That advice about timing resonated last month as she prepared to donate a kidney to her mentor, professor and faculty colleague. Professor and biostatistician Vicki Stover Hertzberg, PhD, who directs the school’s Center for Data Science, had been waiting nine months for a transplant after being diagnosed with kidney failure.
The two professors’ personal relationship is only one aspect of their remarkable story.
Both long ago had personal experiences that made them aware of the high need for living kidney transplants and the safety of donation. At the nationally No. 2-ranked School of Nursing, both women work on a research team that studies renal issues and other health problems related to heat exposure in farmworkers and published their findings in March. Both say their life-giving partnership reflects their school’s caring connections.
Chicas was only one of several Emory employees who answered Hertzberg’s call for potential donors in mid-2021. While others matched enough to donate, Chicas was the closest match.
“So much science has gone into it for such a long time, and to be able to use that science to help Dr. Hertzberg be healthier and live longer, it’s awesome. And I get to be a part of it.”
—Roxana Chicas, PhD, RN
“I have no words to express my gratitude for the individuals who came forward including those who ultimately, for one reason or another, could not be a donor,” Hertzberg said before the March 15 transplant surgery. “And for Roxana to do this is just phenomenal. I find it very overwhelming and very humbling.”
Most of us only need one kidney
Chicas’ first job at a pediatric office in Atlanta, when she was 18, exposed her to kidney issues and solutions. She translated for pediatric nephrologist Stephanie M. Jernigan, an associate professor of pediatrics at Emory School of Medicine.
“Children who were born with just one kidney often lived perfectly normal lives,” she says. “Other children who had kidney transplants did very well, even though it’s a very invasive surgery.”
She also learned to see her own intellectual potential.
Having come from El Salvador at age four and undocumented, Chicas had received temporary protective status that allowed her to work for the pediatricians. She helped them communicate with families who only spoke Spanish, and thought she might be smart enough to become a medical assistant so she could help them more. Pediatrician A. Gerald Reisman, MD, urged her to try nursing instead, and at age 28, Chicas enrolled in what is now Perimeter College at Georgia State University.
That educational decision led to Bridges to the Baccalaureate, an Emory program that nurtures minority students in research. With School of Nursing Dean Linda A. McCauley, PhD, RN, FAAN, as her advisor, Chicas got a BSN and went directly into the doctoral program. She joined McCauley’s team working on farmworker health, which felt personal because her mother, Maria Chicas, farmed in El Salvador. Farmworkers are 35 times more likely to die from heat-related illnesses than any other profession, she says.
“My goal is to do great science that will really improve the working conditions of agricultural workers,” Chicas says. “They are the backbone of this country and the globe. They feed us, and I think we need to value them more and recognize their worth, and they should be treated with dignity and given the same benefits that sometimes we take for granted. Many of them are undocumented and live in poverty, and I hope that I can be a part of a movement to better their lives.”
Heat-related illnesses affect kidney function, and Chicas did a postdoctoral stint in renal (kidney-related) medicine at the Emory School of Medicine. The research team measures indicators of health like core body temperature and kidney function.
“I got lucky, because I could have been working out in the field,” Chicas says. “I’m not there because of sacrifices that my mom made, and many other Latino parents have made and by having a mentor who told me that I can be a professional.”
A mentor in need
Hertzberg became Chicas’ professor and research teammate. From Florida to Mexico to Brazil, Chicas was in direct contact with farmworkers while Hertzberg worked to tell the story of the collected data.
“A wonderful mentor,” Chicas, 39, calls Hertzberg, 67. “She taught me that you can be smart and be strong in your career, and yet still be very kind.”
As the director for the nursing school’s Center for Data Science, Hertzberg is an internationally-recognized expert on “big data” and its impact on health care. She is widely known for her work measuring the social contacts in emergency departments and disease transmission on airplanes.
“Mentoring is what graduate education is all about,” Hertzberg says. “You learn a lot from each other. Part of it is just kind of a natural process because we’re engaged through research activities and part of that is just kind of understanding how the world works and what makes people tick. Roxana is incredibly driven and intrinsically kind, and always keeps me and our team focused on issues that our partner community experiences in ways that we don’t.”
On the farmworker longitudinal study, newer data relates to 25 markers of kidney function disease because of a relatively recent phenomenon called chronic kidney disease of undetermined etiology (CKDu). “Young farmworkers who had been feeling fine or really healthy all of a sudden wake up sick,” Hertzberg says. “Lo and behold, they have kidney failure and need dialysis.”
In late 2020, Hertzberg’s own bloodwork showed acute kidney injury, and when restrictive diet didn’t improve function enough, she was referred for a kidney transplant in mid-2021.
Like Chicas, Hertzberg had learned about the disease long before through a family friend and others. She reached out to her network by email and social media.
“Ideally a living donor is best,” she wrote. “A kidney from a living donor lasts on average 25 years, while a kidney for somebody who is about to have life support turned off is on average 12 years. Obviously, the 25 years is my preference…. the wait for a kidney from the person on life support will take three to seven years.”
“I knew it’s a pretty big surgery, but I was just like, ‘I have an extra kidney. I’m pretty healthy,’” she says. “And I called my mom and asked her what she thought and she was like, well, if that’s what you feel that you’re called to do, then go for it. And I was like, Okay.”
When she found out that there was competition to give a kidney to Hertzberg, Chicas told herself, “If God wants me to be the donor, then I’m going to match. So much science has gone into it for such a long time, and to be able to use that science to help Dr. Hertzberg be healthier and live longer, it’s awesome. And I get to be a part of it.”
Hertzberg even had colleagues clamoring to organize her meal train. This loyalty is partly from working at Emory since 1995, and supporting so many people and projects with her expertise. She served on dissertation committees for Chicas in 2020 and (at the University of Cincinnati) for McCauley in 1988.
Christian Larsen, MD, DPhil, professor of surgery in the Division of Transplantation at Emory and former dean of the Emory School of Medicine, transplanted Hertzberg’s new kidney last month. Larsen and Hertzberg knew each other through their collaborative research. From 2005 to 2010, they teamed-up on a protective immunity project studying aspects of the immune system in kidney transplant patients.
“This is not a road I would have chosen for myself,” Hertzberg says. “So I’m trying my hardest to learn the lessons along the way and to keep being positive. I want to dance at my grandchildren’s weddings, and the oldest one is soon to be five years old.”
Chicas believes that her success, her mentors and her organ donation have proved her favorite quote.
“Mother Teresa said, ‘If you can’t feed 100 people, then feed just one,’” she says. “I’m not a philanthropy. I’m not a billionaire. But I feel like there are certain things that I can do.”
Nephrology Nurses Week kicks off today and is a time to appreciate the dedication and expertise nephrology nurses bring to their roles.
Nephrology nurses have a distinct role in helping patients across the age spectrum who are dealing with issues concerning kidney function and health. Whether it’s a family history that predisposes someone to kidney disease, an older patient who is coping with a new diagnosis, a teen recovering from a kidney transplant, or a person with advanced end stage kidney disease, nephrology nurses specialize in all the ways to help patients.
Anyone interested in a career as a nephrology nurse can reference the American Nephrology Nurses Association for background information, career tips, certification information, and guidance. Nephrology nurses can flourish in any number of settings from corporate to home care to a coordinator of dialysis or transplant services. They have a broad knowledge of the entire body system and will know how kidney function will impact the rest of the body.
Often nephrology nurses will administer the frequent dialysis needed to keep a patient functioning. They might also counsel patients and their families who are preparing for a kidney transplant or recovering from one. Their expertise in helping both the patient learn about typical expected symptoms or results and in helping family members care for a patient will make a significant difference in physical and emotional recovery.
With the rapid treatment advances for complex health issues, many nephrology nurses become well-versed in the many conditions patients have and how those conditions can impact the kidneys and treatments for kidney disease. Because of this, they need excellent teamwork skills and critical thinking skills that will help them assess and prioritize care in crisis situations.
As with other specialties, obtaining certification improves your knowledge base, and it also helps you serve your patients to the best of your abilities. Certification is available for several areas of nephrology nursing including as a nephrology nurse, as a nephrology nurse practitioner, as a dialysis nurse, as a dialysis LPN, or even as a clinical hemodialysis technician.
Studying for and passing a certification exam is well within your reach, especially if you have been in the field for a while. You very likely already know a good deal of the information. But certification helps you stay up-to-date on the latest evidence-based practices, technology, and treatment, and also gives you a peek into the exciting developments in the industry.
As you gain more training, your employment becomes even more valuable to your organization. Certification also shows your dedication to your role. Taking the extra time to advance your learning shows the kind of attention to detail and commitment to high-quality care that employers want to see. When career advisers talk about showing your skills and your results, certification fits the bill.
Take this week to appreciate nephrology nurses and to find out more about the career if it sounds appealing to you.
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.
For More Information About Kidney Disease and Nephrology NursingAmerican Nephrology Nurses’ Association
www.annanurse.orgNational Kidney Foundation, Council of Nephrology Nurses and Technicians
www.kidney.org/professionals/CNNT/index.cfmNational Institute of Diabetes & Digestive & Kidney Diseases
www.niddk.nih.govNational Kidney Disease Education Program
www.nkdep.nih.govNational Kidney Disease Education Program
www.nkdep.nih.gov National Institute of Diabetes and Digestive and Kidney Diseases, 2002. National Kidney Foundation, March 2005. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, 2004.
“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 certifiednephrology 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.
According to a recent study in the Journal of the American Society of Nephrology (JASN), some ethnic groups can be found at the bottom, or missing, from waitlists for kidney transplants. Though the exact causes are not known, experts have a variety of theories and are working hard to address this issue.
At the University of Washington in Seattle, Yoshio Hall, M.D., and his colleagues were determined to fi nd some answers. In their study, they surveyed 503,090 non-elderly adults from different ethnic backgrounds who had started dialysis between the years of 1995 and 2006. In 2008, the researchers had some answers. Of all waitlisted patients, white non-Hispanics were 40% more likely to receive a transplant than African Americans, Hispanics, Asian Americans/Pacific Islanders, and others minorities. Also of note, the rates of deceased-donor transplantations after dialysis were lowest in American Indians/Alaska Natives (2.4%) and highest in non-Hispanic whites (5.9%) and Asians (6.4%).
Today, the reasons behind these discrepancies are still not completely clear, which highlights the need for further investigation. Some theories point to socioeconomic factors, while others suggest a lack of organ availability, or even cultural isolation.
Dr. Hall believes that more research and understanding could result in the reduction of racial, ethnic, and socioeconomic disparities for kidney transplants in the future.
There is an urgent health care crisis affecting America’s communities at a distressing rate. As health care providers, we must generate a course of action to address this emergency. No, this is not another article about the nursing shortage. What I am referring to is a health problem that people of color, particularly African Americans, American Indians, Hispanics and others, are developing at alarming rates.
Scientific journals, national reports and research studies all support the evidence that these minority groups have higher incidences of preventable chronic diseases than the majority population. As health care providers, we should ask ourselves why. Is it because of their diet, culture or socioeconomic status? Is it a result of stress, or is it just genetic? While these questions remain difficult to answer, there is one thing we do know for certain: Kidney disease is rampant in our nation’s minority communities.
My own awareness of the growing crisis of kidney disease in communities of color began about five years ago. As I drove about the city of Cleveland where I live, I kept noticing–no matter what side of town I was on–small corner buildings with the letters “CDC” on them. Not being too concerned or paying much attention, I surmised they were local branches of the Centers for Disease Control and Prevention. However, one thing kept puzzling me: The people who were going into and coming out of these buildings were mostly African Americans.
My curiosity got the best of me; as an inquisitive nurse, I decided to investigate. To my surprise, I discovered that these buildings were Community Dialysis Centers. This hit me like a ton of bricks. Till then, I had only really known one person who had suffered from kidney failure; she was a classmate of mine who had become sick as the result of chemotherapy medication, and that was 30 years ago.
I made a point of identifying just where those centers were located and how many were in my neighborhood. It turned out we had six, all less than 15 minutes from the center of town and each the same distance from each other. Now, that says a lot about the health of a community. These dialysis centers had popped up all over the neighborhood like Walgreens stores.
Today approximately 20 million Americans nationwide have kidney disease; of this group, more than 8 million have seriously reduced kidney function and 10 million have protein in their urine but are unaware of it.1 But what’s even more alarming is that kidney disease affects African Americans four times as often as the overall population. African Americans currently make up 12% of the U.S. population but account for 30% of persons with kidney failure. Furthermore, African-American men age 25 to 44 are 20 times more likely to develop kidney failure than Caucasian men in the same age group.2
Why the disparity? Is it due to lack of access to quality health care and screening, or the inability to afford care due to lack of insurance? One reason could very well be that African Americans–and males in particular–are hesitant about seeking health care. A recent study on patients’ trust of the medical establishment, conducted by researchers at the University of North Carolina-Chapel Hill, revealed that almost 80% of African Americans believe they could be used as “guinea pigs” for medical research without their consent, compared with 52% of whites.3
According to this study, African Americans’ “deep reservoir of mistrust” toward the medical system stems from the 1932-1972 Tuskegee syphilis study, in which researchers withheld treatment from nearly 400 African-American men with syphilis to observe the disease’s progression. It’s not surprising, then, that African-American men with kidney failure are more likely than white men (45% vs. 24.5%) to have late evaluation by a nephrologist, and in many cases do not know they have a problem until they need dialysis.4 Here is a population at high risk that can benefit from culturally sensitive providers.
Hypertension and diabetes, both of which affect minority populations disproportionately, are the two most common reasons for kidney failure. Diabetes is the number one cause of chronic kidney failure, accounting for approximately 44% of new cases in the United States each year. Uncontrolled or poorly controlled high blood pressure is a close second, responsible for about 35% of all chronic kidney failure cases.
Still another reason why the kidney disease epidemic is especially devastating in minority communities is that this is one of the costliest illnesses in the U.S. today. The average cost of dialysis can range anywhere between $45,000 to $50,000 per year alone. Medications for kidney transplant recipients who lack insurance coverage can cost about $11,000 per year.1, 2 Kidney and urinary tract diseases continue to be one of the major causes of work loss among employed men and women. Kidney problems result in more than 1 million physician visits and more than 300,000 hospitalizations in America each year.
What Nurses Can Do
As advocates of quality health care, minority nurses must be aware of the role we can play in heightening the understanding of kidney disease in our communities. This can best be done through our visible presence in the community, and through collaboration with national, state and local agencies that have launched initiatives that address these health disparities and are working toward producing positive health outcomes while diminishing the development of the disease. Not long ago, the focus of health care was on disease management or care management. Today the emphasis is on prevention.
As minority health providers we are uniquely positioned to affect change in our homes, our families and our communities simply by the very nature of our profession. Our loved ones, friends and community look to us for knowledgeable advice and guidance; they value our opinion and referrals. They consider us experts in our practices as we educate, consult, administer and nurture them back to health. They know that this is what nurses do. Ours is the voice they must hear.
Many of our family members and friends receive health care services from health professionals who are Caucasians. I do not mean to take anything away from them, because there are excellent practitioners in every culture. But when it comes to getting the message across about preventing diseases that disproportionately affect people of color, we as minority nurses are the ones who can be the most effective in producing positive health outcomes among our own communities. We have a responsibility to increase knowledge and awareness about the seriousness of kidney disease and the inherent risk factors to a population that is suffering unnecessarily.
Through strategic and innovative planning, we must deliver community outreach based on aggressive educational methods that will facilitate understanding about the risk factors that threaten people of color with high rates of morbidity and mortality. We can no longer take a back seat to personal involvement in the campaign to eradicate kidney disease, diabetes and hypertension.
The good news is that we don’t have to start from scratch. Many national organizations and government agencies have already developed innovative programs in an attempt to address these health issues–programs that nurses can tap into and implement in their own communities without having to reinvent the wheel.
One collaborative effort now underway is the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases (one of the National Institutes of Health). NKDEP has developed a pilot program that is currently being implemented by health professionals in four major cities–Atlanta, Baltimore, Cleveland and Jackson (Miss.)–in an effort to spread the message that preventing kidney failure can indeed be a reality in African-American communities.
Through community programs, public service announcements and education of primary care providers, the NKDEP seeks to raise awareness about the seriousness of kidney disease, the importance of testing those at high risk and the availability of treatment to prevent or slow kidney failure. To learn more about this program, and how you can use it to make a difference in your own community, visit www.nkdep.nih.gov.
As minority nurses, we have a great opportunity to influence our communities, but we must be at the table where decisions are made and policies are discussed. If we are truly to be the front line soldiers in the battle to eradicate preventable kidney diseases, we must develop a passion for the fight, roll up our sleeves and begin the work. Promoting prevention through healthy lifestyles and early detection is the key, and that begins with awareness. Who better to get it done than those in our profession?
1. National Kidney Foundation, 2003. 2. U.S. Renal Data System, 2003. 3. Corbie-Smith, Giselle, et al. “Distrust, Race, and Research.” Annals of Internal Medicine, November 25, 2002. 4. Kinchen, Kraig S., MD, MSc, et al. “The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality.” Annals of Internal Medicine, September 17, 2002.