Table 5.
Theme | Selected quotations/observations |
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Individual | |
Patients’ and nurses’ perspectives | You can have a doctor one week who changes an order and then a different one the next week who changes it again, you might not see either doctor again for 6 months and then another doctor comes and says, why did they make these changes. I’m like, don’t ask me . . . they don’t ask you what the problem is, they just like to change things [. . .] my own doctor is not like that but she isn’t able to come very often. (Satellite patient 15) He doesn’t know me, he’s telling the nurses to drop my weight, I’m trying to tell him that we tried that and I was unwell, and he’s like rushing on to the next person [. . .] I wish they [the doctors] would just listen. (In-center, patient 14) [Primary nephrologist] he’s so wonderful. You know, he’s so great, he’s gone above and beyond you know . . . but I don’t see him enough. (Home patient 1) I think he’s a great physician. I really like him, I think he’s a good nephrologist. I again, would probably get down to that wishing that maybe there was more communication or just even caring about some of the things that I suggest alternatively. (Nocturnal patient 11) The relationships that we are able to build with our patients are a tremendous draw [. . .] it’s tremendously rewarding. (nurse 8) [I]t was so awful when they died, I was so upset . . . I had known him for about 10 years, I knew all about his family . . . he was funny, he used to make us all laugh” (Nurse 6). |
Professional practices, role perception, beliefs, and values | You only need three things in order to be a great dialysis nurse: are you able to justify your fluid loss; are you able to justify your electrolyte prescription based upon your bloodwork; is your access working ok or do you need to address it to the doctor? (Nurse 3) Primarily in here our focus is dialysis, right. It’s the same thing as, I don’t even know if it’s even an implacable question that if you bring someone to ultrasound, do you really have to have all the history of the patient in order to treat them? (Nurse 3) We also have doctors that, when they go in there [dialysis unit] they’re like, just do the same thing as before even though they haven’t really assessed the patient that well. (Nurse 3) I mean the argument is often given as though, we don’t have time for that. And maybe you don’t have time for a 100% of that every encounter every time, but if that’s your fundamental belief of how you perform care, you have time to treat people with respect. You have time to speak to people and understand their preferences and manifest them in the ways that you can. (Nurse 6) |
Unit/facility | |
Stressful work environment, limited support from leadership, management | I’ve been in the hemo unit with people who don’t have good attitude and I just roll my eyes and thinking, go home if you don’t want to be here. Don’t take it out on the nurses, they’re doing the best they can. Don’t be a dick go home. They’re keeping you alive for crying out loud. (Nocturnal patient 8) Am I trusting myself to a leadership team that knows what they are about or not? And, because we don’t have really any communication and the answer to that is somewhat unclear to me. (Nurse 7) So some of the phrases attributed to the leadership are, “the morale in this place is not my problem.” (Nurse 7). |
Limited opportunities for team working/collaborative practices, limited evidence of integrated working both clinically and managerially | [Researcher] Do you have meetings where you can share information and concerns you may have about a patient? No, I just tell the nurse clinician or the doctor if I see them. (Nurse, 5) There’s many barriers to good multidisciplinary care [. . .] trying to get a team to participate in working together to care for the patients is very difficult. (Nephrologist 6) Myself and another physician have tried to participate in these operations meetings, but there is no updates on what’s going on. So, it’s very difficult and intense relationship with the operations. I feel like the management doesn’t have a lot of mentorship and the management style is very controlling . . . it’s just a very difficult culture and I think the physicians have been trying really hard to improve nurse moral but the managers and nursing staff need to take some responsibility and help with that because I personally think that nurse morale is very low. (Nephrologist 6) |
Task-orientated, prescriptive work practices | There’s all these checklists that have been developed, things need to get done and they have this culture of blitzing, so we are going to do this blitz this week, this blitz week, this blitz this . . . instead of looking at the person as a whole [. . .] they [the nurses] should be getting to know the patient as a person instead of just doing these checklists and trying to compartmentalize care. (Nephrologist 6) Medically wise, what their current issue is in the unit, you have to do it yourself and you have to find out, but now again because of the rounds we are doing we are trying to focus on that, which can be hard too because you are swamped at times already and you are trying to learn this patient. (Nurse 2) Their [the management] clear preference is people who know and complete the policies unquestioningly and who place an emphasis on the biomedical, optimizing the biomedical and the timetable, if you demonstrate a critical voice, that will be marked against you. (Nurse 7) Like every patient is different however we follow the same routine for everybody, like this patient, I know he is very stable with his BP and everything, why [do] I still have to check every half hour and have to document every half hour. We are writing stuff nobody is going to read. (Nurse 8). You know it is all routine . . . why not . . . like I use this time a lot to educate patient, to discuss with specific patient what’s your concerns what can I do what can the team can do to make you feel better, to make you feel more comfortable. It’s just routine, routine, routine. I worry I may get in trouble if I don’t follow the routine, if I help the patient first and not the routine, I will get in trouble, I protect myself. After routine I do as much as I can to make it better for the patient. (Nurse 8). [Fieldnote] Nurse crying during interview. Nurse non-Canadian graduate, had worked in native country as manager in dialysis prior to working in this unit. Has been here 10 years. Feels frustrated, micromanaged, not allowed to use professional judgment. No the management are not supportive of this more integrated approach I look at this whole dialysis thing and it is very task focused and we have a lot of dialysis patients and so it doesn’t really foster the nurses being able to deal with some of these psychological stressors that the pts may be dealing that probably need to be dealt with at that moment . . . you know the patient is distressed and maybe needs to speak to the nurse more before they move onto the task, but you know there are several factors which works against the nurse being able to do that. (Social worker, 3) |
Care continuity, communication, scheduling/assignment of patients, time constraints/workload | When you’re on the ward for 2 weeks you can admit patients, see other patients, wrap up their issues and have them wrapped up with before the next person comes on and so there’s been some talk of is this the best way to have some continuity in the dialysis unit to make those rotations two weeks back to back as well . . . it doesn’t give you overall continuity, but is a good first step. (Nephrologist 1) So, it might be me rounding this week and then [another physician] rounding the next week, and so on and so on, so I think the continuity of care becomes a bit problematic, and I think when there’s 52 handovers on patients in a year there is a lot of [. . .] potential for missed information.” (Nephrologist 1) So I think the continuity of care becomes a bit problematic and I think when there’s 52 handovers on patients in a year there is a lot of potential for missed information and for maybe things that have been ordered to not be followed up on. (Nephrologist 1) I think if there could potentially be a system where there was more consistency in the physician who was rounding on the unit then that creates somewhat better individualized care. (Nephrologist 1) So, sometimes it’s hard in that situation cause even though you are the case manager there’s all this management that is happening that you are not aware of until usually something major happens or people want to clarify something. Sometimes I feel like in terms of case management, as soon as people get onto dialysis they are less well cased managed then they were before they were on dialysis. (Nephrologist 2) |
I mean we all take turns rounding on the units. You know depending on somebody’s clinical service, they will do more or less dialysis rounds . . . each nephrologist will usually try to go to every single dialysis unit at least once a year. (Nephrologist 2). With the satellite dialysis units to travel back and forth between multiple satellite dialysis units that are geographically located or multiple sites that are geographically located you know, 20 or 30 km apart within the city and the traffic and all that other stuff then yeah, for sure it impedes your ability to deliver individualized patient care to an extent because you have to round on that dialysis unit. (Nephrologist 5). There is a huge gap in terms of continuity or follow-up of issues. That is a huge challenge and they are only here one day a week. It used to be three times a week at least they would round right so that they could follow-up with an issue on Monday, evaluate it, see how it went. (Unit manager, 1). The same patient is not on the same spot [hemodialysis space], might be the same spot but it’s always a different nurse. (Nurse 3) [Researcher] And how do you keep up with all of those [hemodialysis] patients? MD: I can’t, I try and so I think it comes down to our local practice pattern. (Nephrologist 4). Every five days you’ve got a new nephrologist and there is someone else of the weekend and it’s kind of piecemeal try to care of the patient, I’m not saying my colleagues aren’t competent, caring physicians, it’s just that a lot of those things happen at bedside and the information is not always transmitted or shared. (Nephrologist, 4) [I]t’s just that logistical stuff impedes your ability to spend enough time with the patients because you physically have to round and move on. You know, to get all of that done in a morning and to do a good job of it and give individualized patient care to the you know, 40 plus patients you might see that morning, like that’s damn near impossible. (Nephrologist 5) |
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Stressful environment to work | They are not happy, so some patients they yell. They treat other people sometimes with no respect, which is understandable. So, yeah, so I think the system, the culture and it should be supportive [of the nurses]. (Nurse 6) Because a lot of these new nurses will come to me and say, oh so and so is not nice to me and I tell them, don’t feel too special because they aren’t nice to everyone. (Nurse 3) It’s a really tense environment and staff are very stressed and I think that there is not a good way to bring people together and talk about the patient and try and come up with plans . . . (Nephrologist 6) I think it’s challenging for them. I think there is a huge time constraint. I don’t’ think they have enough time to do that individualized care. Even though we say anemia protocol and INR [International Normalized Ratio] nomogram, they are protocols, you follow it. Sometimes what you see with errors is that lack of individualizing it. (Manager 1) |
Dialysis focused | Primarily in here our focus is dialysis, right. It’s the same thing as, I don’t even know if it’s even an implacable question that if you bring someone to ultrasound, do you really have to have all the history of the patient in order to treat them? (Nurse 3) It’s not about me it’s about their routine [. . .] they have to get things done, I get asked the same questions [. . .] 4 times a week, “any nausea, diarrhea, vomiting . . .” [. . .] a couple of weeks ago I did have diarrhea and vomiting, but the nurse just went “okay” and that was it, nothing was different.” (Patient 8, nocturnal program) |
Organization | |
Resource allocation, increasing demand on services | [Fieldnote] Nurses perceived increase in workload but with no additional resources. |
Structure of care, lack of opportunities for clinical staff to influence/be involved in organization of care | It’s just like an “us or them” kind of structure [. . .] It’s not a partnership and part of it is the structure of the program [. . .] there’s no transparency, we have tried to promote interdisciplinary working but there is little consistent feedback on what’s going on. (Nephrologist 6) [Fieldnote] The organization of the rounding rota does not (obviously) account for nephrologists’ workload or patients/service needs. |