Perceptions of Multidisciplinary Renal Team Members toward Home Dialysis Therapies

Discussion

In this multicenter, provincial survey of nephrologists, nurses, and allied health staff involved in the care of patients with advanced CKD and ESKD, the majority of respondents recognized the benefits of home therapies such that they would choose a home therapy for themselves if they ever required dialysis, and favored an expansion in the capacity of both PD and home HD. However, there were significant differences across respondent groups in the perception of factors that affect patients receiving dialysis in their home, at both the patient and system level. Nephrologists, patients, and predialysis CKD nurses were deemed to have a substantial influence on a patient’s modality choice, whereas dialysis nurses were perceived to have the least influence, despite having perhaps the greatest exposure to patients requiring RRT. Overall, the findings suggest there are identifiable discrepancies in attitudes toward home therapies among different members of the multidisciplinary team.

Our results are consistent with previous surveys that found that nephrologists and nurses were overwhelmingly in favor of a home therapy for themselves if ever needed (>90%), but that this did not necessarily translate into endorsing these modalities for patients, potentially due to a lack of confidence in the topic or a misconception of factors that affect home therapies (16,17). A previous single-center study evaluated the opinions of nurses toward home therapies in a large academic center in Ontario (14). In keeping with our findings, this study found that the majority of nurses shared the view that home therapies were beneficial for patients who work or study full time, represented a lower cost alternative for the health care system, and provided better quality of life for patients. In the Ontario study, there was a marked difference among home therapy and in-center HD nurses when it came to choosing a home therapy for themselves if ever needed (80% versus 52%, respectively). In our study, >80% of respondents from all three nursing categories (in-center, predialysis, and home therapy) were in favor of a home therapy when asked the same question. Nursing staff are not usually provided formal modality education apart from the CNeph(C) course, and one might hypothesize that an environment with fewer nurses that have completed this training may have favored home therapies less due to a relative lack of knowledge and experience. Yet, despite the lower proportion of British Columbia nurses the with CNeph(C) designation compared with those in Ontario, the findings were similar between both studies with respect to choice of modality for patients under specific patient- and system-level factors.

When considering patient- and system-level factors, nursing respondents in both studies favored the dialysis modality in their own scope of practice, such that in-center nurses tended to choose in-center dialysis and home therapies nurses tended to choose home-based therapies for patients in these contexts. This may stem from an individual’s comfort level from working with a certain dialysis modality over a longer period of time, or a lack of understanding regarding what constitutes an insurmountable barrier to a patient receiving a home therapy (16). It could be argued that in-center HD nurses are more likely to have been exposed to patients who experienced complications related to their home therapy that necessitated a transition to in-center HD—an experience that could bias their perception of the appropriateness of home therapies for subgroups of patients. This merits further study, given that such biases can potentially be overcome and the observation that nursing staff were open to receiving further practical education in home therapies. Nursing staff in both studies perceived a minimal influence on a patient’s modality decision and ranked themselves lowest in terms of influence. This is surprising given the key role nurses play in the education of patients and warrants further interrogation (18,19). Although not pursued within this study, it is postulated that the nephrology team members view the in-center nursing role inherently as having a singular focus on their own modality while also facing significant time constraints (e.g., rotating patient loads, truncated patient interactions). Both factors may lead to a decreased capacity to engage patients about the breadth of modalities available. Increasing the exposure of staff members to multiple areas of nephrology may facilitate crosspollination of knowledge and expertise in dialysis modalities, and thus help to reduce inherent biases. In support of this, our findings indicated that the majority of nursing staff favored further practical experiences in home therapies.

To make an informed modality decision, patients rely on their multidisciplinary team for information, guidance, and support (15). The opportunity to discuss modality selection with different members of the team could be beneficial to patients, especially because patients may be more likely to choose a home therapy if they attain the same information from multiple sources (15,20). The attitudes of staff toward home therapies and the prevailing culture of a dialysis program with respect to dialysis modalities could contribute to the uptake of home therapies (4,5). Further, the nurses’ opinion of how well patients are educated regarding dialysis modalities likely varies with their experience with patients who have a suboptimal dialysis start (i.e., those that start acute HD without the benefit of predialysis education). Because patients’ value comprehensive, evidence-based information to make modality decisions, encouraging all team members to have an adequate and balanced understanding of home therapies could promote consistency in the information delivered to patients (17,21).

Initiating or transitioning within dialysis modalities requires a holistic approach to care, including adjustment of medications, dietary modifications, and optimization of social circumstances. The allied health staff—consisting of pharmacists, dieticians, and social workers—are crucial components in the delivery of this care (18,22). This group of professionals work closely with patients during the process of modality selection, however, their perceptions toward dialysis options have not previously been described (18,23). Despite not traditionally being in their scope of practice, half of the allied health respondents in this study regarded themselves as patient educators. They did not strongly favor one modality over another in the context of patient- and system-level factors, which may reflect a lack of direct experience with dialysis therapies. Nonetheless, they remained in favor of a home therapy for themselves if ever needed and advocated for an expansion in the number of patients receiving home therapies. This suggests they are cognizant of the benefits of home therapies from the patient perspective, but may not have sufficient knowledge and understanding of the treatment and how it is delivered to have an informed discussion with patients. The majority of allied health staff was in favor of receiving further education in home therapies. These team members represent an untapped resource that could complement the efforts of nurses and physicians by providing consistent and accurate information to patients (20,23). Furthermore, the allied health staff may serve as a resource for patients to explore their concerns or fears about dialysis that may not be discussed with their nephrologist.

Our study has some limitations. Although there was a reasonably high response rate and good representation from urban and rural sites, there remains the possibility of responder bias in one or more respondent groups. The sample size for nephrologists was relatively small, leading to wide confidence intervals in the estimates. There may be heterogeneity among physicians, for example, related to their primary area of work, which could not be interrogated in this study. Due to the fluidity of nursing roles, renal nurses may have varying exposure to more than one clinical domain during their career, which could shape their perception of dialysis modalities. This survey did not capture specific time frames within each domain, and, therefore, we were unable to interrogate this. The amount of teaching provided by nurses could vary according to discipline, and this may have contributed to some of the differences we observed. This information was not specifically captured in the survey, nor was the underlying reasons why some nurses felt less influential. The latter may be better captured through focus groups. The selection of patient and system factors considered as potential influences on modality choice may not fully reflect the list of factors evaluated by the multidisciplinary team. Although there are certain parameters (e.g., a lack of housing or active psychiatric illness) that are generally considered an absolute contraindication to home therapies, British Columbia does not have a standardized definition for this. Therefore, local program experience and resources for home therapies may influence perception of which barriers are truly insurmountable. The implementation of formal criteria of absolute and relative contraindications would allow for a more comprehensive comparison of different programs. These limitations are balanced by several strengths. To our knowledge, this is the first study to investigate the perceptions of the entire care team, including members of the allied health staff. The survey captured a diverse group of respondents, with varying levels of clinical experience, from academic and nonacademic sites. The survey response rate of 48% exceeded the commonly reported response rates of 30%–40% (24,25). Although the findings of this study have not been externally validated, the robust response rate, inclusion of all health authorities within British Columbia, and the fact that the findings were comparable with a previous study in another Canadian province all contribute to the generalizability of the findings.

Although many factors affect patients’ modality choices, renal team members play a pivotal role. Therefore, prevailing misperceptions toward patient eligibility for home therapies may be inadvertently transferred to patients. Acknowledging and understanding these systemic biases, especially those that are implicit, may allow for the multidisciplinary team to more accurately inform patients and improve their access to home therapies. This study found that, even in the setting of a robust and mature home therapies program, there were substantial differences in attitudes toward home therapies among renal team members, particularly regarding candidacy for a home therapy. Structured, focused, and repeated education sessions for the renal team may help to address misperceptions around factors that influence modality candidacy. Most respondents were open to receiving further education in these areas so that they may be better placed to disseminate accurate information to patients. A similar strategy applied to renal transplant staff, including peer-led discussions around overcoming transplant barriers and educational workshops, has previously demonstrated success in this regard (17). Finally, continuing nursing education initiatives do appear effective at modifying perceptions toward home dialysis, most importantly for surmountable barriers. On the basis of the results of this study, broadening the target audience for home therapies education to include allied health team members may be of benefit.