Understanding the bioecological determinants of vascular access for haemodialysis therapy : a case study in one satellite haemodialysis community

This research project utilised a case study methodology to investigate the bioecological factors influencing the management and care of patients with a vascular access (VA) for their haemodialysis therapy. In Australia in 2012, 61% of patients receiving haemodialysis therapy were treated by a satellite haemodialysis unit (SHDU) (ANZDATA 2013). The boundary for this single case study was one SHDU in Australia and the people associated with this community. This included people living with ESKD receiving a regimen of haemodialysis therapy, those who care for or have an interest in the care of the patient and their VA, their family and or friends as carers and healthcare professionals in the SHDU during the period of data collection. The bioecological model of process, person, context and time (PPCT) (Bronfenbrenner & Ceci, 1994) was used throughout the case study to guide the research method, analysis and presentation of results. The case study report commences with the articulation of the descriptive theory ‚Äö- the articulation of what is known about the phenomenon (Tobin, 2010, pg. 288). This descriptive theory utilised an emic perspective to embed the researcher into the parameters of the case and included three works of scholarship. Firstly a narrative literature review was undertaken with the aim to explore the current understanding of what factors influence the care of patients with a VA for haemodialysis. The narrative review revealed five themes related to care of a patient's VA: patient's experience; relationships-empowerment and shared decision making; environment of healthcare; time; quality of life as the outcome of care. Secondly, a reflection on past clinical practice using a single person case study approach was completed. Thirdly, a review of the journey typically travelled by a person with ESKD and their family and friends as carers was documented by the researcher drawing on clinical experience as a nephrology (renal) haemodialysis nurse and current available literature. This case study collected data through a self-administered questionnaire comprising of open ended questions that varied between the participant groups and Likert scale questions for the patient participants of a range of pertinent variables identified through the descriptive theory. These included physical and mental wellbeing as measured by the SF-36v2¬¨vÜ (physical health component and mental health component), empowerment, family strengths and the SHDU ecology. The questionnaires were completed by 32 patients, 8 family or friends as carers and 14 healthcare professionals anonymously. The mixed methods case study findings demonstrated that the outcomes of managing a patient's VA is influenced by everyone in the ecology of care ‚Äö- the patients, their family and or friends as carers and healthcare professionals. Subsequently, significant and previously unexplored relationships between the three participant groups within the SHDU community emerged. Arising from this research is the recommendation that clinical practice guidelines which concentrate on the biological factors of nursing care should be supported by bioecological domains.