Q:  We have a patient in our dialysis unit who insists that only certain people put them on dialysis.  How should we handle this situation?

A: One of the important questions to ask the patient is why the request is being made. Frequently, it is due to the varying skill of the staff member doing the cannulation.

Communication Is Key
Communication is very important when there is a patient issue. Attorney and former nephrology nurse, Mary Rau-Foster, in her book Dealing With Challenging Dialysis Patient Situations, suggests that facilities use some form of treatment expectation agreement (not a contract) with all patients when they first start at the facility. Her book provides sample agreements and Ms. Rau-Foster encourages facilities to make them their own by using policies, procedures, and philosophy of the organization. Under the “Patient’s Responsibilities” there is a statement, “Cooperate with the staff member assigned to provide care to me. I understand that I cannot require that this facility assign specific staff members to my care. If for some reason I am uncomfortable with any staff member assigned to my care, I will make the charge nurse or nurse manager aware of my concerns.”  Many dialysis organizations use similar documents, and when patients become demanding, explain that this was covered when they signed their papers for dialysis (have the agreement available to show them) and reiterate the rationale for the statement in the agreement — staffing rotation, staff availability, or patient assignments.

Important Steps
Now, that being said, if the request for another staff person for cannulation has to do with skill, the nurse manager needs to take actions.

• First, sit down with the patient and let this individual know you will be evaluating the staff person’s skills. Then request that the patient consider giving that staff person another chance to cannulate them. Most patients will give a person a second chance if they know the staff member is working on improving their cannulation skills.
• Staff with poor cannulation skills need to be retrained and then demonstrate competency on practice arms before being allowed to continue cannulation.  
• Facilities would benefit from developing annual cannulation competency reviews for all patient care staff, including a return demonstration of skills on practice arms. The ANNA position statement Vascular Access for Hemodialysis states, “Staff education should include principles and hands-on cannulation training for vascular access to assure optimal care of the patient’s access. Staff education programs should include satisfactory demonstration of knowledge and skills prior to staff being allowed to independently perform cannulation.” Staff members might counter and point out that they cannulate accesses three times a week, so why do we need to show their skills annually? Unfortunately, Networks and facilities continue to receive complaints from patients being stuck multiple times, being hurt, bruised, and/or having infiltrations.
• There are lots of little things we can do to decrease the pain patients have during cannulation. Take a look at your technique – here are a few types of cannulators who can cause pain, discomfort, and/or damage: the “dive bomber,” the “flipper,” the “digger,” and the “jabber.”  I’m sure we have all seen one of these types of cannulators before, and there are probably a few more descriptors you could add.  Cannulation should be a gentle, fluid motion – stick until flashback, lower, and advance.
• Mentor poor cannulators – assign a buddy with good skills to show poor cannulators how they can improve, then have the buddy observe and comment on their skills. This also shows patients that you are serious about improving cannulation skills at your facility.
• Support staff requests for professional development. Even if you can only send one staff person to a program, it is a way to bring current information back to your unit. When staff members return from a program, have them hold an in-service, create a bulletin board, or write an article to teach the rest of the staff what they learned.