Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of Jersey, College of Nursing, and winner of the American Nephrology Nurses’ Association (ANNA)’s 2005 Nurse Researcher of the Year award.
According to the dictionary, nephrology is “a branch of medicine concerned with the kidneys.” To nurses who work within this specialty, however, it is a great deal more.
“Nephrology nursing offers a lot of career choices,” says Adrian Priester-Coary, MSN, RN, CNN, a nurse educator at the University of Chicago Hospitals. “A nephrology nurse in a hospital can go into an acute/critical care, home training, in-center or clinic setting. You can choose many different paths as you grow in this field.”
Those career paths may include such options as:
- direct care of patients with end-stage renal disease (ESRD) who receive dialysis or who undergo renal transplants;
- education of patients, communities or health professionals about risk factors that can lead to chronic kidney disease (CKD);
- research into the effectiveness of treatment modalities and the impact of nursing practice on patient outcomes;
- advocacy, such as working with government agencies to develop health policies that will improve the care of kidney disease patients.
No matter what their area of expertise may be, nephrology nurses in all of these career settings are working toward the same goal: to help patients who have or are at risk for kidney disease lead the healthiest lives possible.
According to recent statistics, 10 to 20 million Americans have kidney disease, although many are unaware of their condition. The primary risk factors include diabetes (the leading cause of ESRD), hypertension and a family history of kidney problems. People who have at least one of these risk factors are almost five times more likely to develop kidney disease than those who have none.
With both diabetes and hypertension on the rise, especially among African Americans, Hispanics, American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders, it is small wonder that the risk for kidney disease is also much higher in these populations. African Americans, for example, are four times more likely to develop ESRD than Caucasians.
These disparities mean that nurses of color have the opportunity to make significant contributions to the care, education and overall well-being of minority patients with kidney disease. “[Being a minority nurse] gives you insight into the patient’s culture, some of the things that have happened in their lives and why they may have postponed their treatment,” explains Janie Martinez, BSN, RN, CCRN, CNN, a nephrology nurse clinician at Alamo Kidney Health at Bexar County Dialysis Unit in San Antonio. “For a lot of the men, it’s the macho instinct. For women, it’s the nurturing belief that their family comes first, so the little money they have is spent on the family and not on their medication.”
Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of New Jersey, College of Nursing, and winner of the American Nephrology Nurses’ Association (ANNA)’s 2005 Nurse Researcher of the Year award, agrees that having first-hand knowledge of a minority kidney patient’s culture can be helpful. “Because [minority nurses] have many life experiences similar to those of our patients, we share an understanding,” she says. “When patients respond to health care professionals with cultural cues—for example, particular facial expressions or hand movements that may be unique to a certain culture—minority nurses pick up on those cues more easily because we understand them. And we can help nonminority nurses understand the background, experiences and responses to illness that are grounded in minority patients’ cultures.”
Caring Across the Continuum
Nephrology nursing encompasses total patient care, because the kidneys affect every other major system in the body—cardiovascular, pulmonary, gastrointestinal, etc. Comorbidities, especially diabetes and high blood pressure, are usually causative factors in CKD and must be addressed concurrently. And because treatment for kidney disease is costly, patients also face numerous psychosocial and financial issues.
“Many of [our ESRD patients] are indigent. Most are already on Medicare, so getting medication becomes a problem,” says Martinez. “For young people who now have to have dialysis three times a week, it changes their lifestyle completely.” Even patients who are not on dialysis must face many lifestyle changes, such as alterations to diet and exercise and possible side effects from medications.
Nephrology nurses may work with patients at any point along the continuum of care: people who have one or more risk factors but have not yet been diagnosed with CKD, patients who have been diagnosed with abnormal kidney function but do not yet require dialysis, ESRD patients on dialysis and kidney transplant patients.
Although renal failure cannot be reversed, early diagnosis and intervention can slow the disease’s progression. According to Gwen Bryant, BSN, RN, CNN, facility administrator for two DaVita dialysis centers in Detroit, “Seventy percent of renal failure is related to either diabetes or hypertension. So if [nurses] can get out and talk to the population about risk factors, get people to look at the warning signs and know what they are, they can start intervention and slow down the disease.”
Dialysis treatment is so time-consuming that for many patients it can feel like a part-time job: They must come in three days a week for three to four hours at a time. To promote continuity of care, charge nurses work the same days (Monday/Wednesday/Friday or Tuesday/Thursday/Saturday) and the same shifts (sometimes 10 to 12 hours) so patients always have the same caregiver. Working alongside specially trained technicians who actually operate the dialysis machines, nurses keep track of patients’ responses to treatment, monitor their overall health and provide education.
“You spend time with your patient and you learn from each other,” says Bryant. “You can share information that’s going to make their lives—and their families’ lives—better.”
Dialysis centers and hospital dialysis units aren’t the only practice settings where nephrology nurses help ease the burden on ESRD patients and families. Many dialysis patients also require home health care and personal care because they’re too weak to perform some of their common daily activities, plan their diets or accurately monitor their medications. Plus, in today’s increasingly cost-conscious health care industry, in-home dialysis is a growing trend.
“Unfortunately, many of these patients don’t have family support,” says Wanda Chukwu, RN, MA, owner of Assertive Health Services, a home care agency in Detroit that specializes in dialysis patients. “One of my goals is to help promote their needed lifestyle [regimen] when they’re home. If you can increase a patient’s compliance, you’re going to decrease hospitalization.” Home care nurses are also in an excellent position to educate patients and families about risk factors and preventive measures before kidney disease enters the picture.
Moving to Management
Some clinical nephrology nurses find that they have an interest in and aptitude for working with the bigger picture. “I knew I wanted to be a manager,” recalls Sue Jones, RN, CNN, regional director for Gambro Healthcare in Philadelphia. “But I didn’t want to just lead or just manage; I wanted to educate my staff and share knowledge.”
Jones oversees seven dialysis centers with an average daily patient census of 600. Her responsibilities include touring the clinics and communicating with clinical directors about patient problems, adequate staffing and survey readiness. She also makes a point of greeting patients and observing the care being delivered.
Bryant is another manager who shares this interest in maintaining contact with the patients her facility serves. “Because I’m a nurse and I love hands-on work, I come in and make rounds at least twice a day to see all my patients,” she says.
In addition to reviewing clinical outcomes, profit/loss statements and budgetary targets, she also participates in community and corporate education programs, visiting worksites and other community locations to talk to people about kidney disease prevention. For example, in DaVita’s Kidney Education and You (KEY) program, nurses hold seminars, talk to community members about renal failure and risk factors, take blood pressure readings and give out information from the National Kidney Foundation (NKF) and the National Kidney Disease Education Program (NKDEP).
Educating the Masses—and the Nurses
Nephrology nurses agree that this type of educational outreach is critical to stemming the kidney disease epidemic. Many nurses get involved in outreach efforts because they have firsthand experience of how devastating the disease can be.
“I have friends with renal disease who are currently on dialysis and one who is awaiting a kidney transplant,” explains Diana Brown-Brumfield, MSN, RN, CNS, a clinical nurse specialist for surgical services at the Cleveland Clinic Foundation. “I became involved with NKDEP two years ago as a pilot project to educate the Cleveland community about renal disease and how it disproportionately affects minorities. I started doing some education in our local churches about the disease and the effect it has on the minority population. Although I’m not a nephrology nurse, working in surgery affords me the opportunity to get the word out on prevention, because this is a preventable disease if we really focus on it.”
Early education is a goal for many organizations involved in kidney disease prevention, including NKF, the National Institutes of Health (NIH) and state and local support groups for chronic diseases such as diabetes. For example, the goal of NKDEP, an initiative of the NIH’s National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK), is to increase awareness of kidney disease, its risk factors and the importance of early diagnosis and treatment. The program offers extensive informational resources for both patients and health professionals, including “You Have the Power to Prevent Kidney Disease,” a national public awareness campaign targeted to African Americans.
Indeed, patients and the public are not the only ones who need information about kidney disease. Nurses who can provide specialized nephrology education to other health care professionals are needed in hospitals, dialysis centers, universities and colleges.
Priester-Coary works as the nurse educator for three chronic units, one acute unit and one home training unit. “My responsibilities are usually project-driven and based on findings from the CQI [continuous quality improvement] group or other hospital initiatives,” she says. “I review the literature, update policies and procedures, develop the necessary teaching tools and then go on the road to educate the staff.”
Shaping the Future
The sharing of nephrology knowledge is not restricted to the education arena. By making their expertise available to government agencies and other influential health organizations, minority nurses have excellent opportunities to help shape the development of policies, best practices, treatments and products that can improve care for renal patients of color.
For example, NKF has a Council of Nephrology Nurses and Technicians (CNNT) that helps develop health policies that impact professional practice and the delivery of patient care. The council also recommends speakers for NKF’s annual clinical meeting and helps moderate sessions. In addition, council members participate in national activities such as the Kidney Early Evaluation Program (KEEP), in which volunteers provide free screening for CKD in community settings such as churches and in dialysis centers.
Participation in professional associations such as ANNA is another important way for minority nurses to make sure their voices are heard. “One of our goals is to actively recruit minority nurses as elected leaders, committee chairs and members,” says Suzann VanBuskirk, BSN, RN, CNN, president of ANNA.
Association involvement can offer various ways for nephrology nurses to share their “real world” experience with health care policymakers. For example, “ESRD networks are contracted with the federal Centers for Medicare & Medicaid Services (CMS),” VanBuskirk explains. “The individuals who work for those networks—many of whom are nurses with previous experience in dialysis and transplantation—work as quality managers and data analysts. They are involved in quality initiatives and educational offerings and they have wonderful opportunities to work as contracted government employees to make a difference in the outcomes and quality of care that is delivered.”
Nurses’ front-line experience and knowledge is also in demand by manufacturers of dialysis equipment and related products, as well as pharmaceutical companies. These firms hire nephrology nurses as quality/outcomes consultants, clinical educators and/or marketing representatives.
Doing the Research
With the emphasis on evidence-based practice throughout the health care field, the development of policies and best practices depends on the results of careful research. And who better to conduct research on nephrology nursing best practices than nurse scientists?
“As an advanced practice nurse in the dialysis unit, I became interested in what nurses did and how they affect patient outcomes,” remembers Thomas-Hawkins. “I realized I needed to get into a doctoral program to learn how to measure patient outcomes and try to figure out, in a measurable way, what nurses can do to have a positive impact.”
The term measurement may cause some confusion about how researchers actually work. Most nurses in clinical practice are familiar with quality improvement projects in which they collect, analyze and present data on outcomes such as patient falls and nosocomial infections. These projects are good starting points because they help staff understand a problem and try to correct it. Researchers, however, apply far more precise tools and scientific methods when measuring rates of comorbidities, effects of treatment modalities and so forth. This ensures that data gathered from different organizations and demographic areas are comparable; if they are not comparable, they are not useful.
“The importance of having more minority nurse researchers [in nephrology] is probably our interest in addressing issues that are important to the minority community,” says Thomas-Hawkins. “We’re able to tap into issues that are important to our respective [ethnic] groups because these are problems we or our families have actually experienced.”
Diversifying the Ranks
Although no demographic information about the percentage of racial and ethnic minority nurses in the nephrology nursing workforce is currently available, nurses in the field seem to agree that minority representation is low. The numbers obviously vary by geographic region and setting (urban, suburban, rural), but the fact is that many patients of color aren’t receiving care from nurses they feel truly understand them and their needs.
How can you find out if a career in nephrology nursing is right for you? Talking to nurses who are already working in the field may help. And it’s worth noting that nephrology nurses tend to remain in the specialty for a long time.
“I’ve been in nephrology for almost 20 years,” says Janie Martinez. “To me, it’s not a profession, it’s a vocation. There are a lot of rewards when you see younger people and they get to go back into the world.”
Gwen Bryant agrees that the patients make the difference. “Chronic renal failure affects every aspect of a patient’s life—their diet, their family life, their work. If you ask me why I’ve been in nephrology for 25 years plus, I’d say it’s because these patients are the most courageous in the world.”
Learning What You Need to Know
Undergraduate nursing curricula are notoriously lax about including more than a passing mention of nephrology, and even the offerings at the graduate level are meager. Therefore, nephrology nursing education often occurs on the job, whether in an acute care setting or a dialysis clinic/unit.
Most training programs run eight to ten weeks and include classes in anatomy, physiology, the disease process and the principles of hemodialysis, peritoneal dialysis and transplantation. Nurses who will be working with dialysis patients are partnered with a nephrology technician to learn how the artificial kidney works and the impact it has on patients while they are dialyzing. The nephrology nurse-in-training also works with a mentor to learn about the pharmaceuticals used in the specific setting (medications differ between outpatient and acute care settings). If the facility handles specific patient populations, such as pediatrics, nurses also must develop age-specific competencies.
Certification for qualified registered nurses can be obtained through the Nephrology Nursing Certification Commission, which offers two options. The certified nephrology nurse (CNN) examination is designed to test proficiency in nephrology nursing practice. The certified dialysis nurse (CDN) exam is a competency-level test for nephrology nurses working in a dialysis setting. More information is available at the commission’s Web site, www.nncc-exam.org.
Most employers looking to hire nephrology nurses want RNs with at least one year of work experience rather than recent graduates. A background in medical-surgical and/or critical care nursing is highly recommended. “In med-surg, you learn the general basics of patient care and disease processes,” explains Sue Jones, RN, CNN, of Gambro Healthcare. “Then with critical care you go on to the sicker patients and see the impact of what a chronic disease can do. It really helps the nurse to see that continuum from diagnosis of another chronic disease like diabetes to a patient with the need to start on dialysis.”
The various career paths open to nephrology nurses have their own requirements for education, experience and skills. For example, nurses wishing to make the move into management of a dialysis center or unit will require a working knowledge of how that facility operates, usually by working as a charge nurse first. Managers also need excellent communication skills (both oral and written), computer savvy, organizational and time management skills and the ability to deal with conflict among both patients and staff. An understanding of financials, such as budgets and profit/loss statements, is strongly recommended; this can be acquired on the job or through an advanced degree. In addition, managers must be familiar with federal and state regulations to ensure their facilities are in compliance.
If you are interested in starting your own home dialysis, renal care or home health care business, an advanced degree in a related subject is probably helpful. “I’m working on a PhD in organizational management,” says Wanda Chukwu, RN, MA, owner of Assertive Health Services. “I think it helps immensely with the kind of services I offer.”
Nurse researchers require doctoral degrees to learn the rigorous scientific methodologies necessary to conduct accurate studies. “To do a research project, you need to make sure that the instruments you use are valid and reliable and that you’re getting the information you need,” explains researcher Charlotte Thomas-Hawkins, PhD, RN, CNN, assistant professor at Rutgers, The State University of New Jersey. “Certainly nurses with master’s degrees can also conduct research, but they really need to do it with a doctorally prepared researcher. Because there are so few doctorally prepared nurses in any specialty setting, the model for research is for those researchers to do collaborative projects with nurses in clinical practice.”
Nurses interested in becoming nephrology educators may or may not need an advanced degree, depending on the setting. But certification is always a plus, as is a mastery of public speaking. “If you have the desire to learn, plus motivation, patience and compassion for your students, you can teach,” asserts Adrian Priester-Coary, MSN, RN, CNN, a nurse educator at the University of Chicago Hospitals. Nurses who wish to focus on patient education, either at a health care facility or in the community, need to understand the fundamentals of teaching and learning. This knowledge and expertise can be gained as part of degree preparation and nursing practice. To teach at a college or university, however, a master’s or doctoral degree is usually the minimum requirement.
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