Nephrology Nursing Standards of Practice and Guidelines for Care: A Comprehensive Document
Sally Burrows-Hudson
Barbara F. Prowant

Sally Burrows-Hudson, MS, RN, CNN, is Co-Editor, Nephrology Nursing Standards of Practice and Guidelines for Care.  She is President, Nephrology Management Group, Inc. She is a past ANNA President and is a member of the Silicon Valley chapter of ANNA.

Barbara F. Prowant, MS, RN, CNN,is Co-Editor, Nephrology Nursing Standards of Practice and Guidelines for Care. She is a Research Associate, University of Missouri-Columbia School of Medicine, a past ANNA National Secretary, and is a member of the Central Missouri chapter of ANNA.

The new edition of the Nephrology Nursing Standards of Practice and Guidelines for Care was released at the National Symposium in April, 2005 (ref.). Recently reviewed and revised by over 60 nephrology nursing colleagues, this document contains both standards of practice and standards of professional performance written by the American Nurses’ Association (ANA) and endorsed by the American Nephrology Nurses’ Association (ANNA). In addition, the comprehensive nephrology nursing care guidelines describe the nursing care that is required to achieve full implementation of the National Kidney Foundation K/DOQI clinical practice guidelines as well as those guidelines from the American Heart Association, American Diabetes Association, the Centers for Disease Control and Prevention, and the Association for the Advancement of Medical Instrumentation. Included are the nursing assessments, nursing interventions and patient education topics specific to significant clinical problems, complications, and therapeutic regimens.

But how are these useful to the practicing nephrology nurse? The following vignettes illustrate the use of these standards and guidelines in clinical practice settings.

Clinical Case Study
R.V., a 42 year-old Hispanic male, was recently in the clinic for a routine physical exam. Physical examination and laboratory tests revealed the following:
    Weight                       185 lbs
    Body mass index     28.1 kg/m2
    Blood pressure        157/80 mm/Hg
    Serum creatinine    1.3 mg/dL
    GFR                           64 ml/min/1.73m2
    Cholesterol              250 mg/dL
    HDL                           50 mg/dL
    LDL                           140 mg/dL

Administrative Case Study
“The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is coming to our hospital and the dialysis unit has been asked to review the criteria, evaluate policies, and assure an active CQI program. Are there standards for nephrology nursing? Where can I get help with policy development? Where do I find information that is specific to nursing?” (Burrows-Hudson & Prowant, 2005)

The Nephrology Nursing Standards of Practice contain two sections: Standards of Care and Standards of Professional Performance. These two sections are useful in guiding a facility through nursing practice survey criteria. The Standards of Care (page 7) describe the nursing process, that is the expectation that an assessment is performed, outcomes are clearly identified, interventions appropriate to the patient or situation are selected and implemented, ongoing evaluation is in place, and documentation is evident. JCAHO will look for this process when they evaluate the documentation of nursing care. If the patients’ medical records reflect this process, the survey findings will be positive.

To help assess nephrology nursing participation in the dialysis unit’s quality improvement program, the section titled “Professional Performance” may be of help. Within this section are the measurement criteria specifically for the nurse’s role: “The nephrology registered nurse systematically enhances the quality and effectiveness of nursing practice” (page 11). An example of the measurement criteria is that the nephrology nurse “participates in quality improvement activities.” This statement is followed by a list of such activities. The survey process will be successful if, for example, the nursing staff is actively engaged in ongoing quality data assessment, formulation of recommendations, and implementing interventions to improve practice or outcomes. This can be demonstrated through participation on interdisciplinary teams, and developing policies and procedures.

Evaluation Performance – A Professional Development Case Study
Performance reviews are important, but cause the nursing staff significant consternation. Often one really knows the source from which the criteria were derived. In addition, the criteria may change from year to year and are not necessarily related to the development plans of which nurses are required to participate. How can we standardize our performance evaluation criteria? What can we use that is nursing specific and meaningful to professional development?

The Standards of Practice are promulgated by ANA and embraced by ANNA to ensure that the public receives competent nursing care. While competent nursing care and performance are required of all nurses regardless of years of experience, educational level, practice setting, patient population, or disease state, competence is neither achieved upon graduation from nursing school nor upon passing the state board nursing examination. It requires practice, lifelong learning, and continuous improvement in performance. As outlined in Nephrology Nursing Standards of Practice and Guidelines for Care, the areas of focus are: quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. When specifically looking at professional practice evaluation the overarching statement is, “The nephrology registered nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations” (page 12). Nursing leadership can abstract criteria to design a comprehensive professional performance evaluation appropriate to the practice setting. Imagine being able to assess a nurse’s performance against actual professional practice standards. For example, taking only one of the several measurement criteria for each area offers an excellent starting point in professional performance evaluation:

• Quality of Practice: Obtains and maintains professional certification.
• Education: Demonstrates a commitment to life-long learning through self-reflection and inquiry to identify learning needs.
• Professional Practice Evaluation: Takes action to achieve goals identified during the evaluation process.
• Collegiality: Maintains compassionate and caring relationships with peers and colleagues.
• Collaboration: Partners with others to effect change and generate positive outcomes through knowledge of the patient.
• Ethics: Serves as a patient advocate assisting patients in developing skills for self-advocacy.
• Research: Utilizes the best available evidence, including research findings, to guide practice decisions.
• Resource Utilization: Evaluates factors such as safety, effectiveness, availability, cost and benefit when choosing practice options that would result in the same expected outcome.
• Leadership: Demonstrates energy, excitement, and passion for quality work.

The Nephrology Nursing Standards of Practice and Guidelines for Care are a reference for nephrology nurses providing or supervising clinical care. The ultimate goals are to enhance professionalism and to improve patient outcomes. It is now our challenge to be creative in incorporating the use of both the standards and guidelines in our daily practice so that our patients reap the benefits!

References
Burrows-Hudson, S. & Prowant, B.F. (Eds.). (2005). Nephrology Nursing Standards of Practice and Guidelines for Care. Pitman, NJ: American Nephrology Nurses’ Association.