From machine to patient : shifting the focus of care within a hospital haemodialysis unit

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The thesis describes the process and findings of research conducted in an Australian hospital haemodialysis unit (HHU). The thesis consists of three parts. The first part is an in-depth review of the literature in relation to patients requiring haemodialysis treatments and haemodialysis nursing practice. The second component is an ethnography conducted within the HHU. The final component reports on practice development (PD) work performed with nurses within the HHU. Patients receiving haemodialysis face a myriad of physical and lifestyle adjustments. In many instances, suffering and discomfort are an integral part of patients’ illness and treatment experiences and a significant component of their everyday lives. Some patients who attended the HHU for haemodialysis treatments were suffering. I believed that patient centred care would be essential for the recognition and support of patients who were suffering or experiencing pain or discomfort from their treatment. As the Nephrology clinical nurse consultant (NCNC), I had experienced a number of interactions with patients that intimated that the nurses within the HHU did not provide patient centred care. Impetus for the ethnography arose out of my efforts to support or refute my assumption that nurses in the HHU did not provide patient centred care. The findings would be presented to the nurses. The main research aims were to study the culture of the HHU to acquire a comprehensive understanding of how nursing care was conducted and to identify the structural and cultural enablers and barriers to the provision of patient centred care within the HHU. The ethnography was undertaken over twelve months and involved participant observations and interviews with patients and nurses. Five major themes were identified. These themes were “doing more with less”, “who gets a machine?”, “technological creep”, "dialysis centred care” and “the bottom line”. The ethnography provided evidence for my initial assumption that the nurses did not provide patient centred care. The findings from the ethnography became the basis for practice development work with nurses in the HHU. PD work began before final analysis of the ethnographic data, as there were findings I needed to address urgently. The PD work is ongoing but the outcome has been a slow shift in nursing work within the HHU from machine centred to patient centred care. The journey with the nurses in the HHU and personally within the doctoral program has enabled me to develop within the role of NCNC and an account of the evolution of my NCNC role is also outlined within the thesis.
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