Dialysis Nursing in a nutshell

Dialysis nursing intrigued me. I am in my forties and had been in the same area of nursing for quite some time. I wanted to stimulate some brain cells and learn something new. I had no idea what I was in store for. Hopefully, sharing my experience will provide some insight for nurses interested in making the change.

So, why is dialysis so different from any other area of nursing?

1. Take what you learned about a "stable patient" and toss it out the window.

When I started in dialysis I continued to uphold my standards of best nursing practice. I wanted to call the physician when a patient's blood pressure was 200/100 or 86/50. What I once considered a critical lab was a joke to my coworkers. I had to relearn "normal lab values". ESRD patients are a completely different form of stable. Learning your patient is essential in determining when to call in the cavalry, when to monitor and when to call it "all good". There are many determining factors and a dialysis nurse is one part nurse/one part detective. A patient can walk in the door in hypertensive crisis and within hours you might be throwing their chair back to bring their pressure back up. It's a fine recipe of patient history, medication timing, knowing how much fluid to take off and how quickly, patient education and several other treatment tweaks. This can be a benefit of dialysis nursing as you become more experienced. It's rewarding to be such an integral part of improving the patient's treatment and symptoms. On the flipside, it can be a disadvantage when you have a difficult patient who doesn't seem to respond to any of your tricks. It can be quite challenging to play detective while overseeing patient technicians, answering the phone, rounding with physicians, passing medications and caring for 11 other patients.

2. The nursing model and delegation practices don't follow any rule book.

I began my training with a patient care technician. These technicians do not necessarily have any previous history in the medical field or have any certificate or degree in a medically related field. They are trained on the job and have dialysis focused education provided by the company they work for. They are also required to pass a dialysis specific certification. This exam is not a piece of cake. The techs I work with are hard-working, can multitask and never seem to tire. I have an entirely new admiration for what we would refer to as "support staff" in the outside nursing world. What gives me pause is putting technicians in a position to make decisions based on task focused training. Many technicians do not understand why they do some of the things they have been trained to do and can not give rationale behind their practices. I quickly annoyed my techs while I was training. It was essential for me to understand the "why" behind the instruction. They felt I was questioning them or that I was a "know it all". What they failed to understand is how hard I worked for my license and how important it is to maintain it. If I am going to be held responsible for my actions and theirs I need to be sure the information being passed on is based on good practice. Many times the answer would be "because that's how I was trained." Some of the technicians understand the importance of reporting to the nurse. Others quickly make medical decisions for their patients without ever informing the nurse of the patient's condition. It is the nature of dialysis. The technicians are required to set up machines, cannulate patients, monitor vitals, administer heparin, take patients off of the machines and quickly prepare for a new shift of patients. They work very independently and with little or no medical expertise some do not realize the importance of reporting to the RN. In dialysis it is not unusual for technicians to train nurses, question nursing decisions, or to tell the RN what needs to be done.

3. Plan to wear many different hats.

I enjoy being busy. I thrive on multitasking and thinking on my feet. Many days this is a perk of my job. It feeds my need to be challenged. Other days I feel that the dialysis companies are more interested in making money than caring for patients. When I was being interviewed I was told that I would be in charge of 3 to 4 techs. Each tech could have as many as 4 patients. I would pass meds, perform assessments, monitor treatments, round with physicians and perform QA.

The real story? Many days it isn't in the budget to have a technician for every patient assignment. Unlike hospital nursing - if an aide calls out a nurse doesn't assume all of his/her responsibilities- nurses in dialysis take on that that technicians responsibilities, in addition to her own. Imagine this...

You come in at 5 am. You are short a technician. Your challenges for the day..

Your morning responsibilities have just multiplied. You need to perform morning QA, set up a pod of machines, monitor what is happening with other patients as they arrive while cannulating and treating your own patient assignment. Machine checks are due within 30 minutes of treatment initiation for every patient. You must figure out how to care for your patients, without delay, while skirting over to the other patients to do assessments and machine checks. If any patient requires immediate attention you must leave your patients to care for another because you are the only nurse on the floor. If this delays putting one of the patients in your assignment on the machine the entire schedule caves. My fear in all of this is that by assuming technician responsibilities it is difficult to monitor the well being of all patients and be held accountable for the actions of your team. I am by no means too good to perform these duties. If all patients have an assigned technician it is ideal for the nurse to pitch in as time allows/where needed. It is difficult to prioritize when you are expected to take on the full time responsibility of a technician and a nurse. Imagine being in the hospital giving a patient a bed bath. How would you focus on that task while also

monitoring your patients on the floor, responding to call bells, giving prn medications, speaking with physicians, etc? It doesn't work. It isn't safe.

4. Sitting isn't an option

The hours pass by quickly. I like that. It is a challenge, however, to be on your feet for 10 to 14 hours. This is not unique to dialysis. Many nursing specialties share this in common. The difference in dialysis nursing/other specialties is this...When you sit to document, make a call to a physician, review labs no one looks at you as if you were goofing off. An aide or dietician doesn't approach you with a list of things they need help with. I've found at my clinic that if I sit down to perform these tasks I am almost always approached to help the technicians catch up. Again, I am not too proud to perform any task but I would appreciate the understanding that I am not a technician. Some nursing responsibilities involve documentation, monitoring, QA, review and communication with family and medical professionals. On a daily basis I delay these responsibilities until the end of the day to avoid conflict. I am usually at work for at least an hour after everyone leaves. That is a definite con.

In summary I love the practice of dialysis. I would never question my decision if I were permitted to perform my nursing duties in a timely manner and truly be able to "charge". Being a charge nurse doesn't involve a power trip for me. It involves coordination, monitoring, communication and delegation. In dialysis non licensed coworkers are administering medications, making independent medical decisions and consistently dependent on the nurse to assist with their duties (not their fault as the expectations of them are high). Each day I struggle with the pros/cons.