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Nurses touch the lives of everyone they encounter, whether it is caring for individuals, families, or communities. Nurses work endlessly to help patients maintain, attain, or recover from illnesses so they can achieve optimal health and quality of life. The practice of a nephrology nurse has been recognized for over 48 years and requires an intensive knowledge base to care for the pediatric, adult, and geriatric patients with kidney disease. Nurses face many challenges in throughout their profession and workforce which require stamina, perseverance, and commitment. As a result of the current state of healthcare and the COVID-19 pandemic, there has been an enormous burden placed on nurses, especially nephrology nurses.  

Introduction   

The origination of the nephrology nurse stems from the healthcare system’s need to treat end-stage kidney disease (ESRD) through hemodialysis, peritoneal dialysis, and transplantation as the federal government, through the Social Security program in 1973, identified end-stage renal disease (ESRD) as the only disability caused by disease (1). Thus, this expanded the scope of practice for nurses and resulted in a steady increase in nurses wanting to specialize in nephrology. Nephrology nursing has been recognized for over 48 years. 

Treating patients with complex kidney disease has put nephrology nurses at a higher risk of contracting viruses such as COVID-19. Nephrology nurses are essential for the care of millions of patients, and role challenges must be addressed for them to continue providing care to an already vulnerable population. 

Case Studies

Case Study 1

Jessica is a 25-year-old patient who developed a post-surgical infection from her orthopedic surgery. She was placed on vancomycin one gram daily. After five days of treatment, Jessica asked the nurse what her vancomycin serum levels were because no one had been coming to draw blood since beginning the medication. She recalls from a previous infection that someone would come to get blood before allowing her to take any medication, and 12 to 18 hours later, another set of labs were drawn to see what the vancomycin level was in her system. Jessica was told everything was alright and she did not need to worry.  

After seven days, a kidney specialist came in to see her and informed her that her primary doctor had consulted him because the labs they received the previous morning indicated that she had developed acute kidney failure. Jessica is very distraught and does not understand anything that is going on; the physician informs her that she must start dialysis immediately.  

Case Study 2 

Jason is a 6-year-old boy who has been diagnosed with a congenital kidney disease. His parents are informed that he will need to have a kidney transplant, but until then, he will require dialysis. Jason was referred to a nephrologist, but after the first visit, the parents left more confused and troubled than before. A consult has been made for the nurse practitioner (NP) to see them on their next visit. Jason’s parents have been utilizing the internet to get information regarding their son’s condition and what the necessary treatment should be. After speaking with the NP, Jason’s parents asked for more in-depth information to make the right decision for their child. They were told to watch a video that would explain everything, which left them feeling frustrated due to lack of effort by the care team. 

Case Study 3 

Brenda is an RN who recently chose to become a nephrology nurse. She has worked in the dialysis clinic for five months and is considered a beginner. She is pursuing an advanced degree and hopes to become an NP specializing in nephrology. Brenda has just been placed on an on-call rotation for two months. She is being called into the hospital to perform emergency dialysis for two or more patients every two days on top of her regularly scheduled nursing shifts. Since she is still in school, she has asked some experienced nurses to take some of the load from her. The experienced nurses told her that she needed to pull her weight and that going to school was her choice and not their problem. As a result, she continues to work her schedule while attending school.  

One of the senior nurses that Brenda works with had a family emergency and quit with no notice. As a result, Brenda and her colleagues have been informed that there will be an increase in workload and on-call rotations to fill the gaps. Brenda decides to report her concerns to higher management but does not get the support she was expecting; she is now considering leaving nursing. 

*Review the case studies to answer self quizzes after each section. 

What is Nephrology Nursing? 

Nephrology nursing is a specialty in which nurses care for patients of all ages experiencing or at severe risk for kidney disease. Nephrology nurses must have an intensive knowledge base and ability to demonstrate clinical expertise regarding kidney disease care; this goes beyond the required information included in a basic nursing program. An advanced practice nephrology nurse has a master’s degree in nursing (MSN) and is either an NP or a clinical nurse specialist with a primary focus on nephrology (2).  

Nephrology nurses must have a standard knowledge base relevant to all aspects of care for adult and pediatric patients with kidney disease, and their families. The knowledge base necessary includes anatomy, physiology, and pathophysiology.  

The nursing processes as applied to nephrology nursing include (2): 

• Pharmacology and pharmacotherapy 

• Nutrition, growth, and development 

• Teaching-learning theory, counseling, and interview skills 

• Interdisciplinary team skills 

• Research processes 

• Rehabilitation principles 

• Palliative care and concepts related to death and dying 

• Diagnosis and treatment for patients requiring any method of renal replacement therapy 

To become a nephrology nurse, the individual must first become an RN or a licensed practical/vocational nurse (LPN or LVN). Nephrology nursing involves two aspects: preventing disease and assessing the health needs of patients and families. The care nephrology nurses provide consists of working with patients who have experienced the impact of acute or chronic kidney disease (CKD). Because of the specialty, nephrology nurses must be trained, highly skilled, and motivated.  

Why Do We Need Nephrology Nurses?  

Experts project a national deficit of more than 900,000 nurses by 2030, which includes an increased need of 12-30% nephrology nurses, mainly attributed to an increasing elderly population, limitations in nursing school capacity, and growing sick populations and need for dialysis related to long COVID-19 (4). Nephrology nurses are in high demand due to rapid treatment advances for complex health issues that require nurses to be well-versed in identifying various conditions and how these conditions further impact the kidneys. 

As an essential part of the multidisciplinary team in healthcare, the nephrology nurse can initiate comprehensive physical, psychological, and social assessments to provide helpful information needed for identifying and prioritizing symptoms and needs of patients (3). Regarding managing patient symptoms, nephrology nurses have been engaging in patient education that promotes self-monitoring and management of symptoms. Now, nephrology nurses provide more by way of providing dialysis, managing uremic symptoms, prescribing medications, and delivering nonpharmacological interventions (3). 

Additionally, nephrology nurses have a distinct role in helping patients of all ages deal with kidney function and health issues. Whether it is a family history that predisposes someone to kidney disease, an elderly patient who is coping with a new diagnosis of kidney failure, a teenager recovering from a kidney transplant, or a person with advanced end-stage kidney disease, nephrology nurses understand the special care needed for these patients (3). 

On top of this, nephrology nurses are needed because they can function as patient care coordinators while collaborating with healthcare team members to provide required care as effectively as possible. The nephrology nurse acts as the patient’s teacher and advocate, assisting them in seeking information, assuring them of informed consent with treatment decisions, and promoting the maximum level of their desired independence (2). Although their focus is renal care, they must continuously promote, practice, and abide by ethically sound protocols from both their practice and the Nephrology Nursing Standard of Practice and Standards of Care (2).  

Because nephrology nursing is so critical, the American Nephrology Nurses Association offers annual national symposiums and practice and leadership conferences, which provide an in-depth educational session for nurses at all practice levels and in all nephrology subspecialties (2) 

The roles of a nephrology nurse include, but are not limited to: 

•  Hemodialysis/peritoneal nurse 

•  Vascular access coordinator  

•  Transplant coordinator 

•  Organ recovery coordinator 

•  NP or clinical nurse specialist 

•  Pharmaceutical representative 

•  Nurse researcher 

•  Quality management nurse 

•  Renal nurse educator  

•  Corporate sales renal nurse 

•  State or federal surveyor 

Because renal problems usually affect all organ systems throughout the body, nephrology nurses actively participate in professional role development activities, including continuing education, quality assessment and improvement, and the review and clinical application of research findings to stay up to date on all new challenges regarding the renal system (2). 

By creating individual care plans, helping identify support systems, and educating patients on various treatment options, the nephrology nurse truly significantly impacts a patient’s journey through kidney treatment. 

Where are Nephrology Nurses Employed? 

Over time, nephrology nursing has developed into an umbrella term covering several subspecialties and interventions that support various stages of CKD or acute kidney disease (AKD).  

In most cases, a nephrology nurse will practice in primary, secondary, and tertiary care facilities and in-patient homes. Nephrology nurses also practice in critical care settings due to the fast-paced and potentially complex interventions needed for their patients (5).  

Areas where a nephrology nurse’s expertise is most needed include: 

• Early CKD (Stages 2-3) – primary care settings, community settings, and nephrology clinics. 

• Advanced CKD (Stages 4-5) – nephrology and advanced CKD clinics, community settings, and pre-dialysis settings 

• Vascular Access and Peritoneal Access Nurses – nephrology clinics, community clinics, primary settings  

• Kidney Transplant Coordinators – transplant surgical wards, transplant clinics, critical care units, centers, and clinics for follow-up  

• Home Dialysis Therapies – home therapy training centers and patient homes  

• In-Center Hemodialysis – hospital dialysis units, outpatient hemodialysis clinics, and minimal care centers  

• Acute and Critical Care – in-patient wards, acute dialysis units, high dependency units, emergency departments, and critical care units 

• Conservative Management and Care – hospitals, nephrology centers, outpatient dialysis clinics, community settings  

• Palliative Care – hospitals, nephrology centers, outpatient dialysis clinics, and community settings  

• Educator – all nephrology clinical services, hospitals training centers, colleges, universities, and research settings 

• Advanced Practice – hospitals, nephrology centers, outpatient dialysis clinics, community health centers, colleges, universities, and primary settings  

Due to the various opportunities within the specialty, such as dialysis, transplantation, CKD, AKD, and education, many nephrology nurses stay within the profession.  

What Challenges Do Nephrology Nurses Face?  

In its entirety, the nursing profession can be both rewarding and challenging. Changes that have taken place within the industry have been driven not only by socioeconomic factors but also by overall developments in healthcare delivery and professional issues unique to nursing. A unique challenge for nephrology nurses today is the type of patients they are tasked with providing their unique skills. The cardiorenal patient is the latest of many new patients and care can be quite challenging. To care for these patients, the renal nurse must take an “avant-garde” approach (advanced innovator) to the cardiorenal patient’s screening, detection, diagnosis, progression, and management. The renal nurse’s most significant challenge in the care of the cardiorenal patient is the need for cardiac curriculum in the nephrology nurses training (6). 

Generally, the underlying driver of high stress levels and burnout in nursing is compassion fatigue, resulting from exposure to suffering, empathy, repeat exposure, and, ultimately, burnout. In addition to the intensity of long-term relationships between nurses and patients, the high frequency of near-death experiences in dialysis care can cause the nephrology nurse to have an increased amount of emotional tension while in the workplace (7). 

There are many challenges facing the field of nephrology nursing: legislation and regulation, education, nursing shortages, long working hours, technological advances, evidence-based practice, crossing borders, workplace safety, personal health, and dialysis treatment methods. Let us look at the challenges individually and in more depth. 

Legislation and Regulation 

It has been assumed that nurses lack the power to be effective in the legislative arena; therefore, nurses may perceive themselves as powerless. Nurses are impacted daily by policy legislation and regulations developed by non-nursing individuals. Nurses only account for 14% of officials that influence health reform, compared to 75% government officials, 56% insurance executives, 46% pharmaceutical executives, 46% healthcare executives, 37% doctors, and 20% patients (8). Today, nurses have awakened their potential for shaping and leading the development of health and social policies in their workplaces, communities, and nations. Healthcare policies affect every nurse’s daily practice. Nurses bring their expertise as advocates to a larger scale by working in policy and politics (13). 

Education 

Beyond becoming an RN, nephrology nurses must obtain specialized education to remain in their field. They must continually update their education through various programs, conferences, and symposiums. As previously stated, The American Nephrology Nurses Association offers an annual seminar and conference for nephrology nurse managers, advanced practice RNs (APRNs), and clinicians (2). The nurses who cannot attend these events must find other avenues to continue their education, maintain their certifications, and demonstrate advanced knowledge and expertise. This requirement may become difficult to manage between their professional and personal lives and can add a lot of stress that could further impact their work performance (9). 

Shortages of Nurses 

Shortages have been a significant challenge in all areas of the nursing profession. The American Association of Colleges of Nursing reported that the number of nurses leaving the workforce each year has grown steadily, from around 40,000 in 2010 to nearly 80,000 in 2020. The 2022 National Workforce Study revealed that over 800,000 RNs and 184,000 LPNs/LVNs indicated they are likely to leave nursing by 2027, equivalent to nearly 20% of the total licensed RN and LPN/LVN workforces in the U.S. The shortage contributes to nurses being spread thin and overworked (10). 

Nephrology nursing as a specialty has an 80% shortage of nurses in low-income countries and a 60% shortage of nurses in lower-middle-income countries (8). The recruitment and retention of nurses have not kept up with the ever-increasing demand placed on healthcare; it is very frustrating for nurses not to have enough time to devote to each patient or to interact compassionately with their patient’s family because they constantly feel rushed. Hospitals and various other healthcare facilities trying to meet their budgeting goals and save costs wherever they can usually means having fewer staff members working, even at the busiest of times of the day, resulting in less support and a more hectic workload.  

Short-staffed nephrology nurses are at greater risk of making mistakes, experiencing near-death events, and placing their patients in danger—ultimately resulting in them leaving the profession. The U.S. Bureau of Labor projects that the country will need an additional 203,200 RNs annually until 2031 (10). 

Long Working Hours 

Working as a nurse can be physically and mentally draining. Some healthcare facilities have resorted to staffing three 12-hour shifts per week (sometimes in a row) to cut their budget. Nephrology nurses must contend with working multiple 12-hour shifts in a row, being on call, having mandatory overtime, and having to stay over if there is an emergency with a renal patient. Because of the demands of working long, stressful hours, the nurse may find it exceedingly difficult to address the needs of their family and take care of themselves (9).  

Advances in Technology 

Healthcare systems have modernized their hospitals, clinics, and primary practices to be more accessible to patients and other healthcare team members. Technology moves at a breakneck pace and new advances are being initialized almost daily, This immediately impacts how nurses work, requiring them to continually learn new skills in real time (8). Coupled with the challenges of long working hours and nursing shortages, it may be difficult for nurses to keep up with the newly emerging data and equipment. A nurse must be able to keep up with technology to avoid becoming overwhelmed.  

Evidence-Based Practice 

For the nephrology nurse, evidence-based practice is not a new idea; however, they continue to face barriers to implementation due to time constraints, limited access to literature, lack of training in interpreting research, and environments that do not encourage information seeking. Over the past several decades, nurses have generated new knowledge by conducting research studies, but it takes time for the evidence to be implemented. Evidence-based practice has become the best way to make clinical decisions, affects healthcare outcomes, and improves patient care quality (1). 

Bullying and Harassment 

Nursing has always been considered a caring profession, but many nurses have not modeled that same caring behavior toward their colleagues. Unfortunately, the saying “nurses eat their young” has been proven accurate. Veteran nurses are sometimes not as welcoming or collaborative with their younger, less experienced colleagues as they should be (8). In nursing, workplace bullying (WPB) is defined as any negative behavior exhibited by a nurse that is repeated daily or weekly and persistently toward other nurses who have difficulty defending themselves against the threat (12). Research has revealed that WPB is most prevalent during the first year of practice, making new nurses vulnerable. WPB and harassment are most prevalent where there is poor leadership, hands-off management, and scarce resources.  

This behavior negatively affects nurses, patients, and organizational and healthcare outcomes, and is considered the most dangerous challenges of all nursing specialties. Nurses also experience bullying and harassment from patients and their families both in-person and virtually; this remains a dangerous problem (8), 

Workplace Safety 

Nurses are subject to many workplace hazards including exposure to germs, viruses, infectious diseases, blood-borne pathogens, and equipment malfunctions. A nurse must frequently participate in safety procedures. Some ways to achieve workplace safety for nurses include peer-to-peer safety conversations, leader safety rounds, daily safety messages and reminders, and purposeful, safe actions (11). Nephrology nurses operate in a busy environment and sometimes forget to check their surroundings, increasing the chances of an accident. Various articles of clothing and personal protective equipment (PPE) can promote nurse safety, such as gloves, face shields, and shoes.  

Personal Health 

Nursing can be a highly demanding and stressful job. Many challenges affect a nurse’s health, from workload to inadequate staffing. Nurses often put their patients’ well-being above their own, thus causing them to suffer from depression, medical conditions, and, ultimately, burnout. Evidence suggests that the intensity of job burnout resulting from the high-stress environment is exceptionally high among nephrology nurses (7).  

Dialysis Treatment Methods 

The End-Stage Renal Treatment (ETC) Model is an aspect of the Advancing American Kidney Health Initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in 2019. This model is designated to shift the predominant in-center hemodialysis model to a home dialysis model. The most prominent challenge nephrology RNs face is the mandate to conduct dialysis training meant for in-home care. This rollout occurred during one of the most significant nursing shortages among nurses and the increased demand for nephrology nurses to meet the growing demand for home dialysis initiated by CMS (14). 

Consideration for the new ETC program should prioritize new RN hires for in-center dialysis (ICHD) units and migrate seasonal nurses from the ICHD to the home dialysis programs. Formal instructional programs that provide a solid basis for the skill sets needed, particularly for the nephrology nurse to become competent in home dialysis training, provide the ideal foundation for nephrology nurses (14). 

How Do Nephrology Nurses Overcome these Challenges? 

Nurses are resilient and very proactive. To conquer these many challenges, they must become a strong voice advocating for positive change within their profession. Nurses are the healthcare workers most actively involved with patients, their families, and the community. By utilizing their knowledge in their respective specialties, they must stand as advocates for innovation and fundamental change in healthcare legislation and regulations (8).  

To address the nursing shortage, the WPB culture must end; nurses must be aggressive in confronting and addressing any instances of harassment if they witness it.  

Additionally, technology is advancing rapidly, and as time goes on, it will only continue. It is the nurse’s responsibility to stay up to speed. 

Nursing leaders must be more proactive in helping nurses understand evidence-based practice and how it applies to their practice. Nurse educators can host weekly sessions to present what is new in nursing research and encourage staff to participate in furthering nursing practices. Additionally, nurse management team members can sponsor nurses to attend the American Nephrology Nurses Association’s annual symposium and conference to keep their staff current with the ever-changing field of nephrology. 

In addition, it is essential to note that nurses should always prioritize safety. If an unsafe practice is witnessed, it must be reported immediately to prevent a patient or colleague from harm. Personal health and safety are a must. Management should encourage staff to take breaks as they are beneficial to a nurse’s work performance, workplace satisfaction, and mental health.  

Conclusion

The current challenges experienced by nephrology nurses allow opportunities for growth and innovation that can positively redefine and advance the field. As the demand for nephrology nurses continues to grow, addressing and overcoming the many current challenges they face can decrease the global nursing shortage, increase interest in nephrology, expand commitments to research, and prioritize evidence-based practices.  

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