What is the responsibility of the nephrology nurse when the patient is chronically late?
Nephrology Nurses Must Follow the Nightingale Pledge
Mr. Jones is 2 hours late for his treatment again today. What do you do? Put him on and give him his entire treatment pushing back the next shift of patients, or cut his treatment time to keep the unit on schedule?
Nursing has a long history of striving to maintain high levels of professional and ethical practice. Ethical practice is guided by rules of conduct that establish expected behaviors for a particular class of human actions. Practice is established in accordance with the rules and standards of a profession. The Nightingale Pledge (see www.accd.edu/sac/nursing/honors.html.) is an example, as it describes the rules of conduct expected when practicing as a professional nurse. It has been recited during pinning and honors nursing ceremonies in this country since as early as 1883. Some of the statements might sound old fashioned, but the ideals it describes are still the core of good professional and ethical nursing practice:
“I solemnly pledge myself before God and in the presence of this assembly to faithfully practice my profession of nursing.
I will do all in my power to maintain the highest standards and practices of my profession.
I will hold in confidence all personal matters committed to my keeping in the practice of my calling.
I will assist the physician in his work and will devote myself to the welfare of my patients, my family, and my community.
I will endeavor to fulfill my rights and privileges as a good citizen and take my share of responsibility in promoting the health and welfare of the community.
I will constantly endeavor to increase my knowledge and skills in nursing and to use them wisely.
I will zealously seek to nurse those who are ill wherever they may be and whenever they are in need.
I will be active in assisting others in safeguarding and promoting health and happiness of mankind.”
Patients arrive late for treatments for a variety of reasons. When we cut treatment times we are not “maintaining the highest standards of the profession.” We are not “promoting health and welfare,” and we are certainly not “zealously seeking to nurse those in need.” It is well documented in the literature that inadequacy of dialysis is associated with increased morbidity and mortality. Are we acting in a manner that would be considered professional?
Negligence is failing to attend to or perform what is expected or required. By cutting treatment times are we being negligent in our duties? Beneficence is the moral charge to do good. Nonmalfeasance, meaning do no harm, is what Hippocrates emphasized as the cornerstone of ethical practice. When denying treatment to a patient, whether they are chronically late or not, are we doing no harm?
Ethical and professional activities are not about convenience or profit margins. They are about striving to provide the best capable care as a tree professional. This level of professionalism fosters trust. Patients need to trust that we will do the right thing even when they make the wrong decisions. This is an awesome responsibility. We get tired, frustrated, and sometimes downright angry. We work short staffed, and we are always being reminded to be cost effective. All of these factors test our commitment to professionalism and patient care, especially when it seems patients are being irresponsible.
Most nurses feel that patients should come to dialysis when they are scheduled and do what they are asked to do. Ignoring a patient’s autonomy or right of self-determination and removing any ability to determine their own destiny will only erode any trust the patient has placed in us as professionals. We need to support that right to the best of our abilities. It needs to be very clear that we are doing what is best for them because it is both what they want and what we are ethically responsible to provide. Trust is pivotal. Without trust patients would never let us touch them, let alone disrupt their lives by coming to dialysis on time. By acting as professionals and consistently doing the right thing, nurses gain trust. Once that trust has been established, you can begin to change behavior.
Nephrology nurses are strongly urged to think about the Nightingale Pledge when caring for a patient who arrives chronically late for treatment. Ask yourself if you have worked at earning your patient’s trust by “being active in assisting others in safeguarding and promoting health and happiness.” Then make your decision about the care that you are going to provide to this patient.
Caroline Steward, MSN, RN, APNC, CCRN, CNN
Clinical Nurse Specialist, Nephrology Robert Wood Johnson University Hospital New Brunswick, NJ Member, ANNA’s Garden State Chapter
Nephrology Nurses Deserve Respect
The number of patients requiring care for ESRD has risen by great numbers. There are approximately 350,000 patients receiving renal replacement therapies. As floe demand grows for services to this patient population, dialysis industry providers have to recruit and retain qualified nephrology nurses to promote the best care possible.
Dialysis units have to run efficiently, provide optimal services to the patients, and maintain a reasonable work flow throughout the day. The dialysis unit work environment is hectic and fast paced. The numbers of patients and limited resources do not allow for much flexibility in the workday. Patients are taught and encouraged to be on time for their treatments along with the rationale supporting receiving a full treatment. Patients sign consent for treatment, plus facility policies and procedures are reviewed with each patient. Most of the time patients comply, and they are on time for their treatments. However, some patients choose to be chronically late. In many situations this causes problems with the day-to day operations of the units and affects the caregivers providing care.
How do facilities handle this problem? In some situations it is the nephrology nurse who decides to cut the treatment time so the next patient’s treatment is not compromised. In other situations, the unit has to close at a certain time according to the unit/company policy. Alternatively, the nephrology nurse may contact the nephrologist who refuses to shorten the patient’s treatment time, which then requires that the nephrology nurse stay overtime to finish the treatment.
This issue is of great concern to the nephrology community. With the shortage of nurses nationally and world wide, it is important to manage this dilemma. There is a concern for the legal and ethical issues that the nephrology nurse faces. Is the nurse practicing out of his or her scope of practice by shortening the patient’s treatment time? Is it ethical to do this? What if there is an adverse outcome, will the dialysis provider and medical director support the nurse? Should other patients be compromised for the patient who chronically shows up late for treatment?
The recruitment and retention of nephrology nurses is challenging, and these nurses need to be supported and valued. Requiring nurses to stay late because the patient is late will cause frustration, decreased morale and job satisfaction, affect retention, and force the nurse to leave the work environment. Nephrology nurses may even decide to leave nephrology nursing all together. Differences in the culture or value system of the nurses verses the patients likely will negatively influence retention.
Dialysis facility providers need to establish a middle line. There needs to be clarity as to the ethical and legal ramifications on this issue. The goal is to provide optimal patient outcomes and to provide quality patient care without compromising the quality of life of the nephrology nurse and other patients. Care must be given not to impede on the nurses’ tights by forcing them to stay late. The provider needs to support the nephrology nurses and to ensure that the nurses are aware of the policies in place to handle this dilemma. The Medical Director can implement a standing order that allows treatment time to be shortened. An explanation of the risks of shortened treatment times would be given to the patient verbally and presented in writing, which the patient would be required sign. The use of a contract with specific expectations can be reviewed and signed by the patient to promote compliance with unit policies.
One of the most important resources for providing care to patients with ESRD is nephrology nurses. Dialysis facility providers must respect and preserve our most valuable resources.
Sue Fallone, MS, RN, CNN
Clinical Nurse Specialist Adult and Pediatric Dialysis Albany Medical Center Member, ANNA’s Northeast Tri-State Chapter
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