Mary Rose Kott, MS, RN, CNN, is Clinical Nurse Specialist/Medicine and Nurse Practitoner for Pallative Care, Saint Joseph Health Center, Syracuse, NY. She is a member of ANNA’s Acute Care SIG and Ethics Committee, and is a member of ANNA’s Central New York Chapter.

The American Nephrology Nurses’ Association’s (ANNA’s) newest Special Interest Group (SIG) is Acute Care. This SIG recently developed a survey to obtain information about the practice areas from acute care ANNA members as there is a lack of data about this subset of nephrology nurses. The survey was designed to begin to explore the practice of acute care nurses and was distributed via e-mail to 1,000 ANNA members who are registered acute care nephrology nurses. There were 246 responses to the survey. While the tool was not developed and confirmed as a reliable and valid tool, it was a first attempt to describe this population of nephrology nurses. Results of this survey of acute care nurses were presented at the Acute Care SIG networking session during the ANNA National Symposium in Dallas, Texas in April, 2007. The presentation, “Getting to Know You: A National View of Acute Renal Care,” was presented by Acute Care SIG Members’ Mary Rose Kott, MS, RN, CNN;  Sue Fallone, MS, RN, CNN; Helen Williams, BSN, RN, CNN; Maureen Craig, MS, RN, CNN, CCNS; Billie Axley, BSN, RN, CNN; and Michelle Krueger, BSN, RN, CNN. The results are highlighted here.

Where Acute Care Nurses Work and Care They Provide
The acute care nurses responding to this survey worked in various practice environments: 27% work in for profit dialysis facilities, 22% in single hospitals, 18% in university hospitals, and 16% in hospital consortium facilities. Over half of the respondents work in more than one facility: 47% worked in one facility, 31% in 2 to 5 facilities, 9% in 6 to 10 facilities, and 13% in more than 10 facilities. Respondents drove significantly different distances to reach their workplace:

This question was included in the survey to determine how far acute care nurses travel to their jobs. The number of nurses driving longer distances was an outcome that was not anticipated.

The respondents work with several types of renal replacement therapies. These included: intermittent hemodialysis (IHD), daily hemodialysis (HD), continuous renal replacement therapy (CRRT), slow low efficient daily dialysis (SLEDD), and peritoneal dialysis (PD) (see Table 1).

There was a large number of responses from acute care nephrology nurses who work with children that is disproportionate to the distribution of practice areas among the nephrology nursing population at large. Sixty-six respondents (27%) work with children under the age of 12 undergoing replacement therapies with 19% receiving CRRT, 35% IHD, and 31% PD. Ninety respondents (37%) work with children 13-18 years of age.


A Major Loss of Experience
The survey results showed an attrition rate of 50% every 10 years for acute care nephrology nurses. Large numbers of these nurses are leaving acute care with over 30 years of nursing experience.


On-Call
Of the 84% of respondents working in acute care, 49% were on-call one night a week, 22% on-call 2 nights per week, and 15% on-call more than 4 nights a week. Of the total respondents, 45% occasionally were contacted when on-call, 25% mostly, 21% usually, and 5% always. Fifty-three percent (53%) of the respondents worked 16 consecutive hours when on-call.

Supervision
The survey queried participants about the supervision of personnel. Even though LPNs/LVNs are licensed, some functions are not independent of registered nurses, for example, assessment of patients and establishing a plan of care. The survey reflected all personnel, including unlicensed care providers and LPNs/ LVNs who were supervised. Direct RN supervision was identified by 70% for unlicensed caregivers and 36% for LPNs/LVNs when direct care was provided to the patient. When indirect care was provided to the patient, 30% supervised unlicensed caregivers and 40% supervised LPNs/LVNs. Only 24% reported LPNs/LVNs functioning independently in the acute care setting. The question did not establish if this is within the scope of practice in the respective nurse practice acts in the states in which this is occurring. In New York state, for example, the Nurse Practice Act states that LPNs/ LVNs cannot practice without direct supervision of a registered nurse (New York State Education Department, 2006). The concern is whether the nurse practice acts in the states this is occurring permit LPNs/LVNs to practice without direct suspervision of a registered nurse.�

Orientation, Continuing Education, and Competency
Regarding orientation, 93% of the respondents stated that their facilities have orientation programs. Fifty-three percent (53%) said there was an educator on site, while 47% had no educator. The length of orientation varied. A 1-week orientation was reported by 4%, 13% reported a 2 to 5-week orientation program, 40% an orientation program of 6-8 weeks, and 43% responded that their orientation program was based on individual needs. Clinical skills’ checklists and orientation checklists were the preferred methods to document basic competencies achieved during the orientation period (see Figure 1).

 
Seventy-three percent (73%) said that they have continuing education, while 78% have annual competency testing. Methods of competency testing are shown in Figure 2. This addresses the question of how regulatory compliance is maintained with respect to the Joint Commission, the Center for Medicare and Medicaid Services (CMS), and other regulatory agencies.


Influence and Quality Improvement
When asked who influences their practice the most, 81% identified nurse managers, followed by nephrologists (60%), and medical directors (58%) (see Figure 3). Only 68% of respondents reported that medical directors participate in continuous quality improvement (CQI) in the acute dialysis setting, while 96% said that nurse managers participated.


Work Environment
Feeling safe in the work setting is important for staff retention. Of those responding, 35% said they always feel safe, and 32% usually feel safe, but 16% only occasionally feel safe.
 
Only 40% of the participants feel they are always supported by their supervisor. Thirty-seven percent (37%) usually feel supported and 19% mostly supported. Thirty-two percent (32%) rated support by their employer in the care delivered as very high and 34% rated it as high. Thirty-one percent (31%) rated support by their direct supervisor as very high and 29% as high.
 
Job Satisfaction
Respondents were asked to rate their overall job satisfaction on a 5-point scale with options including very high, high, moderate, low, and very low. Over 70% rated their job satisfaction as very high or high (very high 28%, high 43%), 23% as moderate, and only a combined 6% rated their job satisfaction as low or very low.

Discussion
The survey results initiated a very lively and interactive networking session at the annual meeting, including discussion on recruitment and retention in the acute setting. Some suggestions included more attractive salaries and hiring of new graduates. There was discussion concerning workload, number of hours worked in a shift, and how to define what emergent treatments are to hospital MDs and emergency departments. Examples of emergent needs are fluid overload, hyperkalemia, and missed hemodialysis treatments necessitating that a nephrologist call a nephrology nurse to provide emergent dialysis.
 
Some discussion ensued on indirect supervision of unlicensed care providers and varying state laws. Who is responsible for supervising these caregivers? Is the RN assigned to the patient responsible for overseeing the hemodialysis treatment? Is the RN aware of this responsibility? Caring for patients who are undocumented arriving in the emergency department for dialysis and facilitating that care was discussed as was working with violent and aggressive patients. Patients who have been discharged from outpatient programs because of behavior problems and present to the emergency department for treatment present challenges to the staff. The acute care nephrology nurse is notified to dialyze these patients, who increase daily census, increase hours worked, and stress the acute care nephrology nurse.

The general consensus at the end of the session suggested this was the beginning in the identification of acute care practice issues. The Acute Care SIG is striving to obtain as much information as possible to define best practice in this setting and to develop tools to assist acute care nurses to provide optimal care.

References
New York State Education Department, (2006). Education law, article 39, nursing. Retrieved August 28, 2007, from http://www.op.nysed.gov/article139.htm#sect6903