Dialysis, the process of cleansing the blood of accumulated waste products, is a complex treatment requiring a team of highly trained individuals with a variety of skills. For this chronic treatment to be successful, the interdisciplinary team must work with the patient and family, supporting them in the areas of clinical need, psychosocial needs, and religious beliefs. Team members will include, but not be limited to, the physician, nurse, technician, dietitian, social worker, and administrator. Other team members might include a biomedical technician, psychologist, dentist, child development specialist, pharmacist, physician’s assistant, vocational rehabilitation counselor, member of the clergy, nurse practitioner, and clinical nurse specialist, or others who have special skills needed to help the patient reach maximum potential. The patient and family members are integral components of the dialysis team; without them, all efforts of the other team members would be fruitless.
Structure of the dialysis facility
Every dialysis facility has a medical director who is ultimately responsible for medical care in the facility. He must have completed a board-approved training program in nephrology and have at least 12 months of experience in nephrology. The medical director also must be certified in internal medicine or pediatrics. The medical director is required to be knowledgeable of and responsible for the integrity of the water treatment system in the facility. He must ensure that the system will produce water that meets the standards of the Association for the Advancement of Medical Instrumentation (AAMI). The medical director is also responsible for the Quality Assessment and Performance Improvement (QAPI) program. Each dialysis facility has written policies and procedures that guide staff members in the clinical practice and patient care and that monitor established standards of care, quality assurance, equipment and maintenance standards, reuse, and any pertinent medication or treatment protocols. These policies are written by the team and approved by the facility and nursing administrator, as required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for a special care unit. Freestanding facilities do not fall under the aegis of JCAHO. However, their policies and procedures must be approved by the facility’s governing body, which includes the medical director, director of nursing, and administrator, and be in accordance with the laws of that state and the rules of the Centers for Medicare & Medicaid Services (CMS). Whenever a patient in acute renal failure or a severely uremic patient is dialyzed in the hospital setting, a physician should be readily available to handle crises or complications of the treatment.
Role of the physician
The nephrologist assesses the patient and determines when chronic kidney disease (CKD) has advanced and requires the initiation of dialysis treatment. A nephrologist is an internist with further specialty training of two to three years in the field of nephrology. Evidence points increasingly to the importance of having patients seen and followed by a nephrologist early in the course of CKD, and long before progression to the time when maintenance dialysis is required. With early nephrological intervention, appropriate medical therapy can be instituted, perhaps improving or at least maintaining renal function and slowing the need for dialysis.
When the need for dialysis is determined, the nephrologist is responsible for writing the orders for the dialysis prescription—those components of the procedure that make it therapeutic. These include the specific dialyzer, blood and dialysate flow rates, the anticoagulation requirements, the duration or length of time of dialysis, the frequency, and whatever unique instructions may be required for the specific vascular access.
Role of the nurse
What are the functions of the dialysis nurse?
Although nurses are responsible for the direct care of patients undergoing dialysis, technical staff performs much of this care under the nurse’s supervision. The CMS requires that a registered nurse who is responsible for nursing care must always be present in the unit when in-center dialysis patients are being treated. The registered nurse must meet all practice requirements in the state in which she is employed to be able to provide care in the dialysis facility. Patient and family education and ongoing reinforcement and support for self-care are more critical services provided by the nurse. In addition, the nurse is responsible for ongoing assessment of the patient and is generally the one who initiates multidisciplinary care conferences when the patient’s physical, emotional, or social condition indicates the need.
Nursing administration or nursing service organizations may differ among dialysis units. In those facilities using a primary nursing model, each patient has a specifically designated primary nurse who is responsible for overall patient care. However, case management is also appropriate for the care of dialysis patients. This model expands the nursing care and responsibility beyond the dialysis unit to the hospital, ambulatory care or outpatient facilities, and home. Case management ensures continuity of care from both a quality of care and an economic perspective. Whichever model is used, the goal of nursing is to serve as an advocate for those patients who require assistance and to empower them to become their own advocates.
With increasing emphasis being placed on continuous quality improvement (CQI) as one means to ensure delivery of quality care to patients, nurses are taking the lead in this activity. Nurses are also seen in the roles of business manager, research coordinator, fiscal administrator, and chief technician in some settings.
What experience and background are essential for a nurse to be successful in dialysis?
Whereas some facilities may have different requirements for the nurses filling various positions within a dialysis facility, there are minimal qualifications required by all facilities. A dialysis nurse should be a professional nurse with a nursing license in the state of employment, and certification within a specialty, such as nephrology, critical care, and so on, is preferred. A background in critical care nursing or emergency department nursing is particularly useful and, for the nurse who functions in a managerial role, experience with personnel development, leadership roles, and other supervisory positions can be helpful in ensuring success in the position in a dialysis unit. Most facilities have a formal training program for newly hired registered nurses. Less experienced nurses who assume a role as a beginning practitioner need an environment that offers extensive orientation, education, close supervision, and support. The CMS Conditions for Coverage (CfCs) for End-Stage Renal Disease (ESRD) Facilities released April 15, 2008, now require at least 12 months of nursing experience, including 3 months of dialysis experience, as minimum qualifications to act as a facility charge nurse.
What other qualities should the dialysis nurse possess?
Other important qualifications include the ability to interact effectively with patients and personnel as well as a demonstrated interest and skill in both patient teaching and problem solving. Self-confidence and patience also are important in a dialysis nurse. Caring for dialysis patients and their families can be highly stressful because of the intensity of care required, the nature of CKD, and the patients’ struggles with independence versus dependence. Dialysis nurses should be exemplars of the blend of the art and science of nursing. A significant scientific knowledge base and technical skill must be complemented by a caring, compassionate sensitivity; personal resiliency; and an ability to cope with stress. All are useful characteristics in a dialysis nurse.
Furthermore, some interest in teaching and an ability to teach are essential attributes. The dialysis nurse is frequently called upon to provide learning experiences for patients, family members, other dialysis personnel, diverse healthcare professionals, and the public. The dialysis nurse must have supervisory skills to make appropriate assignments to technicians and other personnel and to evaluate accurately the care provided by them.
What is the role of the advanced practice nurse in dialysis?
The use of advanced practice nurses (APNs) in the acute and chronic dialysis settings has become more common as the patient population continues to increase. Nurse practitioners and clinical nurse specialists specializing in renal care now work in a diversity of healthcare settings covering all nephrology specialties. APNs can manage the care of CKD patients at all stages. Some APNs function in the role of clinician, educator, consultant, administrator, or researcher. Current trends suggest an increase in the number of kidney disease patients and a decrease in the number of nephrologists available to provide their care. APNs can work collaboratively with the healthcare team to ensure that all kidney disease patients receieve quality care.
Are there established standards of practice for dialysis nurses?
Regulations governing the administration of the ESRD program under CMS describe a number of standards and criteria related to qualifications of professional staff, acceptable patient care policies and procedures, and unit administration. However, CMS does not issue standards of practice for dialysis nurses.
Professional nursing organizations promote high standards of nephrology nursing practice. In 1987 the Nephrology Nursing Certification Commission (NNCC) was established to develop, implement, and coordinate all aspects of certification for nephrology nurses in the United States; in 1988 the American Nephrology Nurses Association (ANNA) published its first Standards of Care. A nephrology nurse who meets the qualifications and passes the NNCC’s written examination is entitled to use the initials CNN (certified nephrology nurse) as a professional credential. Other certification options include the certified hemodialysis nurse (CHN) or certified peritoneal dialysis nurse (CPDN), available to both registered nurses and licensed practical nurses from the Board of Nephrology Examiners Nursing and Technology (BONENT). The certified dialysis nurse (CDN) is a credential available to registered nurses without a baccalaureate degree from the NNCC. The NNCC also offers the CNN-NP (Certified Nephrology Nurse – Nurse Practitioner) exam to those who are nationally certified as a nurse practitioner and possess a minimum of a master’s degree in nursing.
ANNA published the Scope and Standards of Advanced Practice in Nephrology Nursing. These standards describe competent APN care in nephrology and present competent behaviors of the role.
Since 1977, the Kidney Disease Outcomes Quality Initiative (KDOQI), put forth by the National Kidney Foundation (NKF), has offered clinical practice guidelines for all stages of CKD in the areas of anemia management, hemodialysis adequacy, peritoneal dialysis adequacy, and vascular access for dialysis care. It also offers an additional eight guidelines for CKD in the areas of diabetes, anemia, bone metabolism and nutrition in adults and children, hypertension, dyslipidemia, and classification of CKD. The intended goal of these outcomes is to improve the quality of care and outcomes for all persons with kidney disease and to help reduce the risk of developing kidney disease. These are practice guidelines only and are not intended to be requirements or to be specific to nursing practice; rather, they are guidelines for the general care of the CKD patient in any stage of the disease process (see p. 365 for additional information on NKF KDOQI).
What education is available for nurses interested in dialysis?
Most dialysis units provide specialized learning opportunities for nurses as supervised on-the-job instruction during the period of orientation. Some units offer formal educational programs for dialysis personnel other than their own employees. These more formal programs include both theory and clinical practice. The curriculum should include instruction in the following areas: renal anatomy and physiology, including pathophysiology; fluid, electrolyte, and acid-base balance; dialysis theory; vascular access; dialysis procedures and techniques; recognition of complications and emergency conditions, and appropriate prevention and intervention; psychosocial problems; dietary regimens; medications; and interpersonal relations, including effective intervention in patients with chronic illness.
Some community colleges offer dialysis training programs that teach the theoretic basics of dialysis, with clinical practicums provided by the dialysis facility supporting the student. With the push for professional nurses to have a minimum of a baccalaureate degree in nursing at the entry level, interest is growing in formalizing a nephrology nursing curriculum at the graduate level. Vanderbilt University (Nashville) offers a nephrology nursing specialty arm in its Adult Acute Care Nurse Practitioner program. Other schools of nursing are also addressing nephrology nursing as a specialty area in the graduate program.
Continuing education programs for dialysis nurses are available through a variety of educational and professional organizations. These include the Council of Nephrology Nurses and Technicians of the NKF, ANNA, and local chapters of these organizations. In addition, the American Association of Critical-Care Nurses, Association for Professionals in Infection Control, and other such organizations offer some programs of interest to nephrology nurses.
What is the role of the dialysis nurse manager?
The nursing leader responsible for patient care coordination may assume several titles depending on the facility’s structure. Whether as the nursing administrator, director of nurses, clinical manager, charge nurse, or nursing coordinator, this nurse will have the primary responsibility for direct patient care. Supporting a professional practice model will ensure that patients receive optimal care. The nurse manager must be a full-time employee of the facility, meet the particular state practice requirements, and have at least 12 months of experience in clinical nursing and an additional 6 months of providing care to dialysis patients.
Modeling knowledgeable, skillful care of patients is a vital aspect of the role of the nurse manager, along with recruitment and retention of an adequate number of well-prepared patient caregivers—both nurses and technicians. It is also the responsibility of the nurse manager to equip personnel with knowledge through learning opportunities and to provide resources in the form of supplies and time, enabling staff to give the desired quality of patient care. The nurse manager ensures high quality of care within a cost-effective environment while promoting patient and staff safety.
Role of the dialysis unit administrator
A dialysis unit administrator is responsible for ensuring the fiscal soundness of the dialysis facility. The administrator may make purchasing decisions, and it is desirable that these be made with an understanding of the clinical implications of such decisions. A unit administrator usually comes prepared with either a clinical or a fiscal background. Occasionally an administrator with a clinical background will also acquire a Master of Business Administration (MBA) or other fiscal or business educational preparation. This individual is thus prepared with both the clinical expertise to make decisions in the best interest of patients and the business expertise to make decisions based on what is best for the facility.
Role of the technician
The role of the dialysis technician varies from state to state because of differences in practice regulations and mandates by different regulatory agencies. Some duties that may be permitted in some states but not in others include the intravenous administration of heparin, cannulation of the vascular access, and providing treatment to a patient with a central venous catheter. It is always necessary to check the laws and rules of the state in which the technician is practicing because variations do exist. Technicians have been integral members of the dialysis healthcare team since dialysis programs began. Two major roles exist for technicians: one role is directed at assembly and maintenance of the equipment, and the other role focuses on patient care. In some settings, technicians combine patient and equipment care responsibilities. The timely and accurate assembly of dialysis equipment is vital to any dialysis program. Ongoing maintenance of costly equipment is a highly valued element of a dialysis program. Technicians work with all members of the dialysis team; in most settings they are most closely aligned with nurses. Patient care activities are delegated and supervised by professional nurses.
What abilities are required of the dialysis technicians?
Knowledge of mechanics and technological skill are essential for technicians who assume responsibility for equipment setup and maintenance. An understanding of the principles of physics and computer technology is desirable for technicians. Interpersonal skills are necessary for good relations with patients and their families. Patient care technicians must have some understanding of human anatomy and physiology and the pathophysiology of CKD. The dialysis technician must have a full understanding of the theories and principles of dialysis, treatment complications, and care of the vascular access. Math skills are essential to calculate weight gain and loss, fluid removal requirements, and medication administration. For patient safety, a technician also must possess patient monitoring skills and clinical judgment.
Are there established standards of practice for technicians?
Dialysis technicians are bound by the standards of practice issued by the state in which they practice, if the state has practice guidelines. The ESRD Rules & Regulations approved by the CMS CfCs 2008 imposed education requirements for patient care technicians. Patient care technicians, as of the final rule, must be certified under a recognized state or national certification program within 18 months of hire and meet all state requirements. They must also possess a high school diploma or equivalency and complete a training program approved by the medical director and governing body of their facility. Different levels of regulation continue to exist by state and include licensure, registration, and certification. Currently, three organizations offer national technician certification exams. Some states require a certain exam, so it is best to become familiar with the certification requirements mandated by specific states. Several credentialing programs are available to dialysis technicians (Table 1-1).
Table 1-1 Credentialing Programs for Dialysis Technicians
What educational opportunities are available to dialysis technicians?
Dialysis programs offer on-the-job training for newly hired and inexperienced technicians. Some states mandate the minimum number of hours the dialysis technician must complete in both the clinic and the classroom in order to practice. Certificate programs for dialysis technicians are available through some community colleges, and continuing education programs are conducted by healthcare agencies, specialty organizations, and technical colleges.
The National Association of Nephrology Technicians/Technologists (NANT) offers many educational programs both locally and nationally. In addition, large nephrology meetings may provide advanced learning opportunities for the technician who is seeking an expansion of responsibilities or who is functioning in an expanded role. These include, but are not limited to, the Annual Dialysis Conference, NKF Clinical Meetings, the American Society of Nephrology meeting, the ANNA symposium, and the meetings sponsored by the AAMI.
Role of the renal dietitian
A renal dietitian serves in a consultative role to patients and their families as well as to other members of the dialysis team. The renal dietitian must be state registered and have one year of professional experience in clinical nutrition as a registered dietitian. Dietitians provide an indispensable function in supporting the patient through all phases of CKD. Dietary management is instrumental in delaying the need for dialysis. Furthermore, even after dialysis is initiated, the renal dietitian contributes through ongoing assessment of the nutritional status of the patient and education of the patient and family. See Chapter 14 for a more detailed description of the role of nutrition and the renal dietitian in the care of the person with CKD.
Role of the social worker
What are the main goals of the nephrology social worker?
CKD patients experience multiple losses and require significant psychosocial intervention at various stages throughout their illness trajectory. Two major activities have been described by the Council of Nephrology Social Workers:
• To develop awareness of the psychosocial aspects of chronic renal disease
• To develop and carry out methods for dealing with these problems and needs as key to the role of the nephrology social worker
How does the social worker achieve these two goals in a treatment center?
The social worker assists the patient and family in their adjustment to the illness. This involves a psychosocial assessment, provision of emotional support, and educational reinforcement. A thorough working knowledge of all available resources is essential. The social worker participates with other treatment team members in short- and long-term planning with the patient and family. Evaluation of the patient’s social background is important in successful development of the treatment plan. The social worker apprises other team members of special facets of patient or family behavior, history, and functioning that may influence the individual patient’s care and course of treatment.
What are the necessary qualifications of the nephrology social worker?
A qualified social worker is defined by ESRD regulations as a person who is licensed, if applicable, by the state in which practicing and who meets at least one of the following conditions:
1. Has completed a course of study with specialization in clinical practice and holds a master’s degree from a graduate school of social work accredited by the Council on Social Work Education
2. Has served for at least two years as a social worker, one year of which was in a dialysis unit or transplant program before September 1, 1976, and has established a consultative relationship with a social worker who qualifies under item 1
Continuing education programs are available through the Council of Nephrology Social Workers.
Should psychiatric resources be available to the patient?
An awareness of one’s own mortality and a life restricted by dependence on a machine are just two of the issues that confront the dialysis patient. The social worker assists patients and families in adapting to illness-imposed lifestyle changes, such as alterations in family and societal roles. Psychiatric consultation or team conferences with psychiatric staff are an important resource for the social worker and dialysis team for several reasons.
First, most dialysis patients are subjected to situational stress. Despite this fact, psychiatric intervention may be perceived by the patient as an unnecessary and unwelcome intrusion. The social worker assists patients in resolving problems and in dealing with crises but should have psychiatric resources available for consultation or referral when needed.
Second, some patients become increasingly dependent or noncompliant during periods of their illness. During such times, the social worker should work with the patient, family, and other team members to help understand the behavior. Ultimately, the patient is responsible for much of his or her own management, and this should be emphasized by the social worker.
Finally, because sexual dysfunction can be a problem for patients undergoing maintenance dialysis, the social worker may be the team member whom the patient and/or family approaches for counseling.
Ethics, rights, and responsibilities
For the CKD patient and family, life with maintenance dialysis requires major changes in activity and lifestyle. These disruptions are sometimes unpleasant as well as unanticipated. Frequently the dialysis unit and involved personnel are perceived by the patient as a cause of his or her unsatisfactory situation. Frustration and conflict are prone to develop and must be resolved.
Is written consent necessary before starting dialysis?
Informed written consent for any invasive procedure, including dialysis, is always required. For emergency dialysis, if the patient is too ill to provide written consent, the next of kin or another person who has durable power of attorney may sign the consent for treatment.
It is important that staff members, as well as patients and families, understand the importance of informed consent, because patients and families often have misconceptions or unrealistic ideas about dialysis and what procedures may be involved. The exact format of the consent form is determined by the unit’s or institution’s legal adviser. It should clearly document that an adequate discussion and explanation of benefits, complications, risks, and alternatives are provided and understood by the patient. Separate consent is necessary for access procedures or modification. Update of the dialysis consent form is necessary if there is a significant change in procedure that might affect the patient, such as dialyzer reuse.
What are some of the rights of the patient?
• To be fully informed about his or her illness
• To be informed as to the nature of the treatment and the usual risks
• To be fully informed about alternative methods of treatment
• To expect that treatment will be tailored to individual health needs
• To know that personal privacy will be respected and professional confidentiality will be maintained
• To have input into the treatment regimen
May a patient voluntarily decide to discontinue dialysis?
Many professionals, but not all, believe that a rational adult who, for reasons that are valid to him or her, elects to stop treatment with full understanding of the consequences should have that right. The ethical and legal issues are complex; not all nephrology workers agree, and in some instances courts have ordered dialysis to be continued.
What are some responsibilities of personnel to patients?
• To make the patient as fully informed as possible, as long as it is consistent with high-quality care
• To ensure that all safeguards are met fully and to provide high-quality dialysis service
• To be supportive of patient and family in their adjustment to the illness, its treatment, and the accompanying changes in their lives. This involves teaching them about the disease and its treatment so that they can make informed decisions and set realistic goals.
What are some patient responsibilities?
• To understand and to follow the instructions of the physicians, nurses, and other personnel providing care
• To strive for a high degree of independence through learning and to assume responsibility for self-care as far as possible
• To respect the rights and privacy of other patients
What are some additional personnel responsibilities?
• One person, usually a nurse, must be in charge. Problems should be taken to this individual to prevent misconceptions or ambiguity.
• All personnel must carry out assigned responsibilities to the best of individual ability, provide the best possible patient care, and contribute to the overall smooth operation of the unit.
• All personnel should strive for a pleasant environment that allows for interaction among patients, personnel, and visitors while maintaining an appropriate level of efficiency and professionalism.