Scope of Practice for Nephrology Nursing

Excerpt from Gomez, N. (2011). Nephrology nursing scope and standards from practice. Pitman, NJ: ANNA.

Definition of Nephrology Nursing

Nephrology nursing is a specialty practice addressing the protection, promotion, and optimization of the health and well-being of individuals with kidney disease. These goals are achieved through the prevention and treatment of illness and injury, and the alleviation of suffering through patient, family, and community advocacy.

Scope of Practice for Nephrology Nursing

The purpose of the scope of practice for nephrology nursing is to describe, for the public and the profession, the nature of this specialty’s nursing practice. The specialty’s scope is derived from the scope of nursing practice as defined by the American Nurses Association (2010b) and builds on the previous versions published by the American Nephrology Nurses’ Association (ANNA).

Nephrology nursing encompasses the primary, secondary, and tertiary care of individuals with potential and progressive chronic kidney disease (CKD), end-stage renal disease (ESRD), acute kidney injury (AKI), and other health care conditions requiring nephrologic intervention. Nephrology nursing practice spans the continuum of care for patients with kidney disease. Nephrology nurses provide care to neonatal, pediatric, adult, and geriatric individuals from a variety of ethnic groups. The nursing care may be extremely complex as this patient population may have various comorbid conditions including cardiovascular disease, diabetes, hypertension, infectious disease, and/or mineral and bone disease. In addition, many face psychosocial issues.

The term kidney replacement therapies (KRT) is being used in the nephrology community in place of the older term renal replacement therapies (RRT). These terms identify all therapies used to treat kidney disease including dialysis, transplantation, and palliative care. Throughout this publication, the terms healthcare consumer and patient will be used interchangeably. Healthcare consumer is defined as the patient, person, client, family, group, community, or population who is the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies (ANA, 2010b). The term family relates to the family origin or significant others as identified by the patient. The ANA standards use the term interprofessional defined as reliant on the overlapping knowledge, skills, and abilities of each professional team member. However, the ANNA work group determined to continue the usage of interdisciplinary as reflected in the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfCs) (CMS, 2008).

Overview of the Scope of Practice for Nephrology Nursing

The recognition of kidney disease, acute and chronic, as a major health problem has led to the development of nephrology nursing as a specialty. The practice of nephrology nursing encompasses the roles of direct caregiver, educator, coordinator, consultant, administrator, and researcher. The practice extends to all care delivery settings in which patients experiencing, or at risk for developing, chronic kidney disease (CKD) stages 1 through 5, receive health care, education, and counseling for kidney disease prevention, diagnosis, progression, and treatment.

Optimal individual functioning and family functioning throughout all phases of disease management are the primary goals of nephrology nursing. The nephrology nurse achieves these primary goals by diagnosing and treating human responses exhibited by individuals and families with kidney disease diagnoses or who are at risk for developing CKD. These human responses include, but are not limited to, physical symptoms, functional limitations, psychosocial disruptions, and knowledge needs.

Treatment of these responses involves health promotion and disease prevention counseling, health maintenance education, psychosocial support to build or sustain coping capacity, education to encourage active participation in decision making and self-care, restorative physical care to manage disease and treatment-related symptoms, and the delivery of kidney-replacement therapies including transplantation.

The focus of the nephrology nurse is the patient, an entity that can include individuals, families, groups, and communities. Nephrology nurses manage care to meet the special needs of the patient with kidney disease to maximize independence and quality of life.

Nephrology nursing practice occurs throughout the patient’s life span, along a continuum of care and across delivery settings. Care requirements extend beyond kidney disease to address acute and/or chronic causative disease processes, as well as subsequent comorbid complications. The nature of this nursing care spans the spectrum from preventive and acute through replacement therapies and rehabilitation, as well as palliative, supportive care. Nephrology nursing may be provided in a variety of settings that include, but are not limited to, inpatient, outpatient, freestanding clinics, and home care.

All nephrology nurses are legally, ethically, and morally responsible for practicing in accordance with recognized standards of professional nursing practice, professional performance, the recognized professional code of ethics, and specialty certification.

As illustrated in Figure 1.1, the foundation for nephrology nursing underpins state nurse practice acts and institutional policies and procedures. The apex of this model of professional responsibility is achieved with the individual nephrology nurse’s assumption of personal accountability for continuing education and professional experience over and above the basic requirements for professional nephrology nursing.

General Nephrology Nursing Practice

In addition to basic educational preparation to function as a registered nurse, nephrology nursing practice at the generalist level requires a specific knowledge base and demonstrated clinical expertise in kidney disease care.

The nephrology nurse coordinates care in collaboration with other care providers and health team members to plan and provide required care as effectively as possible. The nephrology nurse acts as a patient guide and advocate, assisting the patient in seeking information, assuring that the patient has the opportunity for informed consent for treatment decisions, and promoting the maximal level of patient-desired independence. The nephrology nurse may also function in the role as a nurse manager to assure patient safety and the delivery of appropriate care.

The nephrology nurse is accountable for delivering care within the framework of the nursing process. The nephrology nurse uses assessment findings to formulate nursing diagnoses and prioritize problems according to patient need. The nephrology nurse engages the patient in mutual goal setting and collaboration in developing a plan of care directed toward achieving identified goals. The effectiveness of the plan of care in goal achievement is evaluated through patient outcomes.

The nephrology nurse actively participates in professional role development activities including continuing education, quality assessment and improvement, and the review and clinical application of research findings to assure evidence-based practice. The nephrology nurse develops ethically sound practice and confronts ethical challenges through application of the Nephrology Nursing Scope and Standards of Practice.

Advanced Practice in Nephrology Nursing

Advanced practice in nephrology nursing requires substantial analytical knowledge in nephrology nursing, and the application and advancement of that knowledge in providing expert care to individuals diagnosed with kidney disease, their families, and the community at large. This advanced practice may include the roles of primary care provider, coordinator, consultant, educator, researcher, and administrator.

Consistent with ANA’s Nursing’s Social Policy Statement and Consensus Model for APRN Regulation: Licensure, Accreditation, Certificaton & Education (APRN Consensus Work Group, 2008), the minimum requirements for an advanced practice registered nurse (APRN) with specialization in nephrology are graduate level preparation and certification in an APRN role and at least one population focus, including family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender related, and/or psychiatric-mental health. The APRN with a specialty in nephrology has additional didactic and clinical course work and experiences in that area.

The advanced practice registered nurse prescribes in accordance to state and federal regulations. The advanced practice registered nurse uses specific pharmacologic knowledge and experience to adjust medications as indicated for the patient with kidney disease. The advanced practice registered nurse participates in the development and assessment of medication protocols.

Nephrology nurses practicing at the advanced level must be able to assess, diagnose, theorize, and analyze complex clinical and nonclinical problems related to the actual or potential diagnosis of kidney disease. In addition, advanced practice denotes the ability to consider a wide range of theory and research relevant to understanding kidney disease-related problems and the ability to select and justify the application of the most meaningful theory or research to assist in problem solving. The advanced practice registered nurse contributes knowledge of nephrology nursing research to interdisciplinary workgroups to assure evidence-based guidelines are incorporated into nephrology nursing practice. The advanced practice registered nurse may serve as the primary care provider to an individual diagnosed with kidney disease, their family, and the community.

As a care coordinator, the role involves the expert use of the application of change process with the interdisciplinary nephrology care team to determine and achieve realistic health care goals for the particular individual, the family, and/or an entire community, while guiding the patient through the health care system. The consultant role in advanced nephrology nursing practice involves providing expert advice about nephrology to colleagues, allied health personnel, and healthcare consumers. The educator role is exemplified by the assessment of learning needs, design, implementation, and evaluation of educational activities. The role of the researcher requires skills in the use of the research process, which includes the ability to identify current researchable problems in nephrology nursing, collaborate in research, and evaluate and implement research findings that affect patient care or nephrology nursing. The administrative role involves use of the managerial process to promote a practice environment that reduces environmental health risks for the nephrology nurse, the patient, and the public.

Nephrology advanced nursing practice is best defined as expert competency and leadership in the provision of care to individuals with an actual or potential diagnosis of kidney disease.

Note: The Nephrology Nursing Scope of Practice is excerpted from the 7th Edition of the Nephrology Nursing Scope and Standards of Practice (2011). Click here for more information regarding this publication.