European Network of Renal Care Associations
The Project “Quality improvement implementation in renal units across Europe”
Zampieron Alessandra, RN, BSN, MSN, DDSI, Coordinator and Lecturer, Bachelor in Pediatric Nursing, Padua University (Italy)
Saraiva Maria, RN, BSN, MSN, PhD, Professor Coordinator Nursing Research, Escola Superior de Enfermagem de Lisboa (ESEL) (Portugal)
Every two years EDTNA/ERCA develops a research project in collaboration with National Associations (NAs). The 2011-2012 project showed that quality improvement is a relevant topic in Renal Units across Europe.
To evaluate and compare quality improvement (QI) implementation in Renal Units across European countries.
Material and methods
Design Cross-sectional study.

Sample Convenience sample composed of dialysis, nephrology and transplants units in European countries.

Procedures Each Association will appoint a Representative colleague to leads the project in every country, and will translate the questionnaire when necessary. Questionnaire would be distributed in paper form as well as in electronic form (doc. file). The Representative of each Association wishing to participate will collect questionnaires over a 12 week period.

Instruments Quality Improvement Implementation Survey (QIIS) developed by S.M. Shortell et al, 1995.
Project “Exploring the Challenges & Opportunities for Renal Care Across Europe”
Challenges and Opportunities for Renal Care Across Europe: Qualitative and Quantitative Study
Zampieron Alessandra, RN, BSN, MSN, DDSI, Coordinator and Lecturer, Bachelor in Pediatric Nursing, Padua University (Italy)
Corso Michele,RN, BSN, MSN, Nurse, Transplantation Department, Padua University Hospital (Italy).
Sedgewick John, MSc.N, MSc HSR, BSc (Hons), Dip N, RGN, RMN, Renal Cert, Cert ED, RNT, PhD (c); Director, of Multi Professional Programmes and Principal Lecturer in Nephrology, School of Health and Social Care, Teesside University (United Kingdom)
Saraiva Maria, RN, BSN, MSN, PhD, Professor Coordinator Nursing Research, Escola Superior de Enfermagem de Lisboa (ESEL) (Portugal)
Every two years EDTNA/ERCA develops a research project in collaboration with National Renal Associations (NAs) In 2010, NA’s President’s confirmed the importance of identifying future projects which would help direct ongoing collaborative research between NA’s and EDTNA/ERCA. This current project , is a reflection of one such project identified – and it was  undertaken in two distinct phases.
This project had two main objectives:

  1. To describe and compare the main problems faced by renal healthcare team in delivering care across Europe.
  2. To describe and compare  opportunities and challenges for further developing renal care across Europe.
Material and methods. 
Phase 1 of this project employed the qualitative methodology of focus group. The focus group included either the president or representative of 12 Renal National Associations who were present during the Ljubljana 40th EDTNA/ERCA International Congress held in September 2011. Focus group members discussed two open questions : 1 “What are the main challenges perceived in delivering renal care within their countries”, 2 “Which strategies they  think are important and need to be implemented in  delivering renal care across Europe?” The focus group was facilitated by the Education Consultant (EDTNA/ERCA) in collaboration with 2 additional facilitators. Field notes were independently taken by facilitator with transcripts of the meeting confirmed between all facilitators to determine accuracy and confirm representation of data.  NA’s representatives were sent transcripts of the focus group to confirm their agreement of the findings. Thematic Content Analysis was performed which identified main themes and sub-themes. The Phase 2 employed the quantitative methodology. Presidents of NA’s completed a questionnaire via email composed of 4 parts: (1) Demographics, (2) Opinions  concerning problems in renal care, (3) Opinions concerning opportunities for developing renal care, (4) Open section for suggestions. The questionnaire used Likert scale with 34 negative items in part 2 (scores between 34-238: high scores indicative of problems). Part 3 comprised 14 positive items (scores between 14-98; high score indicative of opportunities). Pilot testing of the questionnaire for content validity was achieved by an international group of renal experts and nursing students.
Participants identified a number of challenges in delivering renal care for question 1. Themes: Social aspects, Education, Workforce, Clinical, Therapy and Economical issues. Sub-themes: increasing multi-cultural population; increased psychological problems in patients; Minimal renal nursing education at undergraduate level; few postgraduate renal nursing programs; varied education standards and opportunities across country; varied education standards and opportunities across European countries; Minimal continuing education in renal nursing targeted on specific needs; varied requirements for mandatory certification in renal nursing; reduced human resources in renal care, increased ratio patients/staff; varied professional education and experience of migrant nurses; increasing co-morbidity in patients; increasing renal disease  in younger patients; treatment of increasing numbers of older people; increased demands for patient safety; Increased use of home renal therapy; reduced economical resources. For question 2, four themes were identified: Risk management, Education and research, Patient management and Management of renal care. The sub-themes were: Use of check-lists for guarantee patient safety; developing a post-basic curriculum for renal nursing; strengthen the research basis of renal care practice; Enhanced sharing of clinical experiences amongst professionals; providing opportunities to update professional knowledge; maintain a strong focus on patients; improve patients and families education; promote patient empowerment; using skill-mix of professional competencies; increase nurse participation in management and quality control. In the quantitative parts, 12 NAs (Austria, Belgium, Cyprus, Denmark, Germany, Greece, Italy, Israel, Portugal, Slovenia, Turkey, UK) completed the questionnaire. The average value for perceived problems in renal care was121.67(SD 24.83: Min 78 in Slovenia, Max 162 in Germany). The item receiving the highest value related to the lack of safety in the  treatment of renal patients (5.58). The lowest item scored 2.00 by NA’s concerned the non-mandatory requirement for certification in renal nursing. The average value for opportunities in renal care was 75.23 (SD 23.77: Min 22 in Cyprus & Max 98 Slovenia). The item ‘Renal nurses participation in quality control should  be developed received the highest average score (6.17). “It should be used a new European Post-basic curriculum for renal nursing” received the lowest average value of (3.83).
Discussion and implications for practice. 
The study identified various issues and trends in renal nursing, useful for developing the themes and objects of next projects and for planning educational and research initiatives. Concerns are expressed across all European countries regarding patient safety. Strategies to improve renal nurses’ involvement in quality and standards must be strengthened. Developing educational opportunities for renal nurses which are not constrained by curriculum but supports local, regional and national initiatives reflecting the diversity of the European environment remains an important challenge.
Project “Survey on Attitudes of the European Renal Nurses Towards Older People”
The proportion of older people has increased worldwide and so are the health problems related with ageing, such as cardiovascular and renal diseases, that often need long-term care. This enhances the need for skilled and experienced healthcare providers, in many health care settings, who can address and meet the needs of older people. Nurses therefore have a pivotal role as care providers for older people and are uniquely positioned to influence the quality of their care (Stevens & Herbert, 1997). However, previous studies have indicated that healthcare providers do not enjoy taking care of the elderly due to ignorance and poor attitude (Palmore, 1999). As the population grows older, attitudes towards the elderly require evaluating.
The purposes of this cross-sectional study were to identify and describe the attitudes of a sample of nurses toward older people and examine the relationship between their personal characteristics and their attitudes. Attitude can be defined as 'the perception of a person towards a human being, an object or a condition, which is developed by the person's experiences and defines his or her reactions' (Chountoumadi & Pateraki, 1997). Attitude contains three parameters: emotions, knowledge and the way of acting and all three parameters can change (Joy et al., 2000; Soderhamn et al., 2001).
The convenience sample was composed by dialysis, nephrology and transplantation nurses at an international level, with the collaboration of some national renal nurses associations. Participants completed the Kogan’s Attitude Towards Old People Scale (KOAP) and a socio-demographic questionnaire.

The following National Associations participated to the survey:

We received 1061 completed questionnaires from nurses. We received also 15 questionnaires completed by Social Assistants in United Kingdom, but they were excluded in the following analysis because all the project’s focus was related to renal nurses. Participants were mainly female (81%), the average age was 42.69 (SD ±8.70). They prevalently worked in haemodialysis or peritoneal dialysis units (85%). 74% of nurses had older people in their families and 51% have lived with older people. The sample reported slightly positive attitudes toward older people [mean score (± SD) = 151.50 (± 17.9)]. Attitudes were influenced by continent, country, religion, presence of older people in the family and level of nursing education (p < 0.0001). A multiple linear regression suggested that the variables that influenced attitudes towards elderly people were the continent and the presence of old persons in the family.
Attitudes of renal nurses towards older people are slightly positive but could be improved with specific information being given to renal nurses, in order to obtain better care. A good educational resource for renal nurses is the book recently published by EDTNA/ERCA:

Einarsdottir, H., & Pugh-Clarke, K. (2011). Caring for the elderly renal patient. Madrid: Imprenta Tomas Hermanos for EDTNA/ERCA.
  • Chountoumadi A, & Pateraki, L. Short interpretative dictionary of psychological terms (2nd ed.). Athens: Dodoni Publishing Company, 1997, pp. 43.
  • Courtney M, Tong S, Walsh A. Acute-care nurses’ attitudes towards older patients: A literature review. Intern. J. Nurs. Pract. 2000; 6:62-9.
  • Hweidi IM, & Obeisat SM. Jordanian nursing students’ attitudes toward the elderly. Nurse Educ. Today 2006;26:23-30.
  • Joy JP, Carter DE, & Smith LN. The evolving educational needs of nurses caring for the older adult: a literature review. J. Adv. Nurs. 2000; 31:1039-45.
  • Kogan N. Attitudes toward old people: the development of a scale and an examination of correlates. J Abnorm Soc Psychol 1961;64:44-54.
  • Kuhn JK.. A Nationwide Survey of Student Nurses’ Attitudes Toward Aging and their Intent to Work with Elderly Clients after Graduation. PhD dissertation, Temple University. 1990
  • Lambrinou E, Sourtzi P, Kalokerinou A, & Lemonidou C. Reliability and validity of the Greek version of Kogan’s Old People Scale. J. Clin. Nurs. 2005;14:1241-7.
  • Ogiwara S, Inoue K, & Koshizu S, Reliability and validity of a Japanese version of Attitudes toward the Elderly’ Scale. J. Phys. Ther. Sci. 2007;19:27-32.
  • Palmore EB. Ageism: negative and positive (2nd ed). New York: Springer Publishing Company, 1999.
  • Soderhamn O, Gustavsson SM, & Lindencrona C. Reliability and validity of a Swedish Version of Kogan’s Old People Scale. Scand. J. Car. Sc. 2000; 14:211-5.
  • Stevens J, & Herbert M. Ageism and nursing practice in Australia. Royal College of Nursing, Australia’s Discussion Document, No. 3, 1997.
Project “Violence and Aggression: Prevention and Management Strategies in European Renal Units”
Strategies to prevent and manage violence and aggression in the health care setting have become a primary health and safety issue and a training programme has been established. Key components of the programme include staff education and training, risk assessment and management practices, the use of patient contracts and policy development (Forster 2005). Other general interventions include the use of restraints and pharmacological management (Farrell & Cubit, 2005). Intervention strategies include stress management and debriefing for staff who are victims and the creation of a work environment that is conducive to prevent violent behaviour (Warshaw & Messite, 1996).
Aim of the project
The aim of the project is to describe prevention and management strategies of violence and aggression in Renal Units in the different European countries and to verify associations between the different ward settings and the strategies adopted. Results will be used for development of recommendations and educational tools for violence and aggression prevention and management in dialysis, nephrological and transplantation units.

National Associations involved in the project:

Activities and products
The first results of the project were presented during EDTNA/ERCA Conference in Hamburg, last September 2009. We received 436 completed questionnaires (participation rate: 22%) from 12 European countries. The study was realized with the collaboration of National Associations. A parallel study was performed also in Brazil. Results show that written policies and procedures regarding violence and aggression are present only in 18% of units. Educational strategies are available in less than the 20% of units. Incidents are prevented mainly by security staff (48%) or pharmacological treatment (66%). Incident reporting is mandatory for any violent and aggressive behaviour in 66% of units. University and private hospitals implement more strategies than other hospitals. There are some differences between European countries. This study demonstrated that it will be useful to disseminate information for nurses, other health care workers and patients for the prevention and management of violence and aggression. The ppt presentation can be found in the Members-only section of this website (Hamburg Conference).

Results related to Brazil were presented at the International Congress in Campos de Jordão in September 2009. The presentation included all the European results compared with the Brazilian ones and some strategies for Prevention and Management of V&A were also discussed in a workshop.

An article with the title ”Survey on Violence and Aggression prevention and management strategies in European renal units” will be published, in 2010, in the Journal of Renal Care.

An article with the title “Estratégias de Prevenção e Gestão da Violência e Agressão em Unidades de Diálise” will be published, in 2010, at the Acta Médica and in the Journal of SOBEN.

The educational booklets “EDTNA/ERCA Recommendations for prevention and management of violence and aggression in renal units” for helping health care workers to manage this issue will be presented during EDTNA/ERCA International Conference in Dublin, September 2010.

Project “Developing a Comptency Framework for Renal Nurses”
Competencies can be defined as either task-based (i.e. descriptive of a task or skill) or behavioural (i.e. identify certain characteristics). Within daily health care professional clinical work, competencies tend to be a combination of both behaviour and skills.
Aims of the project
To develop a European Competency Framework for nephrology nurses and expand this framework for other healthcare professionals, such as renal technicians, social workers and dieticians.

National Associations involved in the project:

Activities and products
  • 11 National Associations working together that have undertaken and completed surveys of 10% of renal units in their country identifying the skills and tasks of renal nurses. The results were presented during the Vienna Conference (2005) and can be found in the Members-only section of this website (Research Projects).
  • The final result was a competency framework, where it was possible to identify all of the competencies (i.e. skills) required to perform a job effectively (Whiddett et al., 1999). This tool is a practical and easy to use when assessing staff within the clinical area and there are many benefits (training and development of staff, recruitment and retention of staff, performance review, manage poor performance, motivate staff and reward good performance, reinforce organisational values and culture, audit, all care provided by staff is evidence-based, ensure a quality service is provided to patients.

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