Incorporating the Patient-Centered Model in Dialysis Nursing

Patient-centered care focuses on the individual patient’s preferences, goals and perceptions on their health and quality of life. It incorporates informed consent and autonomy which is vital when practicing as a nurse, and as a specialized dialysis nurse (Grubbs et al., 2014). Specialization can be acquired through a regulatory body such as the Canadian Nurses Association (CNA) to focus on a specific nursing field and gain unique skills apart from the standard nursing education. Currently, nephrology nursing is one of the 22 nursing specialities recognized by the CNA (CNA, 2019). The science of nephrology encompasses the study and treatment of kidneys and the related health problems. Some of these kidney-related problems can include: kidney stones, urinary tract obstructions, renal cysts, polycystic kidney disease, forms of acute kidney failure and chronic kidney disease. A nephrology nurse would encounter patients with any of these conditions, whereas a dialysis nurse would typically be caring for patients with chronic kidney disease (Every Nurse Inc, 2019). Unfortunately, since there is no cure for end-stage chronic kidney disease, management of the accompanying symptoms and replacing the filtration efforts that functioning kidneys would offer is the priority in dialysis nursing.

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The role of a dialysis nurse incorporates the three levels of prevention on a regular basis (Every Nurse Inc, 2019). The primary level of prevention includes patient education and awareness so that the patient and family/support system can possess the tools and understanding to prevent the onset of a disease or injury (World Health Organisation, 1986). This encompasses health promotion provided to diabetic and hypertensive patients as these are the two leading causes of chronic kidney disease. The secondary level of prevention includes screening measures to prevent or reduce the progression of disease. In the domain of dialysis nursing, this would involve assessing the current kidney function of patients with early-onset kidney disease. Finally, tertiary prevention includes treatments in patients with end-stage chronic kidney disease. This can include administering medications and assisting with the set up, explanation and execution of hemodialysis and/or peritoneal dialysis. In brief, hemodialysis treatments happen outside of the body through a cycler that filters the patient’s blood before returning it into the body and the treatments take place in-clinic. Peritoneal dialysis happens through the peritoneum (a membrane in the patient’s abdominal cavity) by introducing a filtrate solution that will filter the patient’s blood. These treatments can happen at-home while the patient sleeps (Bednar & Latham, 2014). This state of intervention will also include general education about the condition, results of diagnostic tests, management of symptoms, treatment options and health lifestyle habits. A critical factor that differentiates dialysis nursing from other specialities are the expected health outcomes following onset of kidney disease (World Health Organisation, 1986). Clients seeking dialysis usually bring a host of associated conditions such as diabetes and hypertension. Therefore, dialysis nurses must continuously “humanize the process for people with complex care needs” by advocating for their patient’s wellbeing, encouraging consistent self-management behaviours and fostering an environment for family and community members to participate and support each other (Bednar & Latham, 2014). Overall, preventative interventions initiated by dialysis nurses help patients with chronic kidney disease by equipping them and their support network with the tools to manage symptoms and choose a course of treatment that ultimately places them at the centre of the care process.

Specialization allows dialysis nurses to provide a higher degree of service to patients (Canadian Nurses Association, 2007). Another facet is that specialized nurses need to continuously research new protocols and standards to ensure that they can offer the best evidence-based practice to their patients. Since the conception of the first successful dialysis treatment in 1945 by Willem Kloff, dialysis treatment has seen many changes in favour of patient health outcomes (Bednar & Latham, 2014). These interventions include the use of chronic vascular shunts, to reduce the risk of repeatedly reinserting temporary shunts throughout the course treatment. Sterile solutions and single-use polyvinyl bags were also introduced instead of reusable glass bottles for infection control. Lastly, the creation of automated peritoneal dialysis cyclers to encourages autonomy through a user-friendly experience and individualised treatment for peritoneal dialysis which is often done from the patient’s home, reduces the time spent in-clinic (Bednar & Latham, 2014).

Since end-stage renal disease can affect anyone, a dialysis nurse will encounter patients from a multitude of demographics (Every Nurse Inc, 2019). However, most patients needing dialysis are elderly and may require additional support from their family members and healthcare providers to assist in their disease care (Chen et al., 2018). Therefore, the concept of patient extends to their family and support system members who will also be carrying the burden of this chronic disease with the patient. In addition, elderly patients who are living alone with little to no social support and in early stages of chronic renal disease experience the most difficulty with adopting a consistent regimen of self-management behaviours and as a result, benefit the most from interventions that develop their social support network (Chen et al., 2018). End-stage chronic renal disease requires frequent dialysis treatments to compensate for the inadequate kidney function. Patients may opt to receive in-clinic hemodialysis treatments upwards of three times a week or at-home peritoneal dialysis treatments depending on their specific circumstance (Every Nurse Inc, 2019). The time demands of hemodialysis treatments can deter the patient from participating in community activities, but it also provides the setting for dialysis nurses to have a positive social impact on the patients through a therapeutic relationship, especially with at-risk patients. Nurses can be their first point of contact and can therefore have a vital role over the course of their treatments by providing some social support that may be lacking in other aspects of their lives. It is also important to consider the patient’s preferences, as it is ultimately up to the patient to accept the time demanding treatments (Chen et al., 2018). They may equally choose to reduce them, for example, in favour of their social well-being. Adherence to self-management behaviours initiated by the patient is increased through the advice of the dialysis nurse and encouragement from social groups, are also a determinant in disease control, quality of life and the patient’s perceived health state (Chen et al., 2018). Therefore, incorporating the patient at the centre of their care framework. This is where dialysis nurses need to view the patient as a multi-faceted individual and respect the patient’s conditions.

Promoting health is at the core of the dialysis nurse’s practice. Some definitions of health, such as the absence of disease, are detrimental to a patient experiencing a chronic disease or injury’s self perception as it can produce feelings of hopelessness. The concept of health needs to be carefully defined beforehand within the nursing metaparadigm to ensure the nurse’s duties are in line with a patient-centered model for health promotion. If health is defined as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948) then this fits well. Since end-stage renal disease can not be cured, an individualised care plan, medication, lifestyle changes can manage their symptoms thus allowing the patient to experience a more complete state of health and improved perception on quality of life. There is a positive correlation between registered nurse practices and a client’s clinical, functional, safety and perceptual outcomes (WHO, 1986). Health promotion reduces the health resource inequities when nurses work towards enabling and supporting patients in achieving their fullest health potential through fostering a supportive environment, providing access to pertinent information about their condition, assisting them in acquiring necessary life skills and giving opportunities for their patients to make health choices themselves (WHO, 1986).

Diabetes is the leading cause of chronic kidney disease as it leads to the progression of the disease (Betônico, Titan, Correa-Giannella, Nery, & Queiroz, 2016). Between 20-30% of patients with type 2 diabetes mellitus will also experience kidney impairment, loss of 50% or more of the normal renal filtration (Betônico et al., 2016). Hyperglycemia, increased blood sugar levels, can cause destruction of the delicate nephron structures within the kidney – leading to the progression of the renal disease towards end-stage. The same self-management behaviours that are recommended for the diabetic patient will need to be encouraged while a dialysis nurse interacts with the patient as this condition exacerbates the progression of chronic kidney disease (Bednar & Latham, 2014). With the initial medical diagnosis and choice to pursue dialysis treatments, it is important for the dialysis nurse to minimize the patient’s stress and discomfort by this recent diagnosis. This highlights the importance of the supportive nurse-patient therapeutic relationship. While individualizing the patient’s therapy, the nurse may also consider the presence of other conditions (like chronic hypertension), motivation to self-manage their disease, kidney disease state, time since diabetes onset and previous abilities at controlling their glycemic levels. Along with the social, emotional and mental stresses; it is important to also consider the physiological factors.

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In conclusion, the dialysis nurse’s role is vital in beginning a patient’s journey of self-management and social support, that is necessary in assisting patients with chronic illnesses. As there is no cure for end-stage kidney disease, it is important that patients are treated in a way to maximizes their optimal health status in a way that they personally see as most optimal. The patient-centered care approach requires health care providers like the dialysis nurse to prioritize their patients’ preferences and concerns throughout treatment.

References

• Bednar, B., & Latham, C. (2014). The changing landscape of the nephrology nursing care environment in the United States over the last 45 years. Nephrology Nursing Journal, 41(2), 183-190, 199.
• Betônico, C. C. R., Titan, S. M. O., Correa-Giannella, M. L. C., Nery, M., & Queiroz, M. (2016). Management of diabetes mellitus in individuals with chronic kidney disease: Therapeutic perspectives and glycemic control. Clinics, 71(1), 47–53. https://doi.org/10.6061/clinics/2016(01)08
• Canadian Nurses Association. (2019). Certification Nursing Practice Specialties. Retrieved November 2, 2019, from https://www.cna-aiic.ca/en/certification/get-certified/certification-nursing-practice-specialties.
• Canadian Nurses Association. (2007). Framework for the practice of registered nurses in Canada. In Canadian Nurses Association. Retrieved from http://www.cna-aiic.ca/en/becoming-an-rn/the-practice-of-nursing
• Chen, Y. C., Chang, L. C., Liu, C. Y., Ho, Y. F., Weng, S. C., & Tsai, T. I. (2018). The Roles of Social Support and Health Literacy in Self-Management Among Patients With Chronic Kidney Disease. Journal of Nursing Scholarship, 50(3), 265–275. https://doi.org/10.1111/jnu.12377
• Every Nurse Inc. (2019, May 17). Nephrology Nurse: Requirements: Salary: Jobs. Retrieved November 2, 2019, from https://everynurse.org/careers/nephrology-nurse/.
• Gargiulo, R., Suhail, F., & Lerma, E. V. (2015). Disease-a-Month Hypertension and chronic kidney disease. Disease-a-Month, 61(9), 387–395.
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• Grubbs, V., Moss, A. H., Cohen, L. M., Fischer, M. J., Germain, M. J., Vanita Jassal, S., … Wong, L. (2014). A palliative approach to dialysis care: A patient-centered transition to the end of life. Clinical Journal of the American Society of Nephrology, 9(12), 2203–2209. https://doi.org/10.2215/CJN.00650114
• World Health Organization. (1948, April). Definition of Health: Preamble to the Constitution of WHO. International Health Conference, New York, 19 June - 22 July 1946 ; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948
• World Health Organisation. (1986). Ottawa Charter for Health Promotion: First International Conference on Health Promotion Ottawa, 21 November 1986.  Retrieved from https://www.healthpromotion.org.au/images/ottawa_charter_hp.pdf