions with regards to the CKD (Chaurasia et al., 2018). Patients who are approaching the end of life kidney stage usually face tough times in making a choice between renal replacement therapies (RRTs) and Conservative Kidney Management (CKM). It is very crucial that there is shared decision making. This happens between the medical workers, the renal patient and the family members of the renal patient. The choices available are often discussed in details whilst incorporating the preference of the renal patient (Cassidy et al., 2018). There are some tools that are even used to help on facilitating decision making. An example is the Patient Decision Making Aid (PDA) tool. Though many of these PDAs are still in the development stage, they prove to be useful. This tool in most cases helps the patient in choosing between the RRT and CKM. Some of the decisions made are difficult but yield better outcomes and also improve the patient experience with the aim of alleviating suffering from the patient as much as possible (Davis et al., 2017).

Conclusion

Several complications arising from the management of chronic kidney failure have been outlined in this chapter. There have also been recommendations on how to manage each complication. It is important that the medical workers and also the patients be fully aware of these so as to know how to cope with an arising complication or to prevent it before it occurs.

CHAPTER FIVE CONCLUSION

Introduction

This chapter will give a summary of the important issues that have been the main focus throughout the dissertation. It will also provide a summary of what the author has learnt from the research and identify possible projects to be carried out in the future.

Key themes of the dissertation and the lesson learnt

This research focused on the role of the renal nurse with the objectives of evaluating the extent to which these roles are being fulfilled. It also evaluated the personal growth of the renal nurse in the providence of patient centred care together with the professional advancement of the renal nurse. The main themes that emerged were the role of the renal nurse in the reduction of depression among patients on dialysis, diet restrictions and patient adherence to medication, promoting fluid adherence and guiding decision making with regard to the end of life care. The role of the nurse also future in the management of chronic kidney failure, providing sexual care to patients on dialysis, providing nutritional support for dialysis patients and in the management of secondary hyperparathyroidism in patients. Other aspects such as palliative care, intra-dialytic fluid removal, shared dialysis care and patient’s emotional burden regarding the end of life also involved the renal nurse. The author has learnt a lot of lessons due to the research. Most of these lessons are related to the professional and practise growth of the renal nurse, and other lessons are on the personal growth of the renal nurse. These lessons do not exists exclusively, hence integration of the three aspects of renal nursing is important to ensure that there is growth in all the areas of the life of the renal nurse. Some of the medical lessons learnt are that several complications do arise from conducting dialysis on the patient and several lessons have been outlined. These include complications such as patient Hyper-phosphatemia, Secondary Hyperparathyroidism (SHPT) and Inter- Dialysis Hypotension (IDH). Lessons are about the diet of the patient in relation to the kidney, sexual dysfunction by renal patients, empowering the patient on decision making regarding CKD, psychological state of the patient and diet in relation to the kidney. There was also a lesson on patient interaction with the medication to manage some of the complications that arose from dialysis. In future, it will be of importance to evaluate the working environment of the renal nurse. The day to day interactions with other medical workers and the possible challenges experienced during working hours, including burn out of the renal nurse. It will also be of essence to evaluate the clinical nurse specialist: their roles, jurisdictions and possible career advancements. This will add on to the existing knowledge and also help future researchers while they conduct their work.

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