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Globally, home dialysis prevalence has been declining relative to the increase in end stage renal disease and renal replacement therapy. The goal of this study was to identify international perceptions and practices. A web-based questionnaire was disseminated to nephrology nurses in 30 home dialysis-prevalent nations. Global telehealth use was low (23%), contrasting with 83% respondents agreeing telehealth would improve care. Only 31% of all programs enabled patient training outside of normal working hours (e.g., nights and weekends), and 31% of all program patients had some cost reimbursement, with a significant difference between U.S. and non-U.S. programs (U.S. 11%, non-U.S. 59%, 2 = 93.6, p < 0.0001). Significant differences in the need for monthly clinic visits (U.S. 72%, non-US 44%, 2 = 83.7, p < 0.0001) were also found. Telehealth provision and patient training flexibility is limited, and patient cost reimbursement is low. Increased telehealth, patient cost reimbursement, and flexible training models may promote home dialysis growth., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Fatigue is a subjective overwhelming feeling of tiredness at rest, exhaustion with activity, lack of energy that impedes daily tasks, lack of endurance, or a loss of vigor. Individuals with end stage renal disease (ESRD) experience a high rate and severity of fatigue. Symptom management of fatigue in this population is critical, since fatigue has been linked with lower quality of life and higher mortality rates. In this article, we present a definition and overview of fatigue, a review of factors contributing to fatigue, and ways to manage fatigue in individuals with ESRD., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Effective methodologies for teaching nursing students how to care for pediatric patients with end stage renal disease (ESRD) are not well described. Two teaching methodologies were compared using a mixed-methods approach: an at-home simulation group (three days simulating having ESRD: taking medications, eating a renal diet, nightly peritoneal dialysis), and a video group (children with ESRD and their families sharing their experiences). Data were collected via an anonymous online survey at course completion. Knowledge acquisition was assessed using psychometrically reliable multiple-choice questions; no statistically significant differences between the two groups were found, indicating both learned the material. Qualitative analysis found that both groups valued the assigned teaching method and that it deepened their learning. Students identified challenges that children with ESRD and their families are known to experience. Combining both teaching methods may ultimately be the most effective approach., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

This literature review examined burden, depressive symptoms, and perceived health reported by male caregivers of persons with end stage renal disease. These studies suggest that male caregivers often experience negative outcomes. Compared to non-caregivers, male caregivers had higher levels of anxiety and depressive symptoms. Qualitative studies suggest depression is common and associated with conflict between caregiving responsibilities and work, poor caregiver health, and fears about the future outcomes of relatives for whom they provide care. Future research will assist healthcare providers to identify at-risk male caregivers and develop effective interventions to support this understudied caregiver population., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Effective management of end stage renal disease for individuals undergoing hemodialysis (HD) requires the acquisition of self-care abilities, which have been shown to improve outcomes. Studies have indicated that educational interventions improve self-care abilities in patients with chronic kidney failure. A self-care coaching intervention was designed to bridge this gap. To evaluate, we utilized a pre-test/post-test quasi-experimental design using the Self Care for Adults on Dialysis (SCAD) tool. This was administered prior to, four months, and one year after the intervention. Results demonstrated improvement in self-care related to vascular access and fluid management, both significant aspects of being HD-dependent., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Patients with end stage renal disease (ESRD) experience a high symptom burden and poor quality of life as part of their advanced illness. Latinos experience a higher prevalence of ESRD compared to non-Latino whites; however, they are underrepresented in existing ESRD literature. We conducted a systematic review of qualitative studies that include Latino patients with ESRD and their caregivers in the United States. Of 694 citations published through August 2014, six met inclusion criteria. Four major themes emerged: 1) Losses, 2) Heightened awareness of death, 3) Barriers to quality communication and care, and 4) Mediating Latino traditions and values. A thematic schema was developed., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

There is no consensus on the ideal staffing levels for peritoneal dialysis (PD) units. The objective of this two-phase study was to evaluate nurse staffing levels in a PD unit based on activities and time spent performing them. An instrument was created based on nursing activities identified by a focus group, and the time spent performing these activities was measured over a four-month period. Forty-seven activities were identified, including care assistance activities (29), management activities (12), educational activities (5), and research activities (1). Direct patient care predominated, consuming 55.3% of overall time worked. Based on time spent per activity, we estimate that 70.2 hours of nursing care is required to care for one patient for one year., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Research investigating patient handoff processes has inundated the safety literature, but not in nephrology nurse practice settings. Effective patient handoffs are essential for maintaining patient safety by avoiding errors related to poor information exchange. This mixed methods research study investigated the process of patient handoff across nephrology practice settings and the implications for patient safety and nursing practice. Findings indicate there are too frequently issues with handoffs of patients with chronic kidney disease who must move between many different healthcare providers and healthcare settings. Nephrology nurses reported thar the use of multiple methods for handoff communications and practice sites having differing hours of operation present challenges to practitioners, which result in information too often "falling through the cracks.", Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Competent nurse managers of outpatient hemodialysis (HD) units are invaluable in enhancing patient safety, creating a culture of safety, and preventing adverse events. Yet little is known regarding the characteristics of a professional work environment that supports their important managerial role. The purpose of this qualitative study was to identify those organizational characteristics that outpatient HD unit nurse managers describe as important to a supportive managerial work environment. A total of six major themes with descriptive categories and exemplars emerged from the analysis. Findings from this study can inform HD administrators in their efforts to create and sustain work environments that support the professional practice of outpatient HD unit nurse managers. Notably, findings can also provide guidelines for nurse managers considering employment opportunities in that they can be used to assess and compare the work environments of outpatient HD facilities and organizations., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Exercise programs are rare in hemodialysis clinics. The study goals were to 1) explore nephrology nurses' attitudes toward exercise; 2) compare the attitudes between nephrology nurses who had been exposed and those who had not been exposed to an patient exercise program; and 3) measure the psychometric properties of a survey tool to measure nephrology nurses' attitudes toward intradialytic exercise. Nephrology nurse attitudes were positive toward patients' exercising; however, they did not believe it was their responsibility to conduct the exercise program. Nephrology nurses who had not seen patients exercising during dialysis were more likely to perceive exercise barriers. This study developed a valid and clinically useful 16-item instrument to measure nephrology nurses' attitudes about patient exercise in four areas: patient benefits, patient barriers, nurse barriers, and health professional enablers., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

A meta-synthesis of qualitative literature from 2004-2014 was conducted to identify the facilitators and barriers related to patients' uptake and continued use of home dialysis. These factors were addressed from the patient perspective using a systematic scoping review. A total of 848 citations were retrieved, and 12 studies were ultimately included. Data were analyzed descriptively by content analysis. The most commonly reported barriers were Burden of Care, Invasion of Body, and Disruption of Lifestyle, while the most common facilitators were Support, Physical and Mental Well-Being, Ability to Maintain a Normal Life, and Autonomy. Nursing implications are discussed for supporting facilitators and addressing barriers., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

The Human Resources for Health Program was launched in Rwanda in 2012 as a sevenyear initiative to improve healthcare services and decrease overall dependence on foreign aid. In partnership between U.S. academic institutions and Rwandan education affiliates, nursing resources have become primarily centered on the design and implementation of Rwanda's first Masters of Science in Nursing (MScN) Program at the School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali. The nephrology track consists of seven students with a wealth of clinical and educational experience who will receive the training needed to become advanced, ethical, and capable leaders in the nephrology nursing field. Faculty member William Rosa collaborated with the American Nephrology Nurses Association (ANNA) to provide these students with the online community, continuing education, practice standards, and journal access required to be proficient as graduate nurses through the donations of virtual memberships and copies of necessary texts. This is the University of Rwanda's MScN Nephrology Track story., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Communication and patient handoffs during transitions in care have been increasingly investigated due to their relationships with patient safety, quality of care, and efficiency. Handoffs occur at two points in the delivery of nursing care: nurse transitions in care and patient transitions in care. This article explores the accepted definitions, best practices, and evidence related to patient handoffs and patient safety., Competing Interests: The author disclosed that she is a Fresenius employee, and freelance editor for Lippincott, Williams & Wilkins and Elsevier publishing companies., (Copyright© by the American Nephrology Nurses Association.)

Exercise is an important element of preventative health, but it is not commonly practiced by patients on hemodialysis. This article summarizes the research on potential physiologic and psychological benefits of exercise for patients on hemodialysis and discusses recommendations of how exercise counseling can be conducted by nephrology nurses., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

This study explored the thoughts and feelings of individuals being treated with hemodialysis in the light of spirituality as an important determinant of quality of life. This research combined various methods, including analysis of patient diaries and of interviews, and found that social interaction and competence are the most important themes of spirituality. A quantitative analysis revealed that psychological well-being is more significant than physical well-being during hemodialysis, at least in retrospect., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Receipt of pre-end stage renal disease (ESRD) clinical care can improve outcomes for patients treated with maintenance hemodialysis (HD). This study addressed age-related variations in receipt of a composite of recommended care to include nephrologist and dietician care, and use of an arteriovenous fistula at first outpatient maintenance HD. Less than 2% of patients treated with maintenance HD received all three forms of pre-ESRD care, and 63.3% received none of the three elements of care. The mean number of pre-ESRD care elements received by the oldest group (80 years and older) did not differ from the youngest group (less than 55 years), but was less than the 55 to 66 and 67 to 79 years groups; adjusted ratios of 0.93 (0.92 to 0.94; p < 0.001) and 0.94 (0.92 to 0.95; p < 0.001), respectively. A major effort is needed to ensure comprehensive pre-ESRD care for all patients with advanced chronic kidney disease (CKD), especially for the youngest and oldest patient groups, who were less likely to receive recommended pre-ESRD care.

Patients with chronic kidney disease (CKD) are often referred to a nephrologist late. Contributing factors include primary care providers' lack of awareness of practice guidelines for treating kidney disease and their uncertainty of timing for referral to a nephrologist. The purpose of this quasi-experimental study was to determine if advanced practice nurses working in primary care are knowledgeable about the National Kidney Foundations Kidney Disease Outcomes Quality Initiative Guidelines, if a CKD education program increases knowledge, and if knowledge is retained. Fourteen advanced practice nurses participated in the study. The knowledge outcome was measured using a CKD knowledge-based survey. The results showed a significant increase in knowledge post-intervention; moreover, knowledge gained was retained at the one-month follow-up intervaL This evidence-based practice project was developed to promote timely referral to a nephrologist, which may then slow the progression of kidney disease, decrease morbidity and mortality, and reduce healthcare cost.

Dialysis options education in the United States for patients tends to focus on clinical aspects of ESRD treatment and on how each option is done. The non-profit Medical Education Institute (MEI) has developed an online, patient-centered dialysis decision aid that maps six dialysis options (peritoneal dialysis, standard incenter hemodialysis, conventional home hemodialysis, short daily hemodialysis, and nocturnal hemodialysis--incenter or at home) in four categories onto 24 different lifestyle and health values. This new free, non-commercial tool allows education to start with why an individual might want to choose a particular option, rather than how, a paradigm shift that may enable more effective options education.

Nurses working with patients pre-, during, and post-kidney transplant are faced with ethical decisions in every phase of the transplant process. This article provides interpretive statements for the nine provisions of the 2015 ANA Code of Ethics for Nurses for transplant nurses in facilitating patient-centered decision making throughout the transplant process.

Poorly controlled co-morbidities associated with pediatric chronic kidney disease may be associated with low health literacy skills of caregivers. This article explores what is known about health literacy in the home management of patients with pediatric chronic kidney disease, and examines caregiver and child literacy as it relates to child health outcomes.

Outpatient hemodialysis unit staff members are at risk for psychological stress, including death anxiety, unresolved grieving, and burnout, due tofrequent interactions with chronically ill patients who have a high mortality rate. Experiencing death anxiety and burnout may impair the ability to build interpersonal relationships, decrease job satisfaction, and impact quality of patient care. A quantitative study to evaluate the effect of educational classes on the level of death anxiety and burnout among hemodialysis caregivers revealed a decrease in participants' level of death anxiety and a decrease in emotional exhaustion in one area that was directly related to the work environment Information from the study can be used to decrease psychological stress through education and support for staff members who work in the hemodialysis unit environment.

Much of the evidence supporting a focus on end-of-life care for persons with kidney disease is in the form of expert opinion and professional practice guidelines based on multi-disciplinary input and an exploration of the known illness trajectory for renal disease. Limited intervention studies or randomized control trials related to palliative or hospice care for patients in the U.S. with ESRD remain, providing rich opportunities for nephrology researchers. Nephrology nurses should remain vigilant and open to opportunities to participate in research related to improving end-of-life care for persons with ESRD and should be at the forefront of designing evidence-based practice projects for end-of-life care options for this population.

Urgent-start peritoneal dialysis (PD) refers to the initiation of dialysis soon after a PD catheter placement and is a treatment option available to the late-referred patient with advanced kidney disease. This article reviews nursing aspects of urgent-start PD and can serve as a guide for this evolving clinical pathway that can provide renal replacement therapy for a critical segment of the population with Stage 5 chronic kidney disease who require renal replacement therapy.

Isothermal hemodialysis to improve intradialytic tolerance in hypotension-prone patients has been effective in outpatient settings. The purpose of this pilot study was to examine thermal control in an acute care setting and describe comfort issues associated with thermal control Although complaints of cold or shivering occurred more frequently with the isothermal hemodialysis group, cold discomfort was managed by nursing interventions and was not a cause of significant discomfort. No statistically significant difference was observed in blood pressure or patient's comfort level between standard and isothermal dialysis. However, isothermal hemodialysis may be an appropriate hemodialysis option for control of intradialytic hypotension in the acute care setting. Further research is recommended.

Dry weight has most frequently been defined by the patient becoming symptomatic when fluid removal is attempted Hypervolemia and fluid removal require ongoing evaluation and the use of a number of strategies. This article reviews strategies for removing fluid during hemodialysis, hemodynamics of fluid removal, and interventions associated with the strategies for fluid removal.

The growing incidence of end stage renal disease (ESRD) has resulted in an ever-increasing demand for hemodialysis services throughout the country. Unlicensed assistive personnel (UAP), including dialysis technicians or patient care technicians (PCTs), and licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) perform a vital role in the care of patients undergoing hemodialysis and are a critical staff component in hemodialysis facilities. This analysis provides a broad overview of the positions of states with respect to the administration of heparin and saline via peripheral and central lines by PCTs and LPNs/LVNs in the hemodialysis setting.

Long-term central venous catheter (CVC) use among patients on hemodialysis increases the risk of infection, morbidity, and mortality. This article describes the use of Kotter's process of change to establish a multidisciplinary vascular access team to facilitate the replacement of CVCs with long-term accesses. Through the implementation of vascular access teams and the execution of Kotter's eight-step process for leading change, hemodialysis clinics will have the tools needed to reduce CVC utilization rates and improve patient healthcare outcomes.

Based on a literature review, the physiology of blood pressure control and hemodynamic changes that occur during a hemodialysis treatment, blood pressure evaluations at 15-minute intervals as opposed to 30-minute intervals may enable nephrology nurses and other care providers to recognize and prevent dramatic drops in blood pressure. Through maintenance of blood pressure stability and prevention of intradialytic hypotension, patient morbidity and mortality may be decreased. Blood pressure monitoring is one component for ensuring quality care, decreasing morbidity, and decreasing mortality. Integration of assessment data, estimated dry weight evaluation, and patient adherence are fundamental to the promotion of good health outcomes.

Older adults (65 years of age and older) comprised 4.1% of the population in 1900 (3.1 million), rose to 13.0% in 2010 (40.3 million), and are projected to reach 16.1% in 2020 (54.8 million). With each decade, there has been a steady increase, including older adults, in the population with chronic kidney disease. This article provides a review of the literature related to the demographics of the older adult population and older adults with chronic kidney disease. It also explores life expectancy, health promotion, and the economic impact of chronic kidney disease and its co-morbidities.

Caring for J.D. was a stressful experience. The extent of her wounds, pain, and limited options for treatment was very frustrating for the nursing staff. Although she did not survive, patient outcomes were met to some degree. Her pain was controlled to a greater extent, and there was less infection present in her wounds. The nurses worked with J.D. closely to improve her pain control and facilitate less painful dressing changes. They were vigilant in assessing the progress of her wound healing and communicating any increased signs of infections from her wounds. They sang with her to help distract her from the pain she was experiencing and to help her cope with her lengthy 8-month hospitalization. Providing care for J.D. was also a very important learning experience for nurses in terms of appropriate pain management for patients with CUA, wound care, and the need to sustain adequate nutrition to promote wound healing. CUA is a rare but potentially fatal disease that occurs in patients with end stage renal disease (ESRD). Early diagnosis and treatment are essential to prevent the devastating effects of this disease. Nephrology nurses need to reinforce the importance of keeping calcium, phosphorous, and parathyroid levels within normal ranges for their patients on dialysis. They also need to be vigilant in monitoring for potential CUA skin lesions to prevent and treat it early. To date, treatment options are mostly based on findings from case reports. Treatment requires a multidisciplinary approach with input from nephrologists, nurses, pain specialists, infectious disease specialists, and surgeons. The major goals of treatment are controlling risk factors, controlling pain, and preventing wound infection and possible sepsis. More studies need to be conducted to test interventions that may help treat CUA.

End stage renal disease is a major health issue in the United States. Dialysis, the major form of renal replacement therapy, has physical and psychological implications that can have a major impact on both men's and women's sexuality and sexual performance. Nurses are in a key position to assist men and women on dialysis to develop healthy and realistic approaches to their sexuality. This article reviews the literature on dialysis and sexuality, and recommends nursing interventions that can assist persons on dialysis achieve the level of sexual intimacy and satisfaction they desire.

Hypertension in patients on hemodialysis (HD) contributes significantly to their morbidity and mortality. This study examined whether a supportive nursing intervention incorporating monitoring, goal setting, and reinforcement can improve blood pressure (BP) control in a chronic HD population. A randomized controlled design was used and 118 participants were recruited from six HD units in the Detroit metro area. The intervention consisted of (1) BP education sessions; (2) a 12-week intervention, including monitoring, goal setting, and reinforcement; and (3) a 30-day post-intervention follow-up period. Participants in the treatment were asked to monitor their BP, sodium, and fluid intake weekly for 12 weeks in weekly logs. BP, fluid and sodium logs were reviewed weekly with the researcher to determine if goals were met or not met. Reinforcement was given for goals met and problem solving offered when goals were not met. The control group received standard care. Both systolic and diastolic BPs were significantly decreased in the treatment group.

When individuals with chronic kidney disease require ongoing assistance with activities of daily living and disease management, the consistent care provided by family caregivers often averts the need for institutional placement These caregivers may experience physical and mental burden when supports are not in place to provide occasional help and relief In some states, public programs have been developed to provide assistance to family caregivers, such as respite care, caregiver training, and tax credits. However, policies among the states are not consistent. This study identified factors that have influenced the development of family caregiver-friendly policies and programs in two study states, Connecticut and New Jersey. The case study method used in this research utilized data from informant interviews, document review, and observation of select meetings and hearings to identify 11 factors or themes that impacted public policy development benefiting family caregivers. Two primary factors, state fiscal environment/philosophy and advocacy, were found to be critical to the policymaking process. Based on these findings, specific measures are described that nephrology nurses can take to help influence adoption of policies benefiting caregivers. In addition, information to help caregivers access available programs through agencies, organizations, and informational Web sites is identified.

One group of nurses not frequently studied but who have felt the burden of shortages of registered nurses (RNs) is that of nephrology nurses. Nurses' valuable insights must be solicited for the accurate assessment of current work environment issues and for their specific solutions. The purposes of this study were to explore nurse satisfaction and dissatisfaction with the work environment in outpatient hemodialysis facilities, to solicit nurses' insights on potential solutions, and to develop national strategies for improvement. Focus group qualitative methodology was utilized with focus groups and individual interviews, including a total of 101 RN participants from 45 outpatient hemodialysis facilities. The overall category of this study was Striving to be Heard and Recognized with the following four supportive categories: Maintaining Competency, Resolving Staffing and Resources, Strengthening Organizational Leadership, and Rebuilding Relationships. Nephrology nurse participants have identified strategies within each category for the improvement of their work environment. The voices of nephrology nurses must be heard and acted upon in a timely manner to improve workplace environment.

As life expectancies increase, nurses will care for more individuals with chronic conditions, one of which is chronic renal disease. Increasing diversity and complexity of older adult healthcare needs signals a need to reconceptualize perceptions of successful aging. By emphasizing health promotion and adaptation, successful aging is possible for those with chronic renal disease. This article provides an overview of theory-based strategies for fostering successful aging in the patient with chronic renal disease.

In 2003, the Nephrology Section at Dartmouth-Hitchcock Medical Center embraced a new concept for providing care that included a continuing care manager and a nephrologist working together with the patient to introduce stage-based education and clinical interventions. This study compares the outcomes of patients initiating hemodialysis or peritoneal dialysis who received CKD care using a multidisciplinary care model (n = 89) with those who received traditional nephrology care (n = 82). Overall, the findings in this study support the use of the multidisciplinary clinic as a method for improving care of the patient with CKD initiating dialysis, and reducing hospital admissions and costs. The care coordination provided in the multidisciplinary setting improved the number of fistulas placed (60.7% vs. 21%, p < 0.001), the number of fistulas used for dialysis initiation (40.4% vs. 12.3, p < 0.001), and the management of anemia with higher hemoglobin levels prior to dialysis initiation (10.9 g/dL vs. 10.0 g/dL, p = 0.003). Patients receiving multidisciplinary care were 42% less likely to be admitted to the hospital for dialysis initiation, had significantly fewer days hospitalized (p = 0.001), fewer admissions (p = 0.005), and reduced charges for a 90-day period (p = 0.003) after dialysis initiation.