Do we practice what we preach? Dialysis modality choice among healthcare workers in the United Kingdom.

BACKGROUND: In the United Kingdom, over 80% of end-stage kidney disease patients receive in-center hemodialysis. We conducted a survey of UK renal healthcare workers on their preferred dialysis modality if they needed dialysis themselves. METHODS: An anonymized online survey was disseminated to all renal healthcare workers in the United Kingdom. We asked "Assume you are an otherwise well 40-year-old (and, separately, 75-year-old) person approaching end stage kidney disease, you have no living kidney donor options at present. There are no contraindications to any dialysis options. Which dialysis therapy would you choose?" We also asked about factors influencing their choice. RESULTS: 858 individuals with a median age of 44.3 years responded. 70.2% were female, 37.4% doctors, and 31.1% were senior nurses. There was a preference for peritoneal dialysis over in-center hemodialysis (50.47% v. 6.18%; p < 0.001 for 40-year-old and 49.18% v. 17.83%; p < 0.001 for 75-year-old assumption) and home hemodialysis (50.47% v. 39.28%; p < 0.001 for 40-year-old and 49.18% v. 18.41% for 75-year-old assumption). There was a preference for home hemodialysis over in-center hemodialysis for 40-year-old (39.28% v. 6.18%; p < 0.001) but not for 75-year-old. On logistic regression, senior doctors were more likely to opt for PD when compared to nurses. Nurses, allied healthcare professionals, and those of Asian/British Asian ethnicity were more likely to choose in-center hemodialysis. CONCLUSIONS: Most healthcare workers in renal medicine would choose home-based treatment for themselves although the majority of end-stage kidney disease patients receive in-center hemodialysis in the United Kingdom; the reasons for the discrepancy need to be explored.

Parent Perceptions of an Early Childhood System's Community Efforts: A Qualitative Analysis.

Understanding how parents, and other primary caregivers, perceive and experience early childhood programs and services is essential for identifying family-centered facilitators and barriers to service utilization. Therefore, this paper aims to explore parent knowledge of and experiences with community efforts of an early childhood system in Illinois: the All Our Kids Early Childhood Networks (AOK Networks). Our research team conducted focus group interviews with 20 parents across four Illinois counties. A semi-structured interview guide was used to examine parent perceptions of an early childhood system's community efforts in promoting the health and well-being of children aged from birth to five. Thematic network analysis was used to analyze all focus group data. Parents indicated three salient themes, including: (1) comprehensive information sharing practices, (2) diverse service engagement, and (3) barriers to service access. Overall, parents reported general satisfaction with the quality of available services and provided feedback regarding identified areas of need to increase the accessibility and utilization of local services. Engaging parents as partners is essential to the effective implementation of family-centered early childhood services. Families are the experts of their lived experiences, and incorporating their voices in program development and evaluation efforts works to increase positive child and family outcomes.

Being and becoming a nurse: Toward an ontological and reflexive turn in first-year nursing education.

In this paper, we call for an ontological and reflexive turn in first-year nursing education. An ontological turn focuses on formation, the 'being' and 'becoming' of a nurse, and emphasizes the value of nursing knowledge. First-year nursing students often possess romanticized ideals about being a nurse that devalues the knowledge and expertise of nurses. We posit a thoughtful ontological orientation within nursing education that shifts the emphasis toward becoming skillful nurses, with expertise grounded in nursing perspectives. A focus on formation includes discussions regarding ideologies, dominant perspectives, and reflexive explorations of students' views of nursing juxtaposed with the realities of nursing practice. We propose ontologic reflexivity as an approach to consider what perspectives are prioritized (or not) within the nursing classroom. Within pedagogical dialogic spaces, ontologic reflexivity calls on educators to create opportunities for students to learn the value of nursing knowledge along with other forms of knowledge. We consider ways in which an ontological and reflexive turn within the first year of nursing education may contribute to the formation of nursing students who value nursing knowledge, are open-minded to various forms of knowledge, and possess an intentional reflexive way of being.

"It Is Important for Everyone as Humans to Feel Important, Right?" Findings from a Community-Based Participatory Needs Assessment with Street-level Sex Workers.

A community-based participatory research design informed the development and conduct of a needs assessment with street-level sex workers within a mid-sized city in Ontario, Canada. The research question was: What would help street-level sex workers to live with enhanced safety and dignity within their community? Twenty-four women who accessed a peer-driven drop-in center (SafeSpace) participated in in-depth interviews. Observational data of items requested by women who accessed SafeSpace were also documented over a 6-month time period. The overarching theme of relationships was identified as vital to participants' ability to live and work with enhanced safety and dignity in their community. Subthemes included: Informal/formal surveillance: Relationships to public space(s); Nowhere to go for us: Relationships with/in community services; and You're given the time you need: Relationships in a peer-driven drop-in center for/with/by sex workers. Our findings demonstrate how central relationships are, particularly peer, to enhancing or diminishing sex workers' sense of dignity, self-worth, safety, and enhanced their access to services.

Managing care for people with diabetes undergoing dialysis.

BACKGROUND: Caring for patients with diabetes undergoing dialysis often proves challenging for staff working in haemodialysis units as they are not experts in diabetes and unfamiliar with insulin dosing regimens and the impact dialysis can have on blood sugar levels and lifestyle adjustment. There is a need to improve the knowledge base of renal healthcare professionals to better understand the physiology of diabetes, its relationship with end stage kidney disease, and potential changes that can take place when commencing dialysis. OBJECTIVES: The aim of this paper is to improve the understanding of the epidemiology of diabetes, associated risk factors, and complications associated with combined kidney disease & diabetes. In addition, readers will learn about the impact of dialysis on this complex patient group; adjustments which need to be made to accommodate haemodialysis schedules e.g. timing of meals and insulin requirements; treatment time including travel; the monitoring of blood glucose levels: increased risk of hypoglycaemia; review of oral glycaemic medication and the need to maintain regular health checks and contact with diabetes teams. RECOMMENDATIONS FOR PRACTICE: Specialist evidence based guidelines for the management of patients with diabetes receiving haemodialysis are readily available and can be used to support clinical practice. One of the key components to improving the patient experience is to maintain collaborative working relationship between renal and diabetes teams. LEARNING OUTCOMES: After reading this paper the reader will be able to Understand the risk factors and complications of diabetes and relate to patients in their care Critically review the management of patients undergoing dialysis with diabetes Gain knowledge and understanding of changes in the dosing of insulin needed for patients receiving dialysis Understand how clinical guidelines can be applied in practice.

Perspectives on phronesis in professional nursing practice.

The concept of phronesis is venerable and is experiencing a resurgence in contemporary discourses on professional life. Aristotle's notion of phronesis involves reasoning and action based on ethical ideals oriented towards the human good. For Aristotle, humans possess the desire to do what is best for human flourishing, and to do so according to the application of virtues. Within health care, the pervasiveness of economic agendas, technological approaches and managerialism create conditions in which human relationships and moral reasoning are becoming increasingly de-valued. This creates a tension for nurses, and nursing leaders, as the desire to do what is morally right is often in conflict with contextual demands. In this paper, Aristotle's writing on phronesis is examined with a focus on his classic conceptions of eudaimonia, the virtues, deliberation, judgement, and praxis. Building on Aristotle's work, a number of contemporary views are explored with a focus on what various conceptualizations offer for the discipline of nursing. These expanded conceptions of phronesis include attention to: embodiment in practice; open-mindedness including the capacity to stay curious and open to recognizing what we do not know; perceptiveness as a disposition towards insight and aesthetic understanding; and reflexivity as an ongoing process of interrogation and inquiry into ourselves and our actions. Drawing on these concepts, we discuss the affordances of phronesis as a morally informed guiding force to attend to modern-day challenges in nursing practice and nursing leadership.

The Experience of Older People in the Shared Decision-Making Process in Advanced Kidney Care.

Introduction. This qualitative descriptive study was designed to understand the experiences of older people (>70 years) when making a decision about renal replacement therapy. This was a coproduced study, whereby patients and carers were involved in all aspects of the research process. Methods. A Patient and Carer Group undertook volunteer and research training. The group developed the interview questions and interviewed 29 people who had commenced dialysis or made a decision not to have dialysis. Interview data were transcribed and analysed, and common themes were identified. Results. 22 men and 7 women (mean age 77.4 yrs) from two hospitals were interviewed. 18 had chosen haemodialysis, 6 peritoneal dialysis, and 5 supportive care. The majority of patients were involved in the dialysis decision. Most were satisfied with the amount of information that they received, although some identified that the quality of the information could be improved, especially how daily living can be affected by dialysis. Conclusion. Our findings show that overall older patients were involved in the dialysis decision along with their families. Our approach is innovative because it is the first time that patients and carers have been involved in a coproduced study about shared decision-making.

An overview of NICE guidance: acute kidney injury.

Acute Kidney Injury (AKI) as a financial, resource and human burden on both the NHS and people with AKI. Clearly if AKI is the cause of much morbidity and mortality and significant amounts of it can be prevented and/or detected earlier, this could only be a good thing. In part, the problem with AKI is that it has historically been regarded as little more than a sequal to other more pressing physical illnesses and therefore not taken as seriously as it might. The 2013 guidance from NICE-clinical guideline 169-and the accompanying pathway, seek to address this with an emphasis on assessment and prevention, identification of disease, management and subsequent chronic disease management ( NICE, 2013a ).

Managing anaemia of chronic kidney disease.

Chronic kidney disease (CKD) is a multi-faceted disease which has a number of associated complications. Anaemia is one of the most common complications that develops early in the course of the disease process. It is associated with increased mortality, increased hospitalization rates, and reduced quality of life. Low haemoglobin levels may increase risk for progression of CKD, cardiovascular morbidity and mortality. This article aims to address the importance of early recognition and management of anaemia in CKD, and the role of the health professional in this regard. Issues that will be discussed include causes, screening, guidelines, current research and recommended treatments of anaemia in CKD, along with recommendations for future practice in this pivotal area of renal care.

Patient misidentifications caused by errors in standard bar code technology.

BACKGROUND: Bar code technology has decreased transcription errors in many healthcare applications. However, we have found that linear bar code identification methods are not failsafe. In this study, we sought to identify the sources of bar code decoding errors that generated incorrect patient identifiers when bar codes were scanned for point-of-care glucose testing and to develop solutions to prevent their occurrence. METHODS: We identified misread wristband bar codes, removed them from service, and rescanned them by using 5 different scanner models. Bar codes were reprinted in pristine condition for use as controls. We determined error rates for each bar code-scanner pair and manually calculated internal bar code data integrity checks. RESULTS: As many as 3 incorrect patient identifiers were generated from a single bar code. Minor bar code imperfections, failure to control for bar code scanner resolution requirements, and less than optimal printed bar code orientation were confirmed as sources of these errors. Of the scanner models tested, the Roche ACCU-CHEK® glucometer had the highest error rate. The internal data integrity check system did not detect these errors. CONCLUSIONS: Bar code-related patient misidentifications can occur. In the worst case, misidentified patient results could have been transmitted to the incorrect patient medical record. This report has profound implications not only for point-of-care testing but also for bar coded medication administration, transfusion recipient certification systems, and other areas where patient misidentifications can be life-threatening. Careful control of bar code scanning and printing equipment specifications will minimize this threat to patient safety. Ultimately, healthcare device manufacturers should adopt more robust and higher fidelity alternatives to linear bar code symbologies.

Heart failure and chronic kidney disease: an integrated care approach.

Renal impairment may be evident at any stage of heart failure (CHF). Up to 30% of patients with heart failure have abnormal renal function. Chronic kidney disease (CKD) can be a complication of heart failure and chronic heart disease can be a consequence of CKD. Members of the multidisciplinary team, such as nurses, dieticians and physiotherapists should be encouraged to maximise their knowledge and skills across disease areas to influence and improve outcomes of those with CKD and CHF. In particular management of fluid balance, blood pressure control/monitoring, discussion of blood results and reduction of cardiovascular risk factors. Close monitoring and effective management of modifiable cardiac risk factors, such as diabetes and hypertension can reduce onset and slow progression of CKD. This can be done by applying the key principles of good practice, such as communication between healthcare professionals, patient education and empowerment alongside early identification and management of symptoms of CKD and CHF.

Symptoms in the month before death for stage 5 chronic kidney disease patients managed without dialysis.

CONTEXT: There is little evidence on the symptoms experienced by those with advanced (Stage 5) chronic kidney disease (CKD), managed without dialysis, as they approach death. As palliative care extends to noncancer illnesses, understanding symptom prevalence and severity close to death will clarify which symptom interventions are most needed and which elements of (largely cancer-driven) models of palliative care best translate into end-of-life care for this population. OBJECTIVES: To determine symptom prevalence and severity in the last month of life for patients with Stage 5 CKD, managed without dialysis. METHODS: Longitudinal symptom survey in three U.K. renal units, using the patient-completed Memorial Symptom Assessment Scale-Short Form (MSAS-SF). We calculated the prevalence of individual symptoms (with 95% confidence intervals [CI] to reflect sample size), plus MSAS-SF subscales, in the month before death. Comparison is made with previously published data on symptoms in the last month of life in advanced cancer, also measured using the MSAS-SF. RESULTS: Seventy-four patients (mean age: 81 years; standard deviation [SD]: 6.8) were recruited (response rate: 73%); 49 (66%) died during follow-up (mean age: 81 years; SD: 5.7). "Month before death" symptom data were available for 43 (88%) of the 49 participants who died. Median time of data collection was 18 days from death (interquartile range: 12-26 days). More than half had lack of energy (86%; 95% CI: 73%-94%), itch (84%; 70%-93%), drowsiness (82%; 68%-91%), dyspnea (80%; 66%-90%), poor concentration (76%; 61%-87%), pain (73%; 59%-85%), poor appetite (71%; 57%-83%), swelling arms/legs (71%; 57%-83%), dry mouth (69%; 55%-82%), constipation (65%; 50%-78%), and nausea (59%; 44%-73%). Levels of distress correspond to prevalence, with the exception of dyspnea, which was disproportionately more distressing. The median number of symptoms reported was 16.6 (range: 6-27), rising to 20.4 (range: 7-34) if additional renal symptoms were included. On average, psychological distress was moderate (mean MSAS-PSYCH: 1.55) but with wide variation (SD: 0.50; range: 0.17-2.40), suggesting diverse levels of individual distress. The prevalence of both physical and psychological symptoms and the number reported were higher than those in advanced cancer patients in the month before death. CONCLUSION: Stage 5 CKD patients have clinically important physical and psychological symptom burdens in the last month of life, similar or greater than those in advanced cancer patients. Symptoms must be addressed through routine symptom assessment, appropriate interventions, and with pertinent models of end-of-life care.

Creative iron management--a practical guide.

The use of intravenous (IV) iron is now part of the every day management of anaemia in people with Chronic Kidney Disease (CKD). The increase in the number of referrals to renal services since the introduction of estimated glomerular filtration rate (eGFR) reporting in 2006 in England means that people with CKD are being identified earlier and consequently, complications such as anaemia are being highlighted sooner. The prevalence of anaemia of CKD has been estimated in a population study of stage 3-5 CKD as 4.5% (John et al. 2004). People with stage 3 CKD and diabetes have a 22% incidence of anaemia that is much greater than the incidence of 7.9% in those without diabetes (El Achkar et al. 2005). The increase in numbers requiring anaemia management is having an impact on resources and service provision, in particular the treatment of iron deficiency with IV iron. A need to be creative and investigate alternative ways of using resources and providing services in different settings was identified by the multiprofessional members of the Anaemia Nurse Specialist Association (ANSA) and the CKD forum (a project group of the British Renal Society). The outcome has been the production of a practical guide for healthcare professionals to assist with the development of IV iron services in a nonacute hospital setting. The guide was launched at the annual ANSA conference (April 2009) and British Renal Society conference (June 2009).

CE: Continuing Education article. Patient management in chronic kidney disease stages 4 to 5.

This is the second article in a two part Continuing Education (CE) series on managing patients with Chronic Kidney Disease (CKD). The first CE article addressed the management of patients during CKD stages 1 to 3. This article will focus on the management of patients during CKD stages 4 to 5. Nephrology nurses and other healthcare professionals play an important role in the monitoring and management of the many physical symptoms that patients present with during stages 4 to 5. During these stages the healthcare team must provide psychological support along with educating patients and their families/carers regarding their treatment options including renal replacement therapy, conservative treatment and withdrawal of dialysis.

CE: Continuing Education article. Patient management in CKD stages 1 TO 3.

This is the first article in a two-part Continuing Education (CE) series on the management of patients with Chronic Kidney Disease (CKD). CKD is now recognised as a global public health concern. It has been classified into five stages to assist healthcare professionals to care for patients presenting with this chronic illness. Numerous risk factors are associated with CKD including anaemia, hypertension and cardiovascular risk. Nephrology nurses play an important role in the monitoring and management of these factors along with educating patients and their families/carers to encourage self-management of their illness.

Chronic kidney disease anaemia 1: diagnosis and screening.

This is a two-part unit on managing anaemia in chronic kidney disease. Part 1 outlines the prevalence, causes and signs and symptoms of the condition, which, until recently, was underrecognised and under-treated.

Chronic kidney disease anaemia. 2: Overview of guidance.

This is part 2 of a two-part unit on managing anaemia of chronic kidney disease (CKD). Part 1 outlined its prevalence, causes, signs and symptoms, and screening for it. Part 2 presents key points from published guidance and a summary of treatment options, and discusses nurses' role in managing people who have anaemia in CKD.

Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis.

BACKGROUND: Numbers of patients with stage 5 chronic kidney disease (CKD) managed conservatively (without dialysis) are increasing steadily but prevalence and severity of symptoms in this population are not yet known. AIM: To describe symptom prevalence, symptom severity, and total symptom burden in patients with stage 5 CKD managed conservatively. METHOD: A cross-sectional survey of patients with stage 5 CKD managed conservatively, in three U.K. renal units. Symptoms were assessed using the patient-completed Memorial Symptom Assessment Scale Short Form (MSAS-SF), with additional renal symptoms. RESULTS: Sixty-six patients were recruited (response rate, 62%), with mean age 82 years (standard deviation [SD] +/- 6.6), and mean estimated glomerular filtration rate 11.2 mL/min (SD +/- 2.8). Symptoms reported by more than one third or 33% of patients were (95% confidence intervals shown in parentheses): lack of energy, 76% (66%-84%); pruritus, 74% (65%-82%); drowsiness, 65% (54%-74%); dyspnea, 61% (50%-70%); edema, 58% (47%-66%); pain, 53% (42%-63%); dry mouth, 50% (39%-60%); muscle cramps, 50% (39%-60%); restless legs, 48% (38%-58%); lack of appetite, 47% (37%-58%); poor concentration, 44% (34%-54%); dry skin, 42% (32%-53%); sleep disturbance, 41% (32%-51%); and constipation, 35% (26%-45%). Mean number of symptoms reported on MSAS-SF was 11.58 (SD +/- 5.2), with an additional 2.77 (SD +/- 1.7) renal symptoms. Symptoms were also most severe in the more prevalent symptoms. Pain was an exception, with disproportionately greater severity (32% of all patients reported moderate/severe pain). CONCLUSION: This study demonstrates that patients with stage 5 CKD have considerable symptom control needs, similar to advanced cancer populations, but with different patterns of individual symptoms and severity, particularly pain. Implications for palliative care, hospice, and nephrology services in planning and providing care are discussed.