Abstract
A critical aspect of the training period is teaching the patient how to do PD so that peritonitis is avoided. This involves teaching the patient how to do the dialysis without contamination. The patient must learn the concept of sterility and must understand when contamination occurs, and what to do if it occurs. The patient must understand the consequence of not responding appropriately to contamination.
In addition, the patient must learn much more. Ideally, the patient should understand some of the basics of PD, especially the concept of the peritoneal membrane as the dialyzer and substitute or supplement to kidney function. The patient has to learn how to monitor blood pressure and to assess for edema. The patient needs to be able to troubleshoot problems and understand when to call for help.
Most PD nurses that I know are dedicated professionals who are devoted to their patients. In exchange, patients return this devotion (2,3). The relationship is often close, so much so that, in some programs, the PD nurses become almost a part of the patient's extended family, and for patients without family, a surrogate support system. This caring and supportive environment is no doubt important for the anxious and depressed patient initiating dialysis, and particularly for patients who plan on self-care dialysis.
The authors of the guideline indicate that, in their opinion, nurses are the best trainers of patients beginning PD. I agree with them. This is not the case in every country. In some areas of the world, doctors are the trainers. However, nurses, who are trained to be meticulous and who work closely with patients seem ideal as trainers. Nurses require the support of the physicians, as Bernardini, Price, and Figueiredo point out in the guidelines.
The team approach to patient care is typified by the ideal PD program. The team consists of not only the home dialysis nurses and the physicians, but also the dietician, social worker, administrator, secretarial help, often a physician assistant, and sometimes patient-care technicians. However, I would like to focus on the special relationship between home-care nurses and physicians. This, in the best of worlds, is a close relationship, with the doctors and nurses supporting each other, each with defined roles, often resulting in outstanding care for the home dialysis patient.
The success of the PD program at the University of Pittsburgh is due in large part to the collegial relationship among the nurses and the physicians. Judith Bernardini joined the fledging PD program 25 years ago as the research nurse coordinator. She managed the PD registry, in which data has been collected on more than 1000 PD patients and from which a wealth of important information has been extracted. She worked closely with the PD nurse manager, Carol Dacko, and the other training nurses, Marge Miller and Mary Bird (all three of whom have now been with the program for more than 20 years), in amassing feedback on infections and participated in action plans to lower infection rates. These initiatives would then be carried out by the primary PD nurses. This repetitive cycle of recognition of problems based on the data, followed by a new training initiative, has been successful in maintaining low infection rates.
Discussions at quality improvement sessions, which include the physicians and the nurses, led to the concept of using mupirocin at the exit site as part of routine daily care to prevent infections, instead of applying mupirocin intermittently to the nose. The resultant randomized trial showed the effectiveness of this approach (4). More recently, Bernardini was the study coordinator for a double-blinded, randomized multicenter trial comparing gentamicin exit-site cream to mupirocin exit-site cream, demonstrating the superiority of the former in reducing infections (5). The importance of the nurses, both Bernardini and the PD nurses at each of the three programs, participating in the successful completion of this study cannot be over emphasized.
The physicians provide leadership in this process of continuous oversight and improvement in the PD program and by recognizing the important contributions of the nurses. The physician will be greatly rewarded if he/ she works with the nurses in a collegial fashion, listening carefully to the nurses’ input about the program and the patients. The physician, as pointed out in the Peritoneal Dialysis Patient Training ISPD Recommendations, is responsible for ensuring (along with the program's administrator) that the PD nurse trainer receives adequate support, including time for her/his duties in caring for home patients, and time for continuous education by attending meetings.
Ideally, this integrative multidisciplinary approach to patient care is carried out by seeing the patients together in a clinic, rather than at separate nurse and physician visits, as in many programs. Such an approach leads to an ease in communications about patient problems, and to quick problem solving. In our experience, this leads not only to patient satisfaction with care, but also to physician and nurse satisfaction with their roles in caring for the patient. In our program, the results of patient satisfaction surveys, which are done routinely, show that 87.8% of our PD patients consider their care excellent, and 9.8% very good. Typical comments are, “I couldn't ask for any better care and treatment!” and “The staff seems to really care about my well-being and health.”
Bernardini, Price, and Figueiredo have succeeded admirably in laying the groundwork for a more standardized approach to the critical aspect of the training of the PD patient. This manuscript will, one hopes, not only enhance the ability of trainers to teach patients but should also stimulate research in this critical area. This research should be developed by collaboration among nurses and physicians to improve the care of their patients.