Successful Home Hemodialysis Programs: An Exploration of Key Nursing Care Processes

The aim of this qualitative study was to identify nursing processes of care that help keep patients successfully on home hemodialysis (HHD). A qualitative descriptive approach using appreciative inquiry was used as the framework for data collection and analysis. Four focus groups were held with HHD nursing teams in the Province of Ontario, Canada. Results suggest that successful HHD teams have highly performing nurses who work cohesively as a team, and have consistent structures and processes in place for patient education and follow up. A culture of success has the potential to keep patients successfully on HHD, improve nurse job satisfaction, and retain highly functioning and specialized nursing staff. Quality improvement initiatives aimed at improving rates of HHD are important given the benefits to patients of HHD as a treatment modality.

Mindful Self-Compassion Training and Nephrology Nurses' Self-Reported Levels of Self-Compassion, Burnout, and Resilience: A Mixed Methods Study

Caring for people with chronic kidney disease, let alone during a pandemic, can place nurses at risk for burnout. This study explored the effects of the Mindful Self-Compassion (MSC) 8-week training on nephrology nurses' levels of self-compassion, burnout, and resilience. Twelve nurses participated. Surveys were completed before, immediately after, and three months after training. A focus group was also conducted. Results demonstrated in creased levels of self-compassion, mindfulness, and resilience while levels of burnout decreased. The central qualitative theme was enhanced resilience. Subthemes were creating a community of support, awareness and discovery, and the mastery of the techniques. The MSC training was an effective intervention to build essential skills for maintaining a healthy workforce. Implementation of such training programs within the health care environment are highly encouraged.

An eHealth self-management intervention for adults with chronic kidney disease, My Kidneys My Health: a mixed-methods study

BACKGROUND

There is limited research of electronic tools for self-management for patients with chronic kidney disease (CKD). We sought to evaluate participant engagement, perceived self-efficacy and website usage in a preliminary evaluation of My Kidneys My Health, a patient-facing eHealth tool in Canada.

METHODS

We conducted an explanatory sequential mixed-methods study of adults with CKD who were not on kidney replacement therapy and who had access to My Kidneys My Health for 8 weeks. Outcomes included acceptance (measured by the Technology Acceptance Model), self-efficacy (measured by the Chronic Disease Self-Efficacy Scale [CDSES]) and website usage patterns (captured using Google Analytics). We analyzed participant interviews using qualitative content analysis.

RESULTS

Twenty-nine participants with CKD completed baseline questionnaires, of whom 22 completed end-of-study questionnaires; data saturation was achieved with 15 telephone interviews. Acceptance was high, with more than 70% of participants agreeing or strongly agreeing that the website was easy to use and useful. Of the 22 who completed end-of-study questionnaires, 18 (82%) indicated they would recommend its use to others and 16 (73%) stated they would use the website in the future. Average scores for website satisfaction and look and feel were 7.7 (standard deviation [SD] 2.0) and 8.2 (SD 2.0) out of 10, respectively. The CDSES indicated that participants gained an increase in CKD information. Interviewed participants reported that the website offered valuable information and interactive tools for patients with early or newly diagnosed CKD, or for those experiencing changes in health status. Popular website pages and interactive features included Food and Diet, What is CKD, My Question List and the Depression Screener.

INTERPRETATION

Participants indicated that the My Kidneys My Health website provided accessible content and tools that may improve self-efficacy and support in CKD self-management. Further evaluation of the website's effectiveness in supporting self-management among a larger, more heterogenous population is warranted.

All-Star Quality Improvement: Keep It Simple

An important factor for quality and safety in patient care is an environment in which quality and safety are prioritized and embedded into the culture. Quality improvement (QI) methods can be complex, with some intensive resources required and specific methods employed. However, all staff can be involved in QI if the problem is approached with curiosity and the process is kept simple, with a consistent goal of improving practices. The purpose of this article is to highlight some simple but effective QI methods authored by all-star nephrology nurses that can be easily applied by teams in various settings with minimal resources.

A Research Protocol for Implementation and Evaluation of a Patient-Focused eHealth Intervention for Chronic Kidney Disease

Self-management in chronic kidney disease (CKD) can slow disease progression; however, there are few tools available to support patients with early CKD. My Kidneys My Health is a patient-focused electronic health (eHealth) self-management tool developed by patients and caregivers. This study will investigate the implementation of My Kidneys My Health across primary care and general nephrology clinics. The study aims to: (1) identify and address barriers and facilitators that may impact implementation and sustainability of the website into routine clinical care; (2) evaluate implementation quality to inform spread and scale-up. We will conduct a multi-stage approach using qualitative methods, guided by the Quality Implementation Framework and using a qualitative content analysis approach. First, we will identify perceived barriers and facilitators to implementation and considerations for sustainability through interviews with clinicians, based on the Readiness Thinking Tool and the Long Term Success Tool. Analysis will be guided by the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Appropriate implementation strategies will be identified using the Expert Recommendations for Implementing Change compilation, and implementation plans will be developed based on Proctor's recommendations and the Action, Actor, Context, Target, Time framework. Finally, we will explore implementation quality guided by the RE-AIM framework. There is limited literature describing systematic approaches to implementing and sustaining patient-focused self-management tools into clinical care, in addition to employing tailored implementation strategies to promote adoption and sustainability. We aim to generate insights on how My Kidneys My Health can be integrated into clinical care and how to sustain use of patient-centric eHealth tools in clinical settings on a larger scale.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00038-3.

Resilience, Mindfulness, and Self-Compassion: Tools for Nephrology Nurses

Nephrology nurses are not immune to the effects of a stressful work environment. As a result, their emotional and psychological health can be at risk. In addition, there has been unprecedented stress and uncertainty working as nephrology nurses during the pandemic. These stressors can have negative effects on nurses' health, resulting in burnout and/or compassion fatigue, which can lead to nurses leaving nephrology or the nursing profession. Mindfulness has been suggested as a strategy to mitigate work-related stressors and build a more resilient workforce. Our experience suggests that combining self-compassion practices with mindfulness is also effective. Mindfulness may be beneficial for nephrology nurses, but its use does not negate the need for organizations to address the structural system issues that also contribute to burnout.

A Web-Based Self-Management Support Prototype for Adults With Chronic Kidney Disease (My Kidneys My Health): Co-Design and Usability Testing

Background

Supporting patients to self-manage their chronic kidney disease (CKD) has been identified as a research priority by patients with CKD and those who care for them. Self-management has been shown to slow CKD progression and improve the quality of life of individuals living with the disease. Previous work has identified a need for a person-centered, theory-informed, web-based tool for CKD self-management that can be individualized to a patient’s unique situation, priorities, and preferences. We addressed this gap using an integrated knowledge translation method and patient engagement principles.

Objective

The aim of this study is to conduct systematic co-design and usability testing of a web-based self-management prototype for adults with CKD (nondialysis and nontransplant) and their caregivers to enhance self-management support.

Methods

A multistep, iterative system development cycle was used to co-design and test the My Kidneys My Health prototype. The 3-step process included creating website features and content using 2 sequential focus groups with patients with CKD and caregivers, heuristic testing using the 10 heuristic principles by Nielsen, and usability testing through in-person 60-minute interviews with patients with CKD and their caregivers. Patients with CKD, caregivers, clinicians, researchers, software developers, graphic designers, and policy makers were involved in all steps of this study.

Results

In step 1, 18 participants (14 patients and 4 caregivers) attended one of the 2 sequential focus groups. The participants provided specific suggestions for simplifying navigation as well as suggestions to incorporate video, text, audio, interactive components, and visuals to convey information. A total of 5 reviewers completed the heuristic analysis (step 2), identifying items mainly related to navigation and functionality. Furthermore, 5 participants completed usability testing (step 3) and provided feedback on video production, navigation, features and functionality, and branding. Participants reported visiting the website repeatedly for the following features: personalized food tool, my health care provider question list, symptom guidance based on CKD severity, and medication advice. Usability was high, with a mean system usability score of 90 out of 100.

Conclusions

The My Kidneys My Health prototype is a systematically developed, multifaceted, web-based CKD self-management support tool guided by the theory and preferences of patients with CKD and their caregivers. The website is user friendly and provides features that improve user experience by tailoring the content and resources to their needs. A feasibility study will provide insights into the acceptability of and engagement with the prototype and identify preliminary patient-reported outcomes (eg, self-efficacy) as well as potential factors related to implementation. This work is relevant given the shift to virtual care during the current pandemic times and provides patients with support when in-person care is restricted.

Innovations in Hemodialysis Care: An Evaluation of Quality and the Patient Experience

Hemodialysis (HD) performed in a tertiary care facility is the most prevalent and costly treatment for end-stage renal disease in Canada. This life-sustaining treatment is usually performed thrice weekly in an in-center facility. When people on HD also require a rehabilitation/complex care inpatient program, the burden of transportation for dialysis is immense to both the patient and health-care system. To improve the patient experience, create efficiency, and reduce travel costs, the renal team and a team from a rehabilitation/complex care center collaborated to provide HD services in the rehab/complex care setting. A patient/family representative was involved in all aspects of the design through to evaluation of this project. This study used realistic evaluation to examine the efficacy of this program from the perspective of the patient experience, HD staff, rehab/complex care staff and costs. The decreased travel with having dialysis on-site and adequate resources in the HD unit were the mechanisms for success in improved patient experience, quality of life and rehabilitation patient outcomes, decreased costs as well as increased communication and satisfaction.

Pandemic Uncertainty: Considerations for Nephrology Nurses

The COVID-19 pandemic is a situation of great magnitude that most of us have not experienced in our lifetime. Pandemics are widespread, affecting many geographical areas, and uncertainty is inherent given the rapidly changing situations. As nurses in dialysis providing a life-sustaining therapy, we are required to provide an essential service during pandemics and need to thrive in the uncertainty. This article offers points for consideration that can assist nephrology nurses in their approach to these uncertain times.

Preferences for a self-management e-health tool for patients with chronic kidney disease: results of a patient-oriented consensus workshop

BACKGROUND

Electronic health (e-health) tools may support patients' self-management of chronic kidney disease. We aimed to identify preferences of patients with chronic kidney disease, caregivers and health care providers regarding content and features for an e-health tool to support chronic kidney disease self-management.

METHODS

A patient-oriented research approach was taken, with 6 patient partners (5 patients and 1 caregiver) involved in study design, data collection and review of results. Patients, caregivers and clinicians from across Canada participated in a 1-day consensus workshop in June 2018. Using personas (fictional characters) and a cumulative voting technique, they identified preferences for content for 8 predetermined topics (understanding chronic kidney disease, diet, finances, medication, symptoms, travel, mental and physical health, work/school) and features for an e-health tool.

RESULTS

There were 24 participants, including 11 patients and 6 caregivers, from across Canada. The following content suggestions were ranked the highest: basic information about kidneys, chronic kidney disease and disease progression; reliable information on diet requirements for chronic kidney disease and comorbidities, renal-friendly foods; affordability of medication, equipment, food, financial resources and planning; common medications, adverse effects, indications, cost and coverage; symptom types and management; travel limitations, insurance, access to health care, travel checklists; screening and supports to address mental health, cultural sensitivity, adjusting to new normal; and support to help integrate at work/school, restrictions. Preferred features included visuals, the ability to enter and track health information and interact with health care providers, "on-the-go" access, links to resources and access to personal health information.

INTERPRETATION

A consensus workshop developed around personas was successful for identifying detailed subject matter for 8 predetermined topic areas, as well as preferred features to consider in the codevelopment of a chronic kidney disease self-management e-health tool. The use of personas could be applied to other applications in patient-oriented research exploring patient preferences and needs in order to improve care and relevant outcomes.

Content and Quality of Websites for Patients With Chronic Kidney Disease: An Environmental Scan

Background:

Although numerous websites for patients with chronic kidney disease (CKD) are available, little is known about their content and quality.

Objective:

To evaluate the quality of CKD websites, and the degree to which they align with information needs identified by patients with CKD.

Methods:

We identified websites by entering “chronic kidney disease” in 3 search engines: Google.com (with regional variants for Australia, Canada, the United Kingdom, and the United States), Bing.com, and Yahoo.com. We included the first 50 unique English-language sites from each search. We evaluated website content using a 30-point scale comprising 8 priority content domains identified by patients with CKD (understanding CKD, diet, symptoms, medications, mental/physical health, finances, travel, and work/school). We used standardized tools to evaluate usability, reliability, and readability (DISCERN, HONcode, LIDA, Reading Ease, and Reading Grade Level). Two reviewers independently conducted the search, screen, and evaluation.

Results:

Of the 2093 websites identified, 115 were included. Overall, sites covered a mean (SD) of 29% (17.8) of the CKD content areas. The proportion of sites covering content related to understanding CKD, symptoms, and diet was highest (97%, 80%, and 72%, respectively). The proportion of sites covering travel, finances, and work/school content was lowest (22%, 12%, and 12%, respectively). The mean (SD) scores for DISCERN, LIDA and HONcode were 68% (14.6), 71% (14.4), and 75% (17.2), respectively, considered above average for usability and reliability. The mean (SD) Reading Grade Level was 10.6 (2.8) and Reading Ease was 49.8 (14.4), suggesting poor readability.

Conclusions:

Although many CKD web sites were of reasonable quality, their readability was poor. Furthermore, most sites covered less than 30% of the content patients identified as important for CKD self-management. These results will inform content gaps in internet-accessible information on CKD self-management that should be addressed by future eHealth web-based tools.

Partnering with Patients, Families, and Caregivers in Nephrology Nursing Research

Nurses value patient- and family-centered care as one of the most important elements of nursing, and as such, these foundations are embedded into nursing practice and theory. Patient engagement in health research, as an evolution of patient- and family-centered care, has emerged as a critical new way of doing research over the last several years. However, the benefit, value, and exploration of ways in which patient partnerships can be built within the context of nephrology nursing research are still relatively new. This article describes patient-centered outcomes research, discusses how patients can be involved throughout the research process, and provides examples for effective partnerships in nephrology nursing research.

Evidence-Based Reviews: Trends in Nephrology Nursing

Evidence-based practice (EBP) is one of the essential components of nephrology nursing. Reviews of such evidence are important as a means to synthesize research findings into one meaningful form of data. Publication trends of evidence reviews in nephrology nursing are unknown. The purpose of this systematic review was to identify trends in publications of evidence reviews in the Nephrology Nursing Journal. Titles of all publications in the Nephrology Nursing Journal from January 2003 to September/October 2018 were reviewed. A total of 23 evidence reviews were identified and formed the basis of this systematic review. Narrative analysis and concept mapping were used to synthesize data. There was a trend toward systematic reviews of quantitative studies, as well as evidence reviews that focused on the topics of quality of life and access to health services. The need for systematic rigorous reporting is recommended for EBP, as well as future reviews on identified priority areas of research.

Barriers to Education and Shared Decision Making in the Chronic Kidney Disease Population: A Narrative Review

PURPOSE OF REVIEW

Provision of education to inform decision making for renal replacement therapy (RRT) is a key component in the management of chronic kidney disease (CKD), yet patients report suboptimal satisfaction with the process of selecting a dialysis modality. Our purpose is to review the influencers of RRT decision making in the CKD population, which will better inform the process of shared decision making between clinicians and patients.

SOURCES OF INFORMATION

PubMed and Google Scholar.

METHODS

A narrative review was performed using the main terms "chronic kidney disease," "CKD," "dialysis," "review," "decision-making," "decision aids," "education," and "barriers." Only articles in English were accessed. The existing literature was critically analyzed from a theoretical and contextual perspective and thematic analysis was performed.

KEY FINDINGS

Eight common themes were identified as influencers for decision making. "Patient-focused" themes including social influence, values and beliefs, comprehension, autonomy and sociodemographics, and "clinician-focused" themes including screening, communication, and engagement. Early predialysis education and decision aids can effectively improve decision making. Patient-valued outcomes need to be more fully integrated into clinical guidelines.

LIMITATIONS

This is not a systematic review; therefore, no formal tool was utilized to evaluate the rigor and quality of studies included and findings may not be generalizable.

IMPLICATIONS

Standardized comprehensive RRT education programs through multidisciplinary health teams can help optimize CKD patient education and shared decision making. Involving patients in the research process itself and implementing patient values and preferences into clinical guidelines can help to achieve a patient-centered model of care.

Educational Support Around Dialysis Modality Decision Making in Patients With Chronic Kidney Disease: Qualitative Study

BACKGROUND

Patients with chronic kidney disease (CKD) are asked to choose a renal replacement therapy or conservative management. Education and knowledge transfer play key roles in this decision-making process, yet they remain a partially met need.

OBJECTIVE

We sought to understand the dialysis modality decision-making process through exploration of the predialysis patient experience to better inform the educational process.

DESIGN

Qualitative descriptive study.

SETTING

Kidney Care Centre of London Health Sciences Centre in London, Ontario, Canada.

PATIENTS

Twelve patients with CKD, with 4 patients on in-center hemodialysis, home hemodialysis, and peritoneal dialysis, respectively.

MEASUREMENTS

Not applicable.

METHODS

We conducted semistructured interviews with each participant, along with any family members who were present. Interviews were transcribed verbatim. Conventional content analysis was used to analyze the transcripts for common themes. Representative quotes were decided via team consensus. A patient collaborator was part of the research team.

RESULTS

Three themes influenced dialysis modality decision making: (i) Patient Factors: individualization, autonomy, and emotions; (ii) Educational Factors: tailored education, time and preparation, and available resources; and (iii) Support Systems: partnership with health care team, and family and friends.

LIMITATIONS

Sample not representative of wider CKD population. Limited number of eligible patients. Poor recall may affect findings.

CONCLUSIONS

Modality decision making is a complex process, influenced by the patient's health literacy, willingness to accept information, predialysis lifestyle, support systems, and values. Patient education requires the flexibility to individualize the delivery of a standardized CKD curriculum in partnership with a patient-health care team, to fulfill the goal of informed, shared decision making.

Reaching Consensus on Outcomes for Successful Cannulation of an Arteriovenous Fistula: Patient and Healthcare Provider Perspectives

There is a lack of consensus on what constitutes successful arteriovenous fistula (AVF) cannulation. The purpose of this study was to describe outcomes of successful cannulation of the AVF from both patient and healthcare provider perspectives. This was a mixed method study. Results reflecting the patient's description of success through interviews were reported previously. A sample of nursing and physician experts in vascular access completed a one-time survey. Results from healthcare providers suggest they consider cannulator ability to assess the AVF, knowledge of AVF anatomy, and patient-centered care as most important to cannulation success. Patient comfort, patient-centered care, and available support staff (i.e., expert cannulators) were perceived by both patients and healthcare provider groups as contributing to success. Strategies that promote patient comfort, patient-centered care, and having access to cannulation experts have the potential to improve cannulation outcomes.

Self-management interventions for adults with chronic kidney disease: a scoping review

OBJECTIVE

To systematically identify and describe self-management interventions for adult patients with chronic kidney disease (CKD).

SETTING

Community-based.

PARTICIPANTS

Adults with CKD stages 1-5 (not requiring kidney replacement therapy).

INTERVENTIONS

Self-management strategies for adults with CKD.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using a scoping review, electronic databases and grey literature were searched in October 2016 to identify self-management interventions for adults with CKD stages 1-5 (not requiring kidney replacement therapy). Randomised controlled trials (RCTs), non-RCTs, qualitative and mixed method studies were included and study selection and data extraction were independently performed by two reviewers. Outcomes included behaviours, cognitions, physiological measures, symptoms, health status and healthcare.

RESULTS

Fifty studies (19 RCTs, 7 quasi-experimental, 5 observational, 13 pre-post intervention, 1 mixed method and 5 qualitative) reporting 45 interventions were included. The most common intervention topic was diet/nutrition and interventions were regularly delivered face to face. Interventions were administered by a variety of providers, with nursing professionals the most common health professional group. Cognitions (ie, changes in general CKD knowledge, perceived self-management and motivation) were the most frequently reported outcome domain that showed improvement. Less than 1% of the interventions were co-developed with patients and 20% were based on a theory or framework.

CONCLUSIONS

There was a wide range of self-management interventions with considerable variability in outcomes for adults with CKD. Major gaps in the literature include lack of patient engagement in the design of the interventions, with the majority of interventions not applying a behavioural change theory to inform their development. This work highlights the need to involve patients to co-developed and evaluate a self-management intervention based on sound theories and clinical evidence.

Outcomes for Successful Cannulation of the Arteriovenous Fistula: Perspectives from Patients on Hemodialysis

There is a lack of consensus in the literature on what constitutes successful arteriovenous fistula (AVF) cannulation outcomes from the patient perspective. The purpose of this study was to describe what successful cannulation means to patients on hemodialysis. A qualitative descriptive approach was used. A purposeful sample of 17 patients dialyzing with an AVF participated in one face-to-face interview. Using content analysis, four themes were identified that impact the patient experience in defining successful cannulation: 1) an emotional response - pain and anxiety, 2) a 'friendly' nurse-patient relationship, 3) nursing interventions/technical skills during cannulation, and 4) the impact of the environment. Results provide valuable insight into what patients define as successful cannulation, recognizing that it goes beyond the actual needle insertion procedure.

Cannulation Outcomes of the Arteriovenous Fistula for Hemodialysis: A Scoping Review

The arteriovenous fistula (AVF) is the recommended access for most people requiring hemodialysis. Success or failure of cannulation of the AVF greatly impacts the patient's experience. Research suggests that skill development in this area is needed. This scoping review was conducted to review current research on cannulation of the AVF to find strategies to improve successful cannulation. Results of this scoping review (n = 36)demonstrated that most studies can be categorized under the technique of cannulation, and concerns and preferences with the AVF as a consequence of cannulation. There are large gaps in the literature, with interventions to improve cannulation and a need to understand more about cannulation from both patient and nurse perspectives.

Recent Changes in Anemia Management: The Kidney Disease Improving Global Outcomes (KDIGO) Anemia Guideline versus the Canadian Society of Nephrology (CSN)

The management of anemia is important for health outcomes for people with chronic kidney disease (CKD). Global evidenced-based guidelines must be placed in the Canadian context to be relevant to guide practice. This paper summarizes the response of the Canadian Society of Nephrology to global anemia management guidelines in CKD and the implications for practice.

Dialysis modality decision-making for older adults with chronic kidney disease

AIMS AND OBJECTIVES

To examine the personal and structural facilitators and barriers for home-dialysis decision-making for older adults with chronic kidney disease.

BACKGROUND

Chronic illness is a global problem. Older adults with chronic kidney disease form a large and growing segment of the dialysis population in many high-income countries but are less likely to uptake home-dialysis despite its benefits.

DESIGN

This qualitative ethnography framed in social theory took place in Canada and included adults with chronic kidney disease not on dialysis, older than 65 years of age.

METHODS

Thirteen people (seven men and six women, aged 65-83 years of age) who received care in a team chronic kidney disease clinic took part. Persons with chronic kidney disease were interviewed and group interviews were conducted with four of their chronic kidney disease clinic healthcare professionals. Content analysis was used for data analysis.

RESULTS

The factors influencing older adults' chronic kidney disease modality decisions are similar to younger adults. However, older adults with chronic kidney disease are in a precarious state with persistent uncertainty. Age imposes some limitations on modality options and transplantation. Modality decisions were influenced by health status, gender, knowledge, values, beliefs, past experience, preferences, lifestyle and resources. Support from family and healthcare professionals was the largest determinant to home-dialysis selection.

CONCLUSION

The social and contextual factors associated with age influenced home-dialysis decision-making. Adequate social support, functional status and resources enabled home-dialysis selection.

RELEVANCE TO CLINICAL PRACTICE

Understanding more about the decision-making processes for older adults with chronic kidney disease is important for quality interventions and the economic sustainability of dialysis services.

Shower and no-dressing technique for tunneled central venous hemodialysis catheters: a quality improvement initiative

Self-care practices and quality-of-life nuances juxtaposed our tunneled hemodialysis central venous catheter (CVC) protocols. Despite our advice, individuals with CVCs were showering. As a quality improvement initiative, we compared the standard CVC dressing practices to the "shower and no-dressing" technique. After 1380 catheter months (n = 119) infection rates were 0.31 events per 1000 catheter days. The "shower and no-dressing" technique appears to be a safe CVC dressing option with improved quality of life, no increase in infection rates, and cost-effectiveness.

Temporal trends in "legacy" organochlorine contaminants in blubber of ringed seals (Phoca hispida) from Ulukhaktok, NT, Canada between 1972 and 2010

In blubber of ringed seals (Phoca hispida) from Ulukhaktok, NT, residues of DDT, other organochlorine pesticides, and PCBs declined between 1972 and 2010. The rate of decline varied: concentrations of the DDT-group began to fall after 1981, whereas those of PCBs fell rapidly between 1972 and 1981, and then slowed. Concentrations of cis- and trans-chlordane and of HCB in both sexes, and of cis-nonachlor in males, declined slowly between 1978 and 2010; those of other organochlorine pesticides remained steady. Exponential half-lives of p,p'-DDT and p,p'-DDE in female seals are about 9 and 36 y (corresponding to initial declines of 7.8% and 1.9% per year, respectively) and those of PCB congeners from about 20 to 60 y (declines of 3.2% to <1.5% per year); the more refractory residues may be detectable for centuries to come. Exploratory PCA of PCB congener distribution identified temporal changes apparently not related to molecular structure.

A renal nursing professional practice model: the next generation

Professional practice models provide a structure for excellence in nursing practice. Our centre has had a long tradition of working with a professional practice model with proven nursing outcomes such as job satisfaction, empowerment and perceptions of improved patient care. Our model, in place since 1999, has provided an opportunity to discuss and articulate a vision for nursing practice based on the values of accountability, evidence-informed care and empowerment. In order for the model to effectively guide nursing practice, a revision was necessary to keep pace with the changes in the renal program and the health care environment. The revised model needed to address the enhancements in nursing roles, practice environment, corporate requirements and patient care needs. This paper describes a revised professional practice model unique to nephrology nursing.

Moving beyond the "perpetual novice": understanding the experiences of novice hemodialysis nurses and cannulation of the arteriovenous fistula

Cannulation of the arteriovenous fistula (AVF) is an essential skill for hemodialysis (HD) nurses. With declining rates of AVFs, opportunities to develop expert cannulation skills have become limited. This study explored the concept of perpetual novice and AVF cannulation from the perspective of the novice cannulator. Nine hemodialysis nurses were interviewed using ethnographic methodology. The study identified the interplay between personal and environmental/contextual factors that hindered skill acquisition. Personal attributes identified by participants included HD nurses' approach to learning and previous experience, emotional reaction to stress, and interpersonal relationships with colleagues. Environmental/contextual factors identified as impediments to cannulation skill development included limited learning opportunities, attitudes and demands from patients, unit flow and time pressures, and limitations imposed by the current model of nursing care. This study will be helpful in directing future educational, operational, and supportive interventions for novice HD nurses around cannulation skill development.

Western Canadian Arctic ringed seal organic contaminant trends in relation to sea ice break-up

The association between changing sea ice conditions and contaminant exposure to Arctic animals interests Inuvialuit harvesters, communities, and researchers. We examined organochlorine contaminant (OC) concentrations in the blubber of 90 male adult ringed seals (Phoca hispida) sampled from the subsistence harvest in Ulukhaktok (formerly Holman), NT, Canada, just prior to break-up of the sea ice (1993-2008). OC blubber concentrations were assessed with respect to year and sea ice break-up date. HCB and age- and blubber-adjusted concentrations of p,p'-DDT and ΣCHB (chlorobornane) significantly decreased over the study period. With respect to the timing of the spring break-up, highly lipophlic OCs, such as p,p'-DDE and PCB 153, were higher during years of early ice clearing (at least 12 days earlier than the mean annual break-up date), whereas no trends were observed for α, β, and γ isomers of HCH, trans- and cis-chlordane, oxychlordane, or ΣCHB. The higher contaminant concentrations found in earlier break-up years is likely due to earlier and/or increased foraging opportunities. This situation also has potential for enhancing bioaccumulation and biomagnification of contaminants over the long-term if projected changes continue to result in lighter and earlier ice conditions.

Chronic kidney disease stressors influence choice of dialysis modality

AIM

  This article is a report of a study examining the relationships between chronic kidney disease stressors and coping strategies with dialysis modality.

BACKGROUND

  People with chronic kidney disease are given information to enable dialysis modality choice. This education increases awareness and may alleviate concerns and stress. Disease-related stressors and coping may affect dialysis selection. Understanding the influence of stress and coping on dialysis choices will assist in providing responsive programmes. Reducing stress and encouraging coping may increase home dialysis which, despite economic and patient benefits, remains underused.

DESIGN

  A prospective correlational design was used.

METHODS

  Information was obtained from the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 223 individuals not on dialysis between the years 2005-2007. Data were recorded with respect to modality at dialysis initiation (n = 76) from 2005-2010. The effects of stress, coping and patient parameters on modality selection were compared using bivariate and multivariate analyses.

RESULTS

  Individuals on home dialysis vs. in-centre haemodialysis reported significantly fewer pre-dialysis stressors. Coping was not associated with dialysis modality. Individuals on in-centre haemodialysis had a lower serum creatinine, less advanced kidney disease and weighed more than those who started on a home therapy. Physiological stressors were most common and are amenable to interventions.

CONCLUSION

  Pre-dialysis stress levels predicted dialysis modality. Interventional studies are recommended to address chronic kidney disease stressors with the outcome of improving home-dialysis usage.

Sociodemographic differences in stressful experience and coping amongst adults with chronic kidney disease

AIM

This secondary data analysis aims to determine whether stressful experiences and coping behaviours differ across age, gender and education level and if sociodemographic factors are independently associated with coping behaviour after controlling for stress.

BACKGROUND

Chronic kidney disease is stressful for individuals and their families; however, little research is available on this topic.

METHODS

In this cross-sectional quantitative study, information on stress and coping was obtained using the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 226 non-dialysis chronic kidney disease patients. The data were collected in Canada between 2005 and 2007. The independent effects of age, gender and education on coping behaviour were analysed in four multivariable regression models that adjusted for the three Chronic Kidney Disease Stress Inventory subscales separately, the total 34-item Chronic Kidney Disease Stress Inventory, and chronic kidney disease stage.

RESULTS

Stressful experience did not differ between the genders; however, women were more likely than men to report greater use of coping strategies. This relationship remained significant in each multivariable regression model. An inverse relationship between age and total coping use was significant in the multivariable model that adjusted for physiological stressors, but not in the models adjusting for psychosocial, logistic or total stressors. Significant relationships were observed between higher education and greater coping in bivariable analysis, but not multivariable analysis.

CONCLUSION

Knowledge of the relationships between sociodemographic factors, stressful experience and coping behaviour is necessary to develop and implement educative and supportive interventions further for chronic kidney disease patients and to provide the foundation for interventional and outcome investigations.

Occupational burnout, retention and health outcomes in nephrology nurses

Occupational burnout can have serious implications on productivity, nurses'health, service usage, and health care costs. This study examined the effect of burnout on nurses' mental and physical health outcomes and job retention. Randomly selected Canadian nephrology nurses completed surveys consisting of the Maslach Burnout Inventory and the Pressure Management Indicator. The nurses also completed questions related to job retention. After controlling for age and years of nephrology nursing experience, the multivariate results demonstrated that almost 40% of mental health symptoms experienced by nephrology nurses could be explained by burnout and 27.5% of physical symptoms could be explained by burnout. Twenty-three per cent of the sample had plans to leave their current position and retention was significantly associated with burnout, mental, and physical symptoms. Organizational strategies aimed at reducing perceptions of burnout are important, as a means to keep nurses healthy and working to their fullest potential.

The culture of vascular access cannulation among nurses in a chronic hemodialysis unit

The native arteriovenous fistula (AVF) is the vascular access of choice for patients on chronic hemodialysis (HD) because of its longevity and lower complication rate. Yet from 2001 to 2004 in Canada, there has been a notable increase in both incident and prevalent central venous catheter (CVC) use with a corresponding decrease in AVF use over the same time period (Moist, Trpeski, Na, & Lok, 2008). A similar trend has been found in other countries (Moist, Chang, Polkinghorne, & McDonald, 2007). There are a number of contributing factors to low AVF use in patients on chronic hemodialysis. While some of these factors may be patient-related, nursing interventions specific to cannulation may be a contributor. To date, little is known about HD nurses' attitudes and experiences regarding cannulation. The purpose of this study was to describe the culture and everyday practices of vascular access cannulation of the AVF from the perspective of the HD nurse. An ethnographic research design was employed, utilizing qualitative methods. Ten HD nurses were interviewed using a semi-structured interview tool, and a number of themes were generated from the interviews. One overarching theme of "perpetual novice" was evident, acknowledging the failure to transition from novice to expert cannulator despite working in HD for a number of years. Other common themes that emerged from the interviews were a) the lack of fistulas, b) the fistula as a "hard sell" to patients, c) the skill of cannulation, and d) the assembly-line approach to care. As a result of a number of factors, HD nurses were unable to acquire the skills necessary to become an expert cannulator. Moreover, the decrease in opportunities to practise cannulation has resulted in wide variation in skill level among HD nurses. To improve cannulation skills and achieve successful cannulation of AV fistulas, HD nurses identified a number of educational strategies that should take place. They also identified the need for an improved documentation system in order to track cannulation-related problems. Results of this study may be helpful in understanding the culture of cannulation in a chronic HD unit and in directing future educational, supportive, and practice interventions for HD nurses.

Workplace empowerment and burnout in Canadian nephrology nurses

Nephrology nurses, like nurses in other areas, are impacted by the stress in their work environment. As recruitment and retention issues become more apparent, research in the area of conditions of work life for nephrology nursing has emerged, as an important area of study. Burnout has been reported as high as one in every three nephrology nurses (Flynn, Thomas-Hawkins, & Clarke, 2009). This cross-sectional study examined the influence of empowerment on burnout. Total empowerment was negatively correlated with emotional exhaustion in the bivariate analysis. Multivariate analysis demonstrated that access to resources and nursing education had an influence on burnout for nephrology nurses. Access to resources was a significant negative predictor of burnout for nephrology nurses. Degree-prepared nurses were more likely to experience burnout. Application of these results by providing access to resources for nephrology nurses may impact on occupational burnout.

A comparison of quality of life and travel-related factors between in-center and satellite-based hemodialysis patients

BACKGROUND AND OBJECTIVES

Shorter travel times and distance to dialysis clinics have been associated with improved patient outcomes and a higher health-related quality of life (HRQOL). The objective of this study was to compare HRQOL between prevalent in-center and satellite dialysis patients, as well as compare travel-related factors that contribute to HRQOL between in-center and satellite-based patients. DESIGN, SETTING, PARTICIPANTS, & MEASURES: The London Health Sciences Centre is a tertiary care center with in-center and regional satellite hemodialysis units. Patients who consented and completed a questionnaire (n = 202) were enrolled into a cross-sectional, cohort observational study. Patients were administered the Medical Outcomes Short-Form 36 (SF-36) and the Kidney Disease Health Related Quality of Life (KDHRQOL) tool and were asked questions relating to travel to dialysis clinics.

RESULTS

Patients who underwent dialysis in the satellites had similar demographics, comorbidities, and laboratory parameters. Patients who underwent dialysis in satellite units reported a significantly superior score on the dialysis stress domain of the KDHRQOL questionnaire. There was no significant difference between in-center and satellite patients on the basis of the SF-36. Satellite patients also reported a significantly decreased cost of transportation, a significantly increased proportion who drive themselves to clinics, and significantly decreased travel time.

CONCLUSIONS

Patients who underwent dialysis in satellite units demonstrated similar characteristics, comorbidities, surrogate outcomes, and most aspects of HRQOL. Travel time, cost, and receiving treatment in one's own community are important factors that may contribute to a trend toward higher reported HRQOL by patients in satellite dialysis units.

Implementation of a diabetic foot management best practice guideline (BPG) in hemodialysis units

The aim ofthis study was to examine the impact of introducing the Registered Nurses' Association of Ontario Best Practice Guideline (BPG), Assessment and management of foot ulcers for people with diabetes (2005), on foot ulcer incidence, recurrence, and amputation rate in adult diabetic clients who are undergoing chronic hemodialysis treatments. Fifty-seven individuals from three hemodialysis units participated in the study. Data were collected at three points in time over a 15-month period. A significant reduction in the number of wounds was noted (p < 0.05) from time one to time three, and the grade of wounds (p < 0.01). However, five new amputations were reported Although implementation of the BPG showed a positive patient outcome, further research needs to be conducted with a larger sample size.

Hexachlorocyclohexanes (HCH) in ringed seal (Phoca hispida) from Ulukhaktok (Holman), NT: trends from 1978 to 2006

Trends in alpha-, beta-, and gamma-hexachlorocyclohexane (HCH) concentrations were examined in blubber lipid of ringed seals (Phoca hispida) from Ulukhaktok (Holman), NT (Canada) sampled at intervals between 1978 and 2006. alpha-HCH usually represented approximately 90% of the total HCH isomers. alpha-HCH and gamma-HCH concentrations showed no change over the sampling interval, but beta-HCH concentrations increased significantly, about 8-10-fold in females and 4-5-fold in males. Residue concentrations showed no dependence on age. Concentrations (all data as ng/g lipid, GM (range)) of alpha-HCH were significantly higher (P<0.001 by t-test) in males (217 (93.9-517), n=37) than those in females (138 (40.9-402), n=38). beta-HCH concentrations did not differ between the sexes. Concentrations of gamma-HCH were significantly higher (P<0.05) in males (6.74 (0-46.7)) than in females (4.35 (0-19.0)). Although global emissions of both alpha-HCH and beta-HCH have declined since the early 1980's, the "signal" of HCH emission changes has not yet resulted in a "response" in ringed seal residue concentrations. In the light of our current understanding of the dynamics of HCH in the Arctic, we conclude that any such response may not be detected by retrospective analyses of the sort describe here at least for another decade or so, because of the longevity of the seals.

Mercury trends in ringed seals (Phoca hispida) from the western Canadian Arctic since 1973: associations with length of ice-free season

We examined a unique time series of ringed seal (Phoca hispida) samples collected from a single location in the western Canadian Arctic between 1973 and 2007 to test for changes in total mercury (THg) in muscle tissue associated with (1) year and (2) length of ice-free season. We found no temporal trend with muscle THg whereas a curvilinear relationship existed with the length of ice-free season: seals attaimed higher THg in short (2 months) and long (5 months) ice-free seasons. delta 15N and delta13C in muscle tissue did not illustrate significant trends with ice-free days. We estimated that the turnover time of THg in muscle was about twice as long as stable isotope turnover in muscle, possibly explaining the lack of trend with stable isotopes in association with ice-free duration. Our discussion explains how summer environmental conditions may influence the composition of prey (mercury exposure) available to ringed seals. Results offer insight into how marine mammals may respond to directional changes in the Arctic ice-free season.

Stressors and coping in individuals with chronic kidney disease

The purpose of this study was to develop a valid and reliable instrument to measure stressors of patients with chronic kidney disease (CKD), identify those stressors, and determine which coping strategies were used and effective. The participants reported fatigue, sleep problems, and peripheral neuropathy as the most frequently experienced stressors. Optimism as a coping style was most commonly used and was also the most effective. Stress was inversely associated with age and CKD stage, and positively associated with coping. Knowledge from this study can be used to further patient education and supportive interventions for patients with CKD.

Impact of single-needle therapy in new chronic hemodialysis starts for individuals with arteriovenous fistulae

The native arteriovenous fistula (AVF) is the "gold standard" for hemodialysis (HD) vascular access. Unfortunately, AVFs can develop complications including inadequate maturation, cannulation difficulties and needle infiltration. In an effort to increase successful cannulations, decrease complications and subsequent central venous catheter (CVC) use, our centre introduced single-needle (SN) dialysis in April 2006 for new chronic patients receiving their first six HD treatments. The purpose of this study was to evaluate the impact of implementing SN dialysis on the incidence of CVC placements, investigative procedures required (e.g., arteriography), and missed HD treatments within the first three months of commencing dialysis. A secondary objective was to compare these data with double-needle (DN) dialysis treatments from the previous year. Retrospective chart reviews were conducted for all new chronic HD outpatient starts from April 2005 to 2006 for patients using DN dialysis and from April 2006 to November 2007 for those using SN. Information gathered included demographic data, location and vintage of the AVF, laboratory parameters, frequency of CVC placements, arteriography, and missed HD treatments due to cannulation difficulties. In total, data pertaining to 11 DN and 22 SN patients were collected. Of the 11 DN patients, 2 (18.2%) required a CVC placement in the first three months of treatment as compared to 2 (9.1%) using SN dialysis. Similarly, arteriographic investigations of the AVF were required in 4 (36.4%) DN versus 3 (13.6%) SN patients. There were a total of 19 missed treatments (8 DN; 11 SN). Dialysis blood work results were within safe and acceptable levels for those receiving SN dialysis. Use of SN dialysis for the first six HD treatments resulted in fewer mean CVC placements and investigations while main-raining adequate laboratory parameters. These results lend support for further research in this area.