"Within this document there was no definition of a nurse consultant as such. And it is still not clear whether there is a definition," Frances Coldstream told delegates.

"Certainly, from talking to various nurse consultants or hearing presentations by them, the roles seem incredibly diverse, just like many other roles within nursing.

"The White Paper also talked about the magical figure of 50% clinical practice or 'hands on' nursing, but again gave no tight definition of what clinical practice entailed.

"Again there is room for individual interpretation, and perhaps this is a good thing in both areas as it gives the managers setting up the posts and the nurses appointed more freedom to be imaginative and innovative and meet the needs of their particular patients and area."

What the government did outline was about a page of information giving four areas of responsibility, she explained.

		Expert practice
		Professional leadership and consultancy
		Education and development
		Practice and service development linked to research and evaluation

These categories were very similar to research undertaken in a small general ITU setting by Manley. She undertook a diary analysis and pulled out recurring themes, then categorised activities, Frances Coldstream said.

"This is very much the model that the RCN subscribe to so it was gratifying to see that nursing research was used to underpin the document."

But Making a Difference was not just about launching the nurse consultant role, she continued. It looked at the role's potential within the NHS.

Co-morbidity, increased take-on rates, increasing numbers of elderly patients on dialysis, and changing dialysis-session patterns would all influence the roles nurses could adopt.

"We are probably all aware of the shortage of nephrology nurses," Frances Coldstream continued.

"Various strategies are employed to encourage people to enter nephrology nursing, but if our patient numbers increase and the dependency of patients continues to increase so our staffing levels and skill-mix will need to be reviewed. The skills that nurses are taught and use in their daily practice may also need to be reviewed.

"So, how should the nurse consultant contribute to a pre-dialysis service?"

One road would be to use the recommendations of a framework document from the Kidney Alliance, which the Alliance hopes will be used by a variety of people and groups to improve equity and quality in renal care. It set out seven national service standards, all having implications for pre-dialysis care and management, she explained.

"The first one looks at slowing the progress of renal disease, good diabetic and blood pressure control and the specific needs of certain populations, for example, the Asian population, in relation to diabetes," Frances Coldstream said.

"The document also recommends good preparation for renal replacement therapy, education, counselling, appropriate treatment, maximisation of transplantation resources, timely access (access ready if possible) so that emergency access and its attendant problems is not needed."

Other recommendations included:

		looking at audit against known standards, provision of dialysis, adequacy of dialysis;
		looking at where and how care is offered, named nurses, involvement in local planning.
		considering conservative management where dialysis is the chosen treatment or not, or for people wishing to withdraw from dialysis treatment.
		and advance planning so that the patients wishes are known and respected.

What implications did this have for the pre-dialysis pathway? Frances Coldstream asked

"Referral is the initiation of contact with the pre-dialysis set up," she said.

"We have a specific pre-dialysis clinic but I know not everyone has that luxury. But referral itself has problems, by whom and when, at what stage does a person become pre-dialysis? Where do the referrals come from and who deals with them? The standards we have discussed give some indication, but we have to get the message across."

After referral, a good assessment was essential.

"And at this stage I am thinking of a good nursing assessment, not that our MDT colleagues should be excluded, obviously medical and dietetic assessment for example are also important, but as a starting point for further referral," she stressed.

Patients also needed timely education, as most people had little knowledge of what their kidneys did let alone what dialysis was and how it might affect their life, family, and work. This education should embrace input from MDT, medical colleagues, the anaemia sister, dietitians, social workers, counsellors, and occupational therapy. And they needed further consultations and a plan of treatment, access as and when required, and appropriate treatment begun in a timely fashion.

"It sounds so simple, but we all know that in reality that pathway is not always as smooth as it could be," Frances Coldstream said.

But it was also important for nurse consultants to audit their process to see how well they were doing, and to suggest changes and improvements. Here the initial nursing assessment and the pathway threw up possibilities, she continued.

"We need to look at the person as a whole, get to know them and build a supportive relationship with them," Frances Coldstream said.

"Anaemia management can improve the quality of life of the pre-dialysis patient and its appropriate management is no longer thought to hasten the start of dialysis.

"Medical assessment looking particularly to effective blood pressure management and diabetic control to slow the progress of the renal disease if at all possible.

"Use of ACE-inhibitors to reduce proteinuria.

"Surgical assessment both for access and transplantation, initiating transplantation work-up looking at whether living donation is a possibility or not.

"Education for both the patient and family members is important.

"Dietetic involvement that is monitored and altered as required as the person's needs change.

"Home and/or workplace assessments. People are often very different on their own territory and it can give invaluable insights into their coping mechanisms and support networks which may influence recommendations of one type of treatment or another. Many of our patients work and want to continue to work. A workplace assessment and meeting with occupational health and personnel managers with the person present can help understanding on both sides and an increased awareness of the needs these people may have in the future.

"Social assessment and support and occupational therapy assessment and support may be seen as particularly appropriate for the aging renal population, but this is not always the case. However, as the renal population grows, particularly at the older end of the spectrum, the emphasis on this type of support is likely to grow. Careful follow up and monitoring will be essential.

"I hope that I have demonstrated through this presentation that both the developing role of the nurse consultant and the area of pre-dialysis care are exciting developments which can be brought together to enhance patient care. Both areas merit interest and research to take what has been achieved so far forward," Frances Colds

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