So How Long Does the Misery Last?

flyingsolo · Dec 4, 2006

That information is great! I just have one more question: how long do they train you when you get there fresh from school--I mean, is there an overlap thing with another experienced nurse, or do you learn kinda OJT? That's an early schedule, I mean, starting in the morning, and then going until 430 pm. Do you get time to sit down? I am in my fifties! I can't do so much running around. Thanks for all of your advice. Oh, I am wondering if I can get an internship/externship in a dialysis clinic.

DeLana_RN, BSN, RN · Dec 4, 2006

That information is great! I just have one more question: how long do they train you when you get there fresh from school--I mean, is there an overlap thing with another experienced nurse, or do you learn kinda OJT? That's an early schedule, I mean, starting in the morning, and then going until 430 pm. Do you get time to sit down? I am in my fifties! I can't do so much running around. Thanks for all of your advice. Oh, I am wondering if I can get an internship/externship in a dialysis clinic.

Flyingsolo,

I'm not trying to discourage you by any means, but in general it's best for dialysis nurses to have at least 6 months to a year of hospital experience; the reason for this is not the technical stuff, since they will teach you that (and it's much of the same that the techs do - setting up the machines, hooking up the patients, etc.) However, as a dialysis RN - especially in a chronic, clinic setting where you may have few, if any, other RNs working with you during a given shift - you need to be able to be very independent and ideally have some general nursing experience (e.g., good assessment skills, med knowledge, being comfortable with possible emergencies). Yes, many clinics will hire and train new grads, but you have to consider carefully if this is a good idea. You may do better in a hospital dialysis setting (they sometimes hire new grads), since you usually have more RNs and a much lower nurse : patient ratio.

Also, and again I'm not trying to discourage you, but dialysis can be very physically demanding - you have to stand and walk a lot, clean machines, bend over, that kind of thing. And during turnover (patient shift change) this has to be done at a very fast pace. The hours can even be worse than pp mentioned, I had to start at 5:00 a.m. :uhoh3: (four 10-hour days that often included OT).

I know this may sound negative, which is not my intent. Whether or not a new nurse would do well in dialyis may also depend on the person (e.g., are you very confident as a nurse, and/or have you had previous hospital experience, perhaps as a nurse extern? This would be helpful.) We had nurses in their fifties with no prior dialysis experience start at our clinics, and both did very well - but they had prior hospital/ICU experience; I don't know it that's the reason.

Dialysis is a wonderful specialty, many love it (others hate it - seems like there are few who feel indifferent). It can be very rewarding, you develop a relationship with your chronic patients, you can teach, and use many skills and nursing knowledge. Perhaps if you're in a clinic that has a great preceptor who is willing to teach, you would do quite well right out of school (yes, the large providers usually have 8-week training courses that include classroom or self-study time and OJT).

Can you spend some time in a clinic as part of your studies? Perhaps do your leadership course in a hospital unit, or shadow a clinic nurse? Anything to get more info and a feel for what would be expected of you. Regarding your question - some dialysis RNs started out as techs, which includes much of the training you would get as a new nurse (i.e., the technical skills.) One of my colleagues did this in nursing school and she did very well as a new grad dialysis RN (she worked as tech before starting nursing school; the training can be long and may not be possible with a school schedule).

And finally, yes it takes at least a year to feel confident in dialysis, but this is probably true for most specialties - and in general as a new nurse.

I wish you the best of luck,

DeLana :)

DeLana_RN, BSN, RN · Dec 4, 2006

I would like to hear from experienced nurses about sticking -- is flipping arterial needles bad or good? If good, do you flip them after they're already in all the way or after you're in the access? Does anyone stick bevel down (I saw this recommended in a brochure)? What are techniches for tough sticks, accesses very hard to feel, etc.? And does anyone "buttonhole" AVFs? Does it really improve blood flow to point art needles down? Any technique advice would be very welcome.
This forum has really been a help to me, thanks y'all.

I'm certainly no expert, but after 5 years I do get a few sticks In general, we were taught to always stick bevel up, and I normally do this. After entering the fistula/graft you may carefully flip the needle if necessary - it probably shouldn't be done routinely (if you get good Qb with good pressures), but may be helpful if the needle is against the wall. You want to be very careful when flipping needles since it can cause infiltration or coring of a graft.

Very few people will be able to always stick every access - we had some that only the most experienced staff could get (and I could get some that they couldn't; go figure). Sometimes the patient can help you locate a good place to stick - but be careful, they will sometimes direct you to areas that are numb due to repeated sticks and this can lead to (pseudo)aneurysm formation. 4 months is not a long time, especially if you had no prior phlebotomy/IV experience; it really takes time to get a feel for cannulation. Don't let the techs' sticking skills intimidate you, this is usually all they do so of course they're good and fast at it (don't hesitate to ask them for help!)

This is undoubtedly the hardest skill to learn, be patient with yourself and don't get discouraged after a hematoma; it happens, the patients (usually) understand. Some may not want to let you stick them, and some play games, just get someone else and don't let it bother you.

Best of luck!

DeLana :)

P.S. We didn't learn the buttonhole technique, but I understand this is excellent for a fistula and also makes cannulation much easier.

scrabbler77 · Dec 4, 2006

Thanks, DeLana! I've been reading your helpful advice for a few months now -- I think maybe you should get into teaching!

jrussole · Dec 5, 2006

I can tell you that I tried apheresis. I didn't mind the learning aspect of it. What bothered me was my preceptor. He didn't eat the whole 12 hour shift. He expected me to go all day without a break to eat. Honestly, I couldn't handle not eating for 12 hours. Maybe some of you can, but hypoglycemia is not my cup of tea! I believe if I had a half normal preceptor, I would still be in the profession today. I like it. But his training was unreasonable and hazardous to patients if your not 100% on top of things. Without food, we don't have enough fuel to operate right. He was unreasonable to expect me to go that long without eating. Isn't there a law somewhere related to this matter? I wonder?

Hellllllo Nurse, BSN, RN · Dec 5, 2006

Dialysis is very technical. Besides the technical aspect- nurses need to have very good assessment skills. the nurse must be able to prevent pt's symptomatic hypotension on tx, but not leave too much fluid on them. You need to know when HTN is r/t FVO, when it's because a pt is not taking his meds or is it due to a renin response?

If your pt is not feeling well while on tx, is he developing an infection, volume related s/s or? With many units going to non-reuse dialyzers, I've seen a couple of incidents of first use syndrome lately.

I personally really like the button hole technique w/ fistulas, but very few units utilize this method.

I am usually the only nurse in most of the units I work (I'm a traveler) therefore, I've had to really develop my assessments skills and make decisions on my own.

My belief is that anticipating and preventing problems is fundamental to good dialysis.

Deano49 · Dec 18, 2006

As a staff RN for a 10 station unit in Texas, I can tell you that hemodialysis is very challenging. First of all you either love or hate being a nurse. I am in my 12th year of nursing, I have been a DON for a hospital, worked home health, med surg, state hospital work, trauma and ER. I just finished my 3rd year as a dialysis nurse and I do enjoy it very much. I'm not sure what the job descriptions are at most units, but here are a few of my job duties. Since our technicians live 100 miles from our facility, we (3) employees, myself a staff RN, the clinical manager and 1 PCT run the business. I get to work early, around 4AM, I turn the RO machine on, make the bicarb for the machines, fill all the K+ jugs ( we have none in the walls), do all the water testing, we 3 string all the machines, etc, we are secretary, technician, and wear whatever hat need be for the day. Our Nephrologist's are on call, also 100 miles away. We are not annexed to a hospital, so if a patient goes bad, we call the EMS. I remember first starting being overwhelmed, not from the interest of the field, but from the abundance of learning you have to do, however after a while, most things become second nature, and you begin to enjoy your work. Don't give up so easily, dialysis is a great job, with great benefits. After a while, every job becomes a job, but I really enjoy mine...

hemorn1 · Dec 27, 2006

:saint: I love nephrology nursing too! I started in cardiology, then moved to dialsysis. It was very overwhelming at first, and the techs can make you feel very inferior due to lack of speed and technique. They are very good when they have been doing it for 10+ years! I just asked tons of questions to the other RN and if I couldn't get an answer from her I called the nephrologist. It does take about a year to get comfortable with patient care. I moved into the management position after 3 years, and now I work with ESRD Network. I miss the patients most, but now I'm in the roll of helping facilities optimize their outcomes. It is very interesting and I have been amazed at the political side of dialysis.

As far as cannulating goes, buttonholes are great if done correctly, one person must establish the buttonholes before moving on to the dull needles. You can contact your Network for a Button Hole technique video. I would not suggest trying it without training. When using sharp needles to cannulate, flipping the needle is a very dangerous practice, very old school, and should not be done. If it is a practice in your clinic, it should only be done by someone with very good cannulation skills with years of experience. If the bottom of the graft or fistula is sliced, the patient could easily bleed out.

One of the best things about being a nephrology nurse is the autonomy. But that is also one of the reasons a nurse needs some background experience before going in to dialysis. Most clinics do not have a lot of support to call on in an emergency or critical situation, and the RN must be able to use critical thinking and deal with the situation quickly. And yes, the days are long, but if you work a MWF schedule, that 4 days off a week. That is something else I miss.... now I work 5 days a week!

wmsclan · Dec 29, 2006

i have the fun oppertunity of being the nurse that not only deals with the dialysis but also works the floor of a med-surg/renal floor. we are a 39 bed unit as well as having a dialysis clinc on the same floor. i found that not only do i enjoy the dialysis aspect but also enjoy the patient contact after the treatment. not to mention you can also get to know the patients fairly well. we have a lot of "frequent flyers" that come through the unit due to the multiple medical problems that dialysis pts have. i absolulty love the renal specialty. the pts know that you and your care are one of the reasons that they can continue to live the life they want. that is more than enough reason for me to do what i do. hang in there, it does get better and the pts (while trying at times) know that without you and dialysis their life would be totally different.

DeLana_RN, BSN, RN · Dec 29, 2006

Since our technicians live 100 miles from our facility, we (3) employees, myself a staff RN, the clinical manager and 1 PCT run the business. I get to work early, around 4AM, I turn the RO machine on, make the bicarb for the machines, fill all the K+ jugs ( we have none in the walls), do all the water testing, we 3 string all the machines, etc, we are secretary, technician, and wear whatever hat need be for the day. Our Nephrologist's are on call, also 100 miles away.

You have my respect. When I worked in chronics (5 1/2 years), I had to get up at 4:00 and it just about killed me :uhoh3: - but then again, I'm not a morning person.

I agree with you, HD is very challenging - but also very rewarding.

DeLana :)

DeLana_RN, BSN, RN · Dec 30, 2006

When using sharp needles to cannulate, flipping the needle is a very dangerous practice, very old school, and should not be done. If it is a practice in your clinic, it should only be done by someone with very good cannulation skills with years of experience. If the bottom of the graft or fistula is sliced, the patient could easily bleed out.

I agree that trainees and inexperienced staff should not attempt to flip needles as a feel for the vessel or graft is needed and it takes time to develop that. If done incorrectly, graft coring is a risk, as is infiltration (but this is no more likely than during the initial stick). I have never heard of exsanguination being a risk of needle flipping - yes, exsanguination can certainly happen in a dialysis setting, for instance if the needle(s) come out of the access - and it should never happen if the pt is properly monitored (i.e., lines secure and in view of staff at all times).

DeLana

*Dumping the prime is another practice that can put the pt at risk for exsanguination if staffers aren't careful - they should never leave the pt while starting tx and must pay close attention. At least one large provider has stopped this practice for safety reasons, however, it's still sometimes done (as in my acute setting) and requires the utmost care.

hemorn1 · Jan 3, 2007

Well it can, and has, there were two exsanguinations in the last couple of months in the USA (not sure which states) although they were not from flipping the fistula needle. They were both buttonholes that went all the way through (don't ask me how) and the patients bled out at home. I don't have all the details, but I know it happened, kid ya not! :jester: Scary huh?

I agree that trainees and inexperienced staff should not attempt to flip needles as a feel for the vessel or graft is needed and it takes time to develop that. If done incorrectly, graft coring is a risk, as is infiltration (but this is no more likely than during the initial stick). I have never heard of exsanguination being a risk of needle flipping - yes, exsanguination can certainly happen in a dialysis setting, for instance if the needle(s) come out of the access - and it should never happen if the pt is properly monitored (i.e., lines secure and in view of staff at all times).