Advanced Practice Nurses: Roles in the Hemodialysis Unit

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oth as a “midlevel provider.” Restrictions for APNs range from limiting prescriptive selection to a specified formulary, to co-signature requirement by a physician (MD) for controlled substances, to no prescriptive provision (Pearson, 1996). The lack of a uniform regulatory body for APNs is recognized as an obstacle to defining the clinical role of APNs, particularly in regards to prescriptive authority (Chmielewski et al., 1996 ) . A PN recognition and reimbursement as a primary care provider ( PCP) are often discussed simultaneo u s l y. A PCP is one who assumes independent responsibility for a provided service and contracts with a hospital or agency for pay (Be y e r s , Gunn, Egging, & Thomas, 1997). In contrast, collaborative practice involves physician oversight and many states base reimbursement on the type of practices (collaborative vs. independent). Currently, 13 states and the District of Columbia reimburse NPs without physician collaboration (Ventura, 1998). Barriers still exist for APNs, but substantial progress has been made over the past 25 years. A PN Historical Pe r s p e c t i ve s Nearly 25 years ago, both the government and private sector recognized the need for APNs to assist with intensifying health care demands. The Department of Health, Education, and Welfare established an interdisciplinary committee to examine the expanding role of nurses in health care. These findings gave impetus for federal funding of graduate nursing programs (Kitzman, 1983). Ad v a n c e d practice degrees were emphasized in ambulatory care settings and were limited to adult, obstetric, and pediatric primary care. Certified nurse midwives and certified registered nurse anesthetists were delineated separately because of their unique practice. Advanced practice specialization in other clinical areas emerged in the 1990s (Berger et al., 1996 ) . The need for nephrology APN s was recognized almost 25 years ago even though specialized training was 178 not yet available. Shapiro (1976 ) designed a program to assist dialysis nurses in returning to school for an advanced practice degree in 1976 . After obtaining academic credentials, additional training related to the unique needs of the nephrology patients was offered. These APN s were subsequently employed in satellite dialysis units. Ne p h r o l o g i s t s directly supervised APNs, such that any prescribed therapy by an APN required a physician co-signature. Fiscal analysis demonstrated economic benefit, since each APN assisted in managing 50 chronic dialysis patients at a cost significantly below that w h i ch physicians would incur (Shapiro, 1976). Today’s cost-conserving climate of health care has focused on the economic impact of using APNs to provide some services given by MD s ( Berger et al., 1996). The savings would be largely due to salary differentials, with the APN being paid less than the MD. Cost savings of APN s has not been limited to salary differentials, as APNs have been reported to prescribe less expensive but equally effective diagnostic or therapeutic interventions than MDs (Salkever, Skinner, Steinwachs, & Katz, 1982 ) . Kassirer (1994) disputes this finding and suggests that APNs do not order sophisticated diagnostic tests (e.g., magnetic resonance imaging) because of their lack of familiarity with these tests and that this may jeopardize patient care. Bolton (1998) confirms the economic benefit of APNs in nephrology and emphasizes additional APN qualities including: subspecialty expertise, competency, flexibility, and positive patient reception. Today, some APNs are able to function as PCPs and have established nurse managed clinics, reimbursed at the same rates as physicians (Ve n t u r a , 1998 ) . A PN Me r i t The proposed shortage of available nephrologists to care for the growing ESRD population is a significant incentive for APN sanction. Nephrologists have reported spending 38% of their total ESRD practice time devoted to primary care (Bender & Holley, 1996). A recent outcomebased study that compared NPs to MDs in a ambulatory care setting concluded that primary care provided by NPs was equal to that of MDs. NP s maintained the same authority and responsibilities delegated to their MD counterparts, with random patient assignments (Mundinger et al., 20 0 0 ) . Most nephrologists spend a significant proportion of their time in the care of non-ESRD patients (Ad Hoc Committee, 1997). APNs have been advocated in the management of patients pre-ESRD as well as in the care of dialysis patients, allowing nephrologists to have a more diversified practice (Bolton, 1998). Bolton ( 1998) described a successful collaborative practice model utilizing a NP in the care of pre-ESRD and ESRD patients. Collaborative practice between a MD and APN is comprised of joint commitments to patient care with an integration of talents and skills (Chmielewski et al., 1996). Nephrology APNs in a collaborative practice maintain a great deal of autonomy in providing primary care with support from nephrologists for specific needs (e.g., admitting privileges) that the APN may not be able to provide (Steinman, 1999 ) . The United States Renal Data System (USRDS) reports an annual death rate of approximately 25% (higher than any industrialized country) for ESRD. Age and comorbid illnesses modify individual mortality rates (Agodoa, Wolfe, & Port, 1999 ) . European nephrologists have suggested that American nephrologists spend less time with patients and that this may be a factor in the higher mortality rates (Suki, 1999). With the predicted shortage of nephrologists over the next 10 years, nephrologists will have less time with individual patients; such decreased patient contact time could adversely affect patient mortality. Bolton (1998) made a comparative analysis of nephrologists and NPs in reference to time spent with patients. The average pages/calls received by the NP was twice that of nephrologists NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2
per month. Patients called NPs first for minor illnesses because the NP was perceived as more sympathetic and willing to allot more time to address their needs (Bolton, 1998). A Ne w York dialysis unit recently conducted a survey to find out nurses’ perceptions of an APN colleague. APN availability and accountability for dialysis orders, emergency evaluations, and preventive and health maintenance were considered to be the most valuable contributions of APNs. APN availability was considered to be an improvement over orders written by the nephrologist that rotated through the unit on a monthly basis (Izzo, 1982 ) . Debate continues over the care of dialysis patients by APNs as compared to physician assistants (PA). An editorial by Suki (1999) explored n e p h r o l o g i s t /PA collaborative practice issues, but never identified APN s as a possible alternative. Retention of international nephrology fellows and recruitment of medical school graduates into the nephrology subspecialty were considered preferred alternatives to addressing the shortage of nephrologists (Suki, 1999). Ach i e v ement of these proposals is not likely when there is a lack of evidence for a change in current trends. Conservative estimates of ESRD prevalence rates and workforce requirements still estimate a significant shortage of nephrologists in 10 years (Ad Hoc Committee, 1997 ) . Numerous authors, however, have supported the utilization of NPs over PAs in collaborative practice agreements (Beyers et al., 1997; Bolton, 1998; Sox et al., 1994). NPs were recommended over PAs because NP s were thought to require less supervision than PAs (Bolton, 1998; Sox et al., 1994) and were considered to have more direct patient care experience (Ventura, 1998). Watts and Chmielewski conducted a survey of nephrology APNs with 45 respondents; the majority possessed over 10 years of nursing experience (as cited in Chmielewski et al., 1996). To d a y , NPs (20.7%) outnumber PAs (8.9%) in collaborative practice with nephrologists (Anderson et al., 1999 ) . Considering the complex nature of patients with ESRD, clinical experience is essential to providing quality c a r e . ESRD patients’ unique interrelated considerations include adequacy of dialysis, management of anemia, electrolyte disturbances, renal osteodystrophy, access patency, dietary considerations, treatment of comorbid conditions, and rehabilitative initiatives. Kassirer (1994) noted that NPs were rated superior to physicians in patient satisfaction and in patient compliance with health promotion and maintenance, but maintained a lack of support for APNs as PCPs. Mundinger ( 1994) considered diagnosis and treatment by NPs and physicians to be simi l a r. NPs, however, were more likely to expand treatment to include patient education, counseling, and health maintenance interventions. The nature and perpetuity of diseases/impairments affecting ESRD patients (e.g., hypertension, renal osteodystrophy, anemia, electrolyte imbalances) require continuous therapeutic monitoring to assure adequate management (Daugirdas, 1994 ) . The Department of Veterans Affairs issued a policy promoting employment of APNs because it was felt that APNs could effectively manage up to 80% of patient care requirements (Ventura, 1998). Experienced A PNs in the hemodialysis unit should be able to successfully address the majority of patient care issues, but their practice may best be conveyed in collaboration with one or more nephrologists. A major barrier to nephrologists acceptance of APNs is related to quality of care concerns ( Beyers et al., 1997). Lack of clarity in defining APN roles has led to concerns among both nurses and physicians regarding competency (Chmielewski et al., 1996). The American Nu r s e s ’ Association has defined a graduate level degree as a requirement for identification of APNs (American Nu r s e s ’ Association, 1996). A PN in the Hemodialysis Un i t The following section will address roles of APNs in the care of hemodialysis patients, emphasizing utilization of a collaborative team a p p r o a ch which includes, nephrologist, dietician, social worker, psych o lo g i s t / p s y chiatrist, vascular access surgeon, interventional radiologist, dialysis nurse, and APN . Maintaining effective communication among all members of the team is essential to quality care, and the A PN must assume a pivotal role. It is difficult to separate APN roles (clinician, educator, consultant, counselor, administrator, and research e r ) because of their overlapping nature. Some APNs function as administrators and others practice as case managers, having 24-hour accountability for patients in the caseload (Berger et al., 1996). This article will explore the A PN as a clinician, educator, consultant, and research e r. A scenario will be given for each role to illustrate A PN involvement and emphasize the need for a collaborative practice. Cl i n i c i a n Nephrology APNs institute treatment options for a variety of patient problems and initiate preventive measures to avert development of complications. Hemodialysis patients are subject to unique problems not often observed with other chronic illnesses. Hematological, nutritional, endocrine, musculoskeletal, and immune response abnormalities are just a few of the universal problems associated with chronic dialysis therapy (Daugirdas, 1994). There is a predominance of cardiovascular disease in the ESRD population, such that chronic renal failure has been described as a vasculopathic state (Luke, 1998). Cardiovascular disease has been identified as the cause of up to 50% of deaths in ESRD (Ritz & Querfeld, 1986), with cardiac arrests, acute myocardial infarction, and cardiac arrhythmia accounting for one third of all ESRD deaths (Luke, 1998). Hypertension and diabetes mellitus account for the cause of approximately two thirds of ESRD cases. Because of the magnitude of the problem of cardiovascular disease, nephrology practice must incor- NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2 179
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Advanced Practice Nurses: Roles in the Hemodialysis Unit

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