Editor’s Note: This special section, called Kidney Care 101, is part of a series in NN&I for the health care professionals entering the renal industry. Whether you are an administrator, social worker, nurse, patient, dietitian, technician, or nephrologist, this series of articles will help you get comfortable with how things come together in a dialysis unit. A special section will also be devoted to transplant care.
Once the series is completed, NN&I will offer the complete series of articles as an eBook, available on our website, NephrologyNews.com. Along the way, we encourage NN&I readers to share their own advice on how things work in renal care.
–– Mark E. Neumann
Nephrology nurses face a rapidly changing health care landscape, shifting patient demographics, an explosion of technology, and a multitude of everyday challenges. We need to learn to use strategic thinking to identify issues, collaborate with decision makers, and understand who has the power to control decisions and resources. Changes taking place in the nursing profession in general and nephrology nursing specifically have been driven by socioeconomic factors, as well as by developments in health care delivery and professional issues unique to nursing. This article reviews five of these issues and their impact on nephrology nursing.
1. Legislation and regulation
"Nephrology nurses can no longer afford to remain in the background or to be added as an afterthought to the policy and legislative arenas."
Nephrology nurses face challenges associated with patient safety and satisfaction, access to services, clinical outcomes, health disparities, and regulatory changes. Dealing with these concerns and other workplace issues, nurses have the choice to continue trying to make do while feeling victimized by current changes or to motivate themselves to take action and find opportunities to bring about change in the health care system itself (Mick, 2004).
In a survey released by the Robert Wood Foundation in 2010, 75% of opinion leaders ranked government officials as having a great deal of influence in health reform in the next five to 10 years, compared to their rankings of the influence of insurance executives (56%), pharmaceutical executives (46%), health care executives, (46%), doctors (37%), patients (20%) and nurses (14%).
Opinion leaders identified the top barriers to nurses’ having greater influence on health reform as not being perceived as important decision makers (69%) or revenue generators (68%) compared with doctors, and nurses not having a single voice in speaking on national issues (56%).
It is generally assumed that nurses lack the power to be effective in the legislative arena. Nurses contribute to this assumption by describing themselves as powerless. Whether nephrology nurses recognize it or not, they are impacted daily by policies, legislation, and regulations developed by non-nursing individuals.
Nephrology nurses can no longer afford to remain in the background or to be added as an afterthought to the policy and legislative arenas. Nephrology nurses have the potential to successfully advocate for their patients and their practice. They have a unique perspective on health care policies and expertise to share. Nephrology nurses must become a strong voice actively advocating for positive change.
2. Advances in technology
The rapid growth in information technology has already had a far-reaching impact on health care delivery. Advances in digital technology have increased the applications of telehealth and telemedicine, bringing together patient and provider without physical proximity. Nanotechnology will introduce new forms of clinical diagnosis and treatment by means of inexpensive handheld biosensors capable of detecting a wide range of diseases.
Accessibility of clinical data across settings and time has improved both outcomes and care management. Through the Internet, patients will be increasingly armed with information previously available only to clinicians. The use of electronic medical records imposes significant challenges to the nurse. In some instances tasks previously taking seconds to complete on paper now require more time with multiple clicks through a maze of menus.
In nephrology there is the additional burden to use multiple systems, each with its own security system and registration requirements, to meet the requirements of the Quality Incentive Program (QIP). Currently, data entry is required through claims reports, CROWNWeb, and the National Health Safety Network (NSHN). The American Nephrology Nurses Association has recently met with the Centers for Medicare & Medicaid Services (CMS) to reinforce the critical need to include nephrology nurses in the development and implementation of these systems.
3. Evidence-based practice
The importance of evidence-based practice is not new. Nurses (as well as physicians) continue to face barriers to implementation. These barriers include time constraints, limited access to the literature, lack of training in interpretation of research, and a work environment that does not encourage information seeking. Getting past the workplace restraint and the comments like, “That’s the way we have always done it” remain the biggest barrier to nurses readiness and willingness to embrace evidence-based practice. For example, the treatment for hypotension during a hemodialysis treatment for decades was a trendelenburg position. Evidence has shown us this is no longer the best intervention for the patient, yet practice (and policies) is slow to change.
Education is another big factor. Nursing educational programs 20 years ago did not address an evidence-based approach to care. ANNA has made a commitment to educate the nephrology nurse in evidence-based care. Articles, webinars, and presentations are scheduled throughout the year to focus on this important topic. But that effort is not enough. The best way to make evidenced-based care a reality is to have nephrology nurse leaders encourage evidence-based practice at the chairside.
4. Crossing borders
Licensure requirements for nurses are different in each state. From a legal standpoint, a professional nurse license is an affirmation by a duly constituted body, usually a state, that a nurse has met certain prescribed qualifications and is therefore recognized under the laws of the state as a nursing professional. The Nurse Licensure Compact allows a nurse to practice in any Compact-participating state on the home-state license. Thus, the Compact is often cited as the answer to questions about licensure jurisdiction for cross-border practice. To date, however, only 24 states have chosen to belong to the Compact and concerns exist about its consequences. (ANA, 2012). A significant consequence created by compact licensure is the inability nationwide to keep nurses from avoiding the penalties of misconduct by hopping across state lines. Critics say the compact may actually multiply the risk to patients. There is no central licensing for the compact, so policing nurses is left to the vigilance of compact member states. But maintaining the current licensure process, where each state licenses and disciplines its own nurses, creates challenges. For example, this means that if a nurse practicing as a CKD Educator or home training nurse provides care to a patient not in his/her licensed state (and the state where the patient is located is not a member of the Compact) the nurse must be licensed in both states: where she/he resides and where the patient is during the telephonic intervention.
This issue is most evident during weather-related disasters when specially trained nephrology nurses are unable to deploy to affected states due to licensure issues. ANNA is working with the Kidney Community Emergency Response Coalition (KCER) to develop a process that allows nurses to more smoothly obtain permission to cross state lines to work in affected states.
5. Nurse sensitive outcomes
Nursing-sensitive outcomes reflect the structure, process, and outcomes of nursing care. The number of nursing staff on duty, the skill level of those nursing staff, and their education/certification indicate the structure of nursing care. Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improves if there is a greater quantity or quality of nursing care (e.g., fewer falls, fewer infiltrations). Much of the burden of measurement and data collection falls on nurses. There needs to be a focus to ensure we are measuring the right things with as little burden of measurement as possible.
ANNA is in the process of defining nephrology nurse sensitive quality indicators utilizing a broad-based approach to include structural, process, and outcome measures. These indicators will address implications for clinical practice, research, education, and public policy.
Nephrology nurses are continually facing unique challenges in their work environments. The development of skills to help navigate these challenges while continuing to provide quality care is critical.
-American Nurses Association, Nursing World: Interstate Nurse Licensure Compact: States 99 Participating in the Nurse Licensure Compact; linking to the National Council of State Boards of 100 Nursing (NCSBN) map (2012): http://www.nursingworld.org/MainMenuCategories/Policy-101 Advocacy/State/Legislative-Agenda-Reports/LicensureCompact.
– Groundbreaking new survey finds that diverse opinion leaders say nurses should have more influence on health systems and services RWJ survey 1/19/2010
– Heller BR, Oros MT, Durney-Crowley J. (2000) The future of nursing education: Ten trends to watch. Nursing Health Care Perspective. Jan-Feb;21(1):9-13
– Mick S. (2004). The physician surplus and the decline of professional dominance. Journal of Health Politics, Policy and Law, 29(4-5) 643-659.