Abstract
Objectives
This study aimed to explore the current status of advanced nursing practice among blood purification specialist nurses in China, providing insights into their roles and contributions in clinical practice, education, and research.
Methods
This study employed a cross-sectional survey using the convenience sampling method to explore the advanced nursing practice of blood purification specialist nurses in China from August 10 to September 10, 2022. A total of 1,919 blood purification specialist nurses from 882 hospitals in China were surveyed using a self-designed questionnaire.
Results
The blood purification specialist nurses in China had a wide-ranging involvement in clinical nursing practice, teaching, and research. The most frequently performed advanced nursing practice among participants in clinical settings was nutritional management, including assessment (1,597 cases, 83.2 %) and education (1,828 cases, 95.3 %) of patients’ diets and nutritional status. The least performed advanced nursing practices were attending nursing clinics (93 cases, 4.8 %) and inter-hospital nursing consultations (123 cases, 6.4 %). Participants with varying work experience in blood purification, educational levels, professional titles, and from different hospital levels demonstrated different performance rates in various advanced nursing practice items. Working years in blood purification, professional titles, and position were independent factors influencing the practices of nursing clinics, consultations, or both.
Conclusions
The scope of advanced nursing practice for Chinese blood purification specialist nurses was relatively extensive, and they demonstrate their value in many aspects of specialized nursing. Their working experience in blood purification, professional titles, and position might affect their involvement in the key activities of advanced practice.
Keywords: Advanced practice nursing, Advanced practice, Blood purification, Clinical nursing research, Hemodialysis
What is known?
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Chronic kidney disease (CKD) is one of the globally increasing health burdens. Therefore, to ensure high-quality medical services for patients with end-stage renal disease (ESRD), it is particularly important to promote the training of blood purification specialist nurses.
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Blood purification specialist nurses, as advanced practice nurses in nephrology departments in China, have already started practicing in clinical settings.
What is new?
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The blood purification specialist nurses in China had a wide-ranging involvement in clinical nursing practice, teaching, and research.
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Their working experience in blood purification, professional titles and positions affect their involvement in the key activities of advanced practice.
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This study surveyed the clinical practice of blood purification specialist nurses nationwide. It compared their roles with those of international advanced practice nurses and explored how they effectively fulfill their roles in clinical practice.
1. Introduction
Chronic kidney disease (CKD) is one of the globally increasing health burdens [1]. If patients do not receive effective treatment in the early stages of chronic kidney disease, there is a high risk of developing end-stage renal disease (ESRD), which means that the patients’ renal function is basically lost and needs kidney replacement therapy. Globally, the most common form of kidney replacement therapy is dialysis (78 %), with the remaining 22 % of patients living with a kidney transplant [2]. Davis and Zuber stated that the growth rate of nephrologists was much slower than that of ESRD patients [3]. Therefore, to ensure high-quality medical services for ESRD patients, it is particularly important to promote the training of blood purification specialist nurses.
Advanced practice nursing was defined as advanced nursing interventions that influence clinical healthcare outcomes for individuals, families, and diverse populations by the International Council of Nurses (ICN) [4]. From the 1960s, the concept of advanced nursing practice existed in America, and appeared in the UK in the early 1980s [5]. Nowadays, the advanced practice nurses (APNs), as established healthcare providers, deliver care throughout many areas of the world [5]. The two most commonly identified APN roles are Clinical Nurse Specialist (CNS) and Nurse Practitioner (NP) [4]. However, many countries were in different stages of developing these roles, and many APN positions had developed on an ad-hoc basis with varying responsibilities, roles, and nomenclature [4,6].
Recent studies emphasize the significant contributions of APNs in healthcare delivery. A comprehensive review [7] highlighted their crucial role in providing holistic care, improving access, alleviating shortages, enhancing quality, and addressing health inequities, making them essential for global health needs. A recent study [8] provided a comprehensive taxonomy of policy interventions designed to integrate APN into healthcare systems across ten countries. By incorporating insights from experts worldwide, this taxonomy can be applied at three levels: macro (national policies and regulations), meso (organizational and institutional policies), and micro (individual practices). The study underscored the importance of policy support in the successful integration and development of APN roles globally.
In 1991, the concept of “clinical nurse specialist (CNS)” was introduced in China as “specialist nurse (SN)” [9]. Until now, there has been no CNS or NP title in mainland China. As the primary stage of APN, specialist nurses were expected to provide a degree of advanced practice to patients with certain diseases. A specialist nurse in China is defined as a registered nurse who possesses substantial clinical experience in a specific field and has obtained a corresponding specialist certification through systematic training, typically organized by professional associations. This is consistent with ICN, which states that an APN has acquired, through additional education, the expert knowledge base, complex decision-making skills, and clinical competencies for expanded nursing practice. Additionally, their characteristics are shaped by the context in which their credential is used.
Along with the development of APN, numerous advanced practice nurses in the blood purification area provided advanced care for CKD patients in many countries. In the 1980s, the American Nephrology Nurses Association (ANNA) sought to establish specialized care for kidney disease as a distinct nursing field [10]. In America, Advanced Practice Registered Nurses (APRNs) in Nephrology have been certified by the Nephrology Nursing Certification Committee (NNCC) since 2006 [11]. APNs in nephrology mainly work in dialysis clinics and vascular access clinics in America [12]. They could address dialysis prescriptions, anticoagulation regimens, anemia management, adjustments to dry weights, and the treatment of common dialysis-related complaints. Additionally, they can treat acute health problems, including gastrointestinal issues, vascular access infections, upper respiratory infections, and pain management. Otherwise, chronic comorbidities could be effectively managed by the APN, including diabetic complications treatment, insulin management, and uncontrolled hypertension [10].
The Chinese Nursing Association (CNA) began training blood purification specialist nurses in 2009 [13]. In this study, the blood purification specialized nurses are defined as those who have been trained by CNA or a provincial nursing association and have obtained a certificate. To understand their roles in daily practice, we examined the current status of clinical advanced nursing practice among blood purification specialized nurses nationwide and provided a reference for improving the training and management of blood purification specialty nurses.
2. Methods
2.1. Study design
This study employed a cross-sectional survey using the convenience sampling method to explore the advanced nursing practice of blood purification specialist nurses in China from August 10 to September 10, 2022.
2.2. Setting and sample
The inclusion criteria for participants included holding a specialist nurse certificate in blood purification, understanding the purpose and significance of this study, being willing to participate voluntarily, and working in the field of blood purification during the investigation period (including clinical, educational, and management roles).
2.3. Ethical consideration
The study had been reviewed by the Ethics Committee of Peking University Third Hospital (Approval No. M2022441-01). The information about the aim and the procedure of the study was shown at the beginning of the questionnaire through the online Wenjuanxing platform. The participants filled the questionnaire using their own cellphones if they agreed to participate in the study; otherwise, they might exit the questionnaire interface. Since this was the only way to link the participants to their real identities, the requirement for signed informed consent was waived.
2.4. Measurements
2.4.1. Survey tool
A self-designed questionnaire was used as the survey tool. Based on an extensive literature review of advanced nursing practices and blood purification nursing, the researcher designed the initial draft of the questionnaire and then revised it after consulting with 10 medical and nursing experts in the field of blood purification. All of them were females from Beijing City and Guangdong Province, with an average age of 54.00 ± 6.91 years. All experts held an associate senior professional title (or above). Among them, eight experts held Bachelor’s degrees, and 2 held Doctoral degrees. Five experts evaluated the relevance of each item in the questionnaire to advanced nursing practices in blood purification, using a four-point scale (1 = not relevant, 2 = somewhat irrelevant, 3 = somewhat relevant, and 4 = relevant). In other words, a higher score indicated a higher relevance. The item-level content validity index (I-CVI) was calculated as the number of experts who rated the item as 3 or 4 divided by the total number of experts. The scale-level content validity index (S-CVI) was calculated as the average CVI across all items. After two rounds of modification and consultation, the numbers of I-CVI and S-CVI of the questionnaire were both 1. Before the formal survey, a pilot study was conducted with 15 blood purification specialist nurses from one hospital. Since no feedback for modification was received, the 15 responses were also included in the final analysis.
The questionnaire consists of two parts: general information about the participants and details on advanced nursing practices related to blood purification. The general information of participants section includes age, gender, education, hospital affiliation, working years, years of experience in blood purification, year of obtaining the qualification of blood purification specialist nurse, current professional rank and title, and current position, etc. In the second section, participants were asked whether they took part in the following advanced nursing practices of blood purification (23 items): named clinical practices (providing nursing clinic care, providing consultations inter-departments/hospitals, and other clinical practices such as vascular access management, nutritional management, patients’ coaching and nursing quality management, etc), teaching and research practices (clinical and theoretical teaching, participating in academic activities, such as research practices and achievements, etc). Participants involved in nursing clinics and consultations needed to identify the problems they solved for patients. An open-ended question was included for each aspect of advanced nursing practices to allow participants to supplement their own work, reflecting their opinions on advanced nursing practice.
2.4.2. Data collection
The formal survey was conducted using the self-administered questionnaire service of the Wenjuanxing platform. All items were set as “required” to ensure completeness and uniqueness of the participants’ responses. Each device was limited to participating once. In the introduction section, we used uniform instructions to explain the filling requirements and created a separate recruitment poster to highlight the study’s significance, target participants, and filling requirements. In August 2022, the researcher forwarded the instructions and the questionnaire link to the WeChat group of the Blood Purification Nursing Committee of the CNA, encouraging all committee members to widely disseminate the questionnaires and invite qualified blood purification specialist nurses to complete the questionnaire. Finally, all questionnaires were reviewed individually. Questionnaires with a response time of less than 2 min or those containing obviously illogical answers were considered invalid and excluded. A total of 1,922 questionnaires were collected, and 1,919 valid questionnaires were obtained with an effective return rate of 99.8 %.
2.5. Data analysis
All data were exported directly from the Wenjuanxing platform and analyzed using general descriptive statistics. Statistical analysis was conducted by SPSS 23.0. Normally distributed continuous variables were described by mean ± standard deviation, while non-normally distributed continuous variables were described by median and quartile range. Count data were described by frequency, percentage, or composition ratio. The Chi-square test was used to compare the participation rates in different types of advanced nursing practices among nurses with varying education levels, hospital grades, professional ranks, and positions. The Bonferroni method was used for multiple comparison correction of the Chi-square test. Binary logistic regression (using the backward stepwise method) was employed for Multivariate analysis. A significance level of P < 0.05 was used to define statistical significance.
3. Results
3.1. General information
The region covered by the participants encompassed 31 provinces, municipalities, and autonomous regions of China. Among the 1,919 participants, 1,810 (94.3 %) were female, and 109 (5.7 %) were male, with an average age of 38.01 ± 6.84 years and a nursing experience of 17.42 ± 8.12 years; the years of experience in blood purification were 10.76 ± 5.60. Their specialist nurse certifications were obtained from the CNA (750, 39.1 %), Beijing Nursing Association (238, 12.4 %), and other provincial nursing associations (931, 48.5 %). The information on education level, professional title, and position of nurses is shown in Table 1. The number of participants from Beijing City (368, 19.2 %), Jiangsu Province (241, 12.6 %), and Heilongjiang Province (134, 7.0 %) ranked in the top three.
Table 1.
The basic information of the participants.
| Items | n | Percentage (%) |
|---|---|---|
| Gender | ||
| Female | 1,810 | 94.3 |
| Male | 109 | 5.7 |
| Education level | ||
| Master’s degree | 33 | 1.7 |
| Bachelor’s degree | 1,641 | 85.5 |
| Junior college degree | 236 | 12.3 |
| Technical secondary school degree | 9 | 0.5 |
| Professional title | ||
| Junior professional title | 605 | 31.5 |
| Intermediate professional title | 1,013 | 52.8 |
| Senior professional title | 301 | 15.6 |
| Position | ||
| Nurse | 1,396 | 72.7 |
| Head nurse | 465 | 24.2 |
| Supervisor nurse | 53 | 2.8 |
| Director of nursing department | 5 | 0.3 |
The 1,919 participants came from 882 hospitals in China, of which 359 (40.7 %) were tertiary Grade A hospitals, 164 (18.6 %) were tertiary Grade B hospitals, 313 (35.5 %) were secondary hospitals, 18 (2.0 %) were primary hospitals, and 28 (3.2 %) were independent hemodialysis centers.
3.2. Advanced nursing practices of blood purification specialist nurses
The most performed advanced nursing practice among the participants in clinical settings was nutritional management, including assessment and education of patients’ diets and nutritional status, accounting for 83.2 % and 95.3 %, respectively. The least performed advanced nursing practices were attending outpatient nursing clinics and inter-hospital clinical nursing consultations, accounting for 4.8 % and 6.4 %, respectively. The detailed participation status of other advanced nursing practices is shown in Table 2.
Table 2.
Advanced nursing practice of blood purification specialist nurses (n = 1,919).
| Items | n | % |
|---|---|---|
| Clinical Nursing Practice | ||
| Attending blood purification specialist clinic | 93 | 4.8 |
| In-hospital clinical consultancy | 535 | 27.9 |
| Inter-hospital clinical consultancy | 123 | 6.4 |
| Other Clinical Nursing Practice | ||
| Vascular access management | ||
| Assisting vascular access surgery | 370 | 19.3 |
| Difficult arteriovenous fistula cannulation | 1,543 | 80.4 |
| New arteriovenous fistula cannulation | 1,567 | 81.7 |
| Nutritional management | ||
| Evaluating diet and nutrition | 1,597 | 83.2 |
| Routine diet and nutrition direction | 1,828 | 95.3 |
| Education and management of patients | ||
| Responsible for the training of new patients | 1,204 | 62.7 |
| Responsible for daily management of regular dialysis patients | 1,354 | 70.6 |
| Nursing quality management | ||
| Supervision of daily quality control on special inspection of department | 1,186 | 61.8 |
| Participating in nursing quality management meeting of department | 1,466 | 76.4 |
| Participating in the arrangement and formulation of nursing standard process in specialty | 1,186 | 61.8 |
| Undertaking coordination and communication work in hemodialysis center | 1,266 | 66.0 |
| Teaching and Scientific Research | ||
| Teaching | ||
| Undertaking clinical teaching of students | 845 | 44.0 |
| Undertaking clinical teaching of colleagues | 1,006 | 52.4 |
| Undertaking the theoretical teaching of students | 768 | 40.0 |
| Undertaking the theoretical teaching of colleagues | 922 | 48.0 |
| Scientific research | ||
| Undertaking nursing scientific research project | 301 | 15.7 |
| Participating in nursing scientific research | 404 | 21.1 |
| Publishing papers in the past 3 years | 663 | 34.5 |
| Obtaining patents in the past 3 years | 286 | 14.9 |
| Editor-in-chief or co-editor of books in the past 3 years | 134 | 7.0 |
3.2.1. Specialist outpatient clinic and clinical nursing consultation
A total of 93 (4.8 %) nurses participated in the blood purification specialist clinic. Among them, 51 (54.8 %) attended an onsite multidisciplinary team clinic, 33 (35.5 %) attended an onsite independent nursing clinic, 9 (9.7 %) attended an online team clinic, 2 (2.2 %) attended an online independent nursing clinic, and 22 (23.7 %) attended other forms of clinic. The problems solved by blood purification specialist nurses in the outpatient clinic and clinical consultation are shown in Table 3. In addition to the specified items in the questionnaire presented in Table 3, the participants mentioned that the problems to be addressed in the consultation also included psychological counseling, education for family members, care for specific populations (such as the older adults), nurses’ training, and prevention of nosocomial infections, among others.
Table 3.
Problems solved by blood purification specialist nurses in outpatient clinic and clinical consultation.
| Items | n | % |
|---|---|---|
| Problems solving at the nurse specialist clinic (n = 93) | ||
| Vascular access issues | 84 | 90.3 |
| Blood pressure and volume problems | 63 | 67.7 |
| Anemia | 55 | 59.1 |
| Calcium and phosphorus metabolism disorders | 52 | 55.9 |
| Nutritional problems | 60 | 64.5 |
| Other issues | 18 | 19.4 |
| Problems solving at in-hospital nurse specialist consultation (n = 535) | ||
| Guiding the operation skill of blood purification | 368 | 68.8 |
| Guiding the maintenance of vascular access | 480 | 89.7 |
| Difficult arteriovenous fistula cannulation | 391 | 73.1 |
| Guiding blood pressure and volume control | 153 | 28.6 |
| Guiding anemia management | 101 | 18.9 |
| Guiding calcium and phosphorus metabolism disorders management | 102 | 19.1 |
| Guiding diet and nutrition management | 271 | 50.7 |
| Other issues | 74 | 13.8 |
| Problems solving in inter-hospital nurse specialist consultation (n = 123) | ||
| Guiding the operation skill of blood purification | 99 | 80.5 |
| Guiding the maintenance of vascular access | 98 | 79.7 |
| Difficult arteriovenous fistula cannulation | 84 | 68.3 |
| Guiding blood pressure and volume control | 42 | 34.1 |
| Guiding anemia management | 31 | 25.2 |
| Guiding calcium and phosphorus metabolism disorders management | 28 | 22.8 |
| Guiding diet and nutrition management | 54 | 43.9 |
| Other issues | 35 | 28.5 |
| The form of inter-hospital specialist clinical consultation (n = 123) | ||
| Bedside | 88 | 71.5 |
| Dedicated remote consultation network | 27 | 22.0 |
| Wechat video | 59 | 48.0 |
| Telephone | 62 | 50.4 |
| Other issues | 18 | 14.6 |
The number of people attending independent blood purification specialist clinics in Beijing, Jiangsu Province, and Heilongjiang Province (12, 16, and 17 cases, respectively) remained the top three among the different areas.
3.2.2. Other clinical practices
For the open-ended questions, which allowed participants to report their own work that reflected advanced nursing practice in their opinion, a content analysis was used to summarize four themes (vascular access-related practices, nutrition-related practices, patient education-related practices, and hemodialysis program management), along with representative response examples. The detailed information was shown in Table S1, Appendix A.
3.3. Comparison of advanced nursing practice in participants with different characteristics
The nonparametric Z-test was used to compare the differences in the distribution of working years in blood purification according to whether participants were involved in advanced nursing practice or not. The results showed that participating in clinical consultations, quality management, teaching, and research, among other activities, was associated with longer working years in blood purification (all P < 0.05), as shown in Table S2, Appendix A.
Chi-square test was used to compare whether there were differences in the participation of advanced nursing practice among specialist nurses with different academic qualifications. The results showed that participants with higher educational levels engaged in more practices related to nursing quality management, teaching, and research (all P < 0.05), as shown in Table S3, Appendix A.
Chi-square test was used to compare whether there were differences in the participation of advanced nursing practice among specialist nurses with different professional titles. As shown in Table S4, Appendix A, attending specialist clinics, participating in clinical consultations, assisting with vascular access surgery, training patients, participating in daily management, undertaking teaching, and conducting nursing scientific research, etc., were associated with different professional titles (all P < 0.05).
The Chi-square test was used to compare whether there were differences in the participation of advanced nursing practice among specialist nurses from different hospital levels. The results showed that participants in lower-level hospitals undertook more clinical practice, such as providing routine diet and nutrition guidance, training new patients, and quality management. In contrast, specialist nurses in tertiary hospitals participated in more teaching and scientific research activities (all P < 0.05), as shown in Table S5, Appendix A.
3.4. Binary logistic regression analysis of participating outpatient or consultation
Since providing outpatient or consultation services mainly reflects the autonomous role of specialty nurses, we conducted univariate analysis using the Mann-Whitney U test for continuous variables and the Chi-square test for categorical variables. The results indicated that age, years of nursing experience, years of experience in blood purification, education level, professional title, and position had significant differences between participants who did or did not involve themselves in outpatient, consultation, or both (all P < 0.05), as shown in Table S6, Appendix A.
Multicollinearity analysis revealed no serious multicollinearity among the independent variables (VIF < 10). All independent variables (Table S7, Appendix A) were included in the binary logistic regression analysis, which employed a backward stepwise approach. The Hosmer-Lemeshow test showed that the model fit well (P > 0.05). The results showed that years of experience in blood purification (OR = 1.035, 95 % CI 1.014–1.056, P = 0.001), professional title (junior professional title as reference, intermediate professional title: OR = 1.379, 95 % CI 1.044–1.822, P = 0.024; senior professional title: OR = 3.136, 95 % CI 2.152–4.572, P < 0.001), and position (using nurse as reference, head nurses: OR = 2.800, 95 % CI 2.179–3.597, P < 0.001; supervisor nurses: OR = 2.414, 95 % CI 1.342–4.345, P = 0.003) were independent influencing factors of participating outpatient, consultation or both (Table 4).
Table 4.
Stepwise logistic regression analysis for outpatient and consultation participation.
| Items | B | Standard Error | Wald χ2 | P | Exp(B) | 95 % CI |
|---|---|---|---|---|---|---|
| Constant | −1.981 | 0.140 | 200.512 | <0.001 | 0.138 | |
| Years of experience in blood purification | 0.035 | 0.010 | 11.032 | 0.001 | 1.035 | 1.014–1.056 |
| Professional title a | ||||||
| Intermediate professional title | 0.321 | 0.142 | 5.110 | 0.024 | 1.379 | 1.044–1.822 |
| Senior professional title | 1.143 | 0.192 | 35.351 | <0.001 | 3.136 | 2.152–4.572 |
| Position b | ||||||
| Supervisor nurse | 0.881 | 0.300 | 8.646 | 0.003 | 2.414 | 1.342–4.345 |
| Head nurse | 1.030 | 0.128 | 64.808 | <0.001 | 2.800 | 2.179–3.597 |
| Director of nursing department | 1.226 | 0.940 | 1.702 | 0.192 | 3.409 | 0.540–21.517 |
Note: a Junior professional title (Ref); b Nurse (Ref).
4. Discussion
The present survey revealed that Chinese blood purification specialist nurses had a wide-ranging involvement in advanced clinical nursing practice, teaching, and research, which highlighted their role and value. The results showed that blood purification specialist nurses were highly involved in clinical specialized nursing skills and practices, such as vascular access care, nutritional management, patient education, and management, which demonstrates their professional role in clinical settings. The least performed advanced nursing practices were attending an outpatient nursing clinic (93 cases, 4.8 %) and inter-hospital clinical nursing consultation (123 cases, 6.4 %). Participants with varying characteristics demonstrated different performance rates in advanced nursing practice activities.
The ICN summarizes the nature of international advanced nursing practice including [4]: managing full episodes of care and complex healthcare problems, integrating research, education, leadership and clinical management, having an extended and broader range of autonomy, case-management at an advanced level, advanced assessment, judgement, decision-making and diagnostic reasoning skills, having advanced clinical competencies and providing support and/or consultant services to other healthcare professionals, etc. In some countries, APN was described as sharing patient care or undertaking a similar (or complementary) role to doctors [14,15]. A cross-sectional study in California reported the activity categories of APN, which the 5 top activities practicing CNSs (n = 545) reported were consulting with other disciplines (91 %), attending meetings (91 %), teaching staff (90 %), consulting with support staff (88 %), and evaluating patient treatments (88 %) [16]. In the present study, participants were engaged in a similar scope of practice activities. However, they reported a significantly higher frequency of involvement in direct clinical practice. Nonetheless, their level of participation in consulting, teaching, and research still required improvement. Actually, one of the most significant differences between advanced nursing practice and professional clinical practice is the level of autonomy afforded to nurses. Although consultation and outpatient participation, which demonstrated nurses’ roles in independent problem-solving and multidisciplinary collaboration, were evident in this survey, their participation rate was relatively low. They also did not have independent prescription rights.
Decades ago, studies from Western countries reported that the CNS continued to function in traditional roles, similar to those of other nurses, except for participating in various advanced practice nursing roles [[17], [18], [19]]. In this study, blood purification specialist nurses also had a high level of participation in clinical nursing practice, including specialized skills in vascular access care. However, they were more skilled and professional, and could handle more complicated vascular access problems, such as new or difficult fistula cannulations. So, their work content also reflects their ability and advanced nursing practice in blood purification care.
Furthermore, this study revealed that the majority of blood purification specialist nurses were involved in the nutrition management of patients, including diet and nutrition evaluation and routine dietary and nutritional guidance. The importance of nutritional management in blood purification, combined with the limited availability of dietitian resources in Chinese hospitals, leads to blood purification specialist nurses undertaking a substantial amount of nutrition management work in China. The nutritional management of kidney disease in other countries is relatively comprehensive, with a dedicated position of a kidney dietitian responsible for the nutritional management of patients with chronic kidney disease, as well as those undergoing hemodialysis, peritoneal dialysis, and kidney transplantation. In contrast, the implementation of clinical nutrition work in most hospitals in China is still in its infancy, or a gradual development stage, and the overall staffing of dietitians in hospitals is insufficient. In this situation, it is challenging for the hospital’s nutrition department to devote sufficient attention to kidney disease [20]. Blood purification specialist nurses, to some extent, complement the role of dietitians by providing nutritional assessments, education, and other services to patients. While these skills are indicative of expert-level proficiency, they may not fully encapsulate the core tenets of advanced practice, which emphasize greater autonomy, system-level influence, and leadership. It indicated that Chinese specialist nurses were transitioning from expert clinicians to advanced practitioners, but might require further development in areas such as system-level influence and leadership. This transition is crucial for enhancing the quality of care and promoting improvements in the health system.
In the Republic of Ireland, CNSs also communicated and negotiated decisions in collaboration with other healthcare professionals and community resource providers. They worked closely with medical and paramedical colleagues and might make alterations to prescribed clinical options in accordance with agreed-upon protocol-driven guidelines [21]. The National Kidney Foundation in the United States also notes that Nurse Practitioners (NP) typically work alongside doctors in the care of kidney patients, whether in medical offices or dialysis units [22]. In this survey, specialized blood purification nurses in China also actively practiced in multidisciplinary cooperation, with 27.9 % participating in clinical consultancy, which indicated that blood purification nurses in China had shown their professional value, and they could continue to develop in terms of leading, cooperation, and participating in policy formulation in the future.
Moreover, compared to traditional nurses, Chinese specialist nurses in hemodialysis not only perform basic clinical work, but also perform multiple roles such as supervising clinical practice, being involved in patients’ education and management, which is consistent with the fact that advanced nursing practitioners prioritize the education of patients as a key role [23,24]. In Canada, three key areas of CNS practice include the management and care of complex and vulnerable populations, the education and support of interdisciplinary staff, and the facilitation of change and innovation within the healthcare system [25]. In terms of teaching, blood purification specialist nurses were involved in undertaking clinical teaching of students (44.0 %), clinical teaching of staff (42.4 %), theoretical teaching of students (40.0 %), and theoretical teaching of staff (48.0 %), which reflects their role as educators and consultants.
The research ability of APNs enables them to discover, analyze, and solve nursing problems from a specialist perspective, and to play the role of nursing experts in practice. Advanced practice nurses in nephrology also need to identify clinical problems in work, use evidence-based nursing to organize research, and continuously improve quality [26]. In this study, it was observed that blood purification specialist nurses had been involved in publishing articles, obtaining patents, and compiling books over the past three years; however, the participation rate still needs to be further improved. The overall low participation rate in scientific research may be related to the low proportion of graduate education (only 1.7 %). A study on APN in approximately forty countries showed that nearly all the countries reported the master’s degree as the primary form of education for APN [6].
Participating in the nursing clinics and consultations demonstrated their ability to independently solve patient problems. According to this survey, 51 specialist nurses participated in onsite team specialist clinics, and 33 held independent nursing specialist clinics. A detailed investigation into participation in outpatient clinics and consultations reveals that they have played a crucial role in resolving various issues, including vascular access, blood circulation, calcium-phosphate metabolism, and nutritional aspects, which reflects the specialist abilities of blood purification specialist nurses. Although APNs were considered to be working as independent practitioners in many countries, the level of autonomy in carrying out their role varied considerably [27]. In Canada, Nurse practitioners provide direct care to patients, diagnosing and managing diseases, prescribing medications, and initiating referrals to specialists, among other tasks [4]. Nurse practitioners in Australia can also assess and utilize diagnostic tools and prescribe therapeutic interventions [4]. Compared with the APN in developed areas, Chinese blood purification specialist nurses were involved in all aspects but had no autonomy to prescribe independently. Even so, the outpatient clinic and nursing consultation practice of specialist nurses for blood purification were being carried out, which reflected their work gradually becoming independent. Therefore, hospitals should actively establish and improve nursing consultation and clinic systems to promote the professional value of specialist nurses. In recent years, an attempt has been made to promote the policy of independent prescription for specialist nurses, as Shenzhen city has included it in the medical regulations [28]. It is expected that qualified specialist nurses will have the right to independently prescribe tests, medical consumables, and certain types of medications nationwide in the future.
The majority of blood purification nurses participating in this survey came from eastern or coastal areas in China, showing a significant difference in quantity between the eastern and western regions. This result may be related to different healthcare and economic development situations in different regions. The areas with more specialist blood purification nurses also had more nurses attending nursing clinics, which showed their independent problem-solving abilities in patient care in this study. To some extent, the results suggested that regions with abundant nurse resources could foster the development of specialist nurses and offer them more opportunities to engage in advanced nursing practice.
This study showed that blood purification specialist nurses with different seniority levels, educational qualifications, professional titles, and from different-level hospitals were related to the degree of participation in various advanced nursing practices. In addition, the results of the binary logistic regression analysis suggested that participation in outpatient and consultation services among blood purification specialist nurses was significantly influenced by years of experience, professional title, and position. Each year of experience in blood purification increased the likelihood of participation by 3.5 %, highlighting the importance of accumulated professional knowledge and skills. Nurses with intermediate and senior professional titles were more likely to participate in nursing clinics, consultations, or both, highlighting the importance of advanced education and experience. Participants in higher positions were more involved in the key activities of advanced nursing practice, indicating that leadership positions offered greater opportunities for advanced practice. It is suggested that promoting advanced nursing practice requires addressing disparities in experience, education, and leadership opportunities. Policymakers should consider strategies to enhance professional development and create incentives for career advancement, rather than providing specialized training only to nurses.
5. Limitation
This study has several limitations. First, this study attempted to explore the advanced practice situation of blood purification specialist nurses nationwide. Although based on the extensive input from members of the Blood Purification Special Committee of the CNA, it may not include all blood purification specialist nurses and may have some selection bias. Second, China encompasses a vast geographical area, and each province or region has distinct cultures and varying levels of economic development, which may result in differences in the medical environment and nursing practices. We did not conduct an in-depth investigation and analysis of different medical backgrounds.
Furthermore, the study used a convenience sampling method, which may introduce selection bias, as participating nurses may be those who are more accessible or willing to participate in the study. This may lead to more active participation in advanced nursing practices in individuals in the sample. Currently, specialized nurses are mostly trained or certified by nursing societies in local provinces, which may also impact the advanced nursing practice content of specialized nurses in clinical practice.
6. Implication
This study found that the majority of blood purification specialist nurses in China currently work in tertiary and secondary hospitals, with a smaller number working in primary hospitals. However, existing research has confirmed the prominent role of advanced practice nurses in primary healthcare [29,30]. Similarly, the workplace of blood purification specialist nurses should not be limited to general hospitals. Still, it should also be placed in primary healthcare institutions to fully leverage the diverse professional abilities of specialized nurses and reduce the pressure of medical demand. For this reason, policymakers, educators, and clinicians need to consider how and to what extent the APN can mitigate some of the challenges surrounding our healthcare system.
Policy support is necessary for the professional development of blood purification specialty nurses. Opening prescription rights and establishing independent specialty clinics not only promote enthusiasm for the development of specialty nurses but also ensure the implementation of their advanced nursing practices.
On the other hand, to ensure the quality of training for blood purification specialist nurses, it is necessary to establish national training and certification standards and to improve the pathways for specialist nurses to enhance their academic qualifications or pursue further education.
7. Conclusion
The results of this study indicate that the scope of advanced nursing practice for Chinese blood purification specialist nurses is relatively extensive, and they demonstrate their value in various aspects of specialized nursing, which has contributed positively to the development of hemodialysis nursing. Their working years of blood purification, professional education background, professional titles, hospital grades, and positions may have a potential impact on their practical content.
Data availability statement
The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.
CRediT authorship contribution statement
Weiyi Jin: Conceptualization, Data curation, Formal analysis, Writing - original draft, Writing - review & editing. Jing Xiang: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing - review & editing, Supervision, Project administration. Weiwei Zhao: Conceptualization, Methodology, Validation, Investigation, Resources, Writing - review & editing. Guanghui Xiao: Conceptualization, Methodology, Validation, Investigation, Resources, Writing - review & editing. Chunyan Feng: Methodology, Validation, Investigation, Resources, Writing - review & editing. Jinrong Zhu: Methodology, Validation, Investigation, Resources, Writing - review & editing. Manman Gao: Methodology, Validation, Investigation, Resources, Writing - review & editing. Zizhen Wang: Conceptualization, Methodology, Validation, Writing - review & editing. Chunyan Su: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing - review & editing, Supervision, Project administration.
Declaration of competing interest
The authors have declared no conflict of interest.
Acknowledgments
Thanks to all the authors and medical workers for their contributions. We are also deeply appreciate the participation of all respondents in this cross-sectional study.
Footnotes
Peer review under responsibility of Chinese Nursing Association.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2025.12.006.
Appendics. Supplementary data
The following are the Supplementary data to this article:
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.