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Article Excerpt
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In 1827, Richard Bright published the first volume of Reports of Medical Cases in which he described the association of 'dropsy' and albuminuria with diseased kidneys, thus establishing a relationship between the symptoms and pathology of kidney failure. His highly regarded work provided sound footing for further study of kidney diseases. Medical research in the late 1800s expanded knowledge of the causes, classification, and pathology of kidney failure, but treatment was restricted to symptomatic relief for acute renal failure and palliative measures in cases of chronic renal disease. Rest, dietary control, diuretics and digitalis, and promotion of extrarenal elimination were the only treatments available until the 1940s (Fishberg, 1940; Loomis, 1888; Purdy, 1886; Saundby, 1889).
Nursing care of patients with renal failure is discussed in the nursing literature as early as 1915 (Gillespie, 1915), but as a specialty, nephrology nursing did not emerge until much later. Between 1915 and 1950, a handful of articles about kidney disease appeared in nursing journals or text-books. Consistent prescriptions for nursing care were offered: (a) record intake and output, (b) carefully control the diet, (c) stimulate elimination of wastes through the gastrointestinal tract, (d) provide rest, (e) prevent infection, (f) decrease muscle activity to reduce the production of metabolic wastes, and (g) keep the patient comfortable (Fyler, 1938; Harmer & Henderson, 1939; Pearce, 1938; Wood, 1926a; Wood, 1926b).
Although most nursing authors focused on physical care, other concerns were mentioned. Titus (1926) wrote that since the renal patient was 'likely to be irritable and depressed" (p. 449), imposing restrictions to promote rest made the nurse's duty "no small task" (p. 449). Gartstone and Guttentag (1941) identified medical and sociomedical duties of the public health nurse caring for homebound kidney patients. The nurse's medical duties were to insure that the patient was following the diet and seeing a physician intermittently and to observe for symptoms of the disease. The sociomedical tasks included finding work for the patient and recognizing new cases of renal disease.
Rest, diet, and medication, a combination that has eventually come to be termed conservative management, were the only treatments available for patients with chronic renal failure until the middle decades of this century. Nurses were involved in carrying out these treatments, though they were limited. Nephrology nursing as a specialty appeared only after the renal dialysis and transplant programs had been established in hospitals across the country. To fully understand the development of the specialty of nephrology nursing, it is important to review corresponding developments within the nursing profession as a whole. A comparison demonstrates the similarities among the work of nurses in dialysis and the work of those in transplant programs, the roles of nurses within other practice settings, and the changing concept of nursing care.
Growth and Changes in Health Care at Mid-Century
Rapid advances in medical research and technology coupled with a post-World War II nursing shortage brought about great changes in the practice of nursing. Beginning in the late 1950s, the United States was in a period of social change and unrest. By the 1960s, the country was involved in the Vietnam War. Desegregation was a national issue. Antiwar and race demonstrations were common. Idealism was the inspiration behind many actions, including President Johnson's Great Society. The social ills of the country were battled with fervor and government dollars. Medicare and Medicaid were implemented to assure the elderly and the poor access to health care.
Advances in medical technology and education during this period were fueled by federal dollars. Realization of the benefits of federal research expenditures during World War II provided a rationale for expanding government support for research. Vast increases in appropriations were channeled through the National Institutes of Health (NIH). In 1947, the budget appropriation for NIH was just over $7 million; in 1961, only 14 years later, Congress appropriated $783 million for the Institutes (Strickland, 1972). The increase in appropriations supported the scientific and medical research necessary for developing new healthcare technologies and training medical specialists to implement new modes of care.
Advances in Nursinq Practice
The Assistant's Role
Nursing changed in response to these changes in medicine and health care. One of the changes was in the nurse's relationship with the physician. Rather than being called a handmaiden, the nurse was now the physician's assistant; she took pride in assisting with complex, technological procedures. Fuerst and Wolff (1959) in the text Fundamentals of Nursing, described the physician assistant's role:
As important as any other of her responsibilities to the patient is the nurse's role in assisting the physician with the therapeutic and diagnostic measures. And, in those situations when the nurse becomes involved in new technics [sic] or in research, she will need to show foresight, judgment and originality in helping to devise procedures that may have been nonexistent a few months before (p. 489).
Expanded Knowledge Base
The second notable change was the expanded knowledge base. Nursing textbooks reflected the growing importance of scientific knowledge in nursing. Fuerst and Wolff (1959) also addressed this change:
... in order to function in a professional capacity, it is essential for the practitioner to understand the principles underlying the practice ... for they are the foundation on which to build a plan of action in a problem-solving approach to nursing situations (p. ix).
The three principles forming the basis for total nursing care were (a) maintaining the patient's individuality, (b) maintaining physiologic functioning during illness, and (c) protecting the patient from external causes of illness (p. 33).
Publications in nursing journals and reports of conferences demonstrate the growth of scientific knowledge in nursing. Nurse authors explained when, why, and how to use the various machines and treatments that were now the responsibility of nurses. The American Nurses' Association introduced "Clinical Sessions" at the 1962 biennial convention. The objective was to improve nursing practice through education about clinical conditions and techniques. Presenters were required to "show the application of new or very recent knowledge from a basic or applied science to a particular clinical nursing problem" (American Nurses' Association, 1962, p. 1).
Personal Care Role
The third change, concern for the patient as a person, was a response to the increasing complexity of medical care. Nursing leaders argued that being a physician's assistant, a skilled technician, and knowledgeable about science were complements to the nurse's traditional role, not substitutes. Montag and Swenson (1959) organized their beginning nursing textbook on the basis of the patient's personal needs. They wrote:
... there is one aspect of all these factors in comprehensive nursing which concerns only the nurse: providing and carrying out nursing measures for the hygienic care and comfort of the patient ... Should the nurse lose this unique aspect of her work, then indeed she will no longer be a nurse (p. 4).
Personal needs include hygiene, comfort, rest, sleep, diversional therapy, and teaching.
For other writers and educators, the nursing role went beyond personal care to a concern about interpersonal needs. In 1952, Hildegard Peplau published Interpersonal Relations in Nursing. In the book's forward, Louise McManus wrote, "There is increasing recognition that the role of the nurse involves much more than nursing procedures and overt technical operations, and includes 'what goes on between the nurse and the patient,' or covert behavior" (Peplau, 1952, p. ix). Peplau defined nursing as "an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living" (p. 16).
Abdellah, Beland, Martin, and Matheney (1960) also sought to advance nursing's role by explaining, "The bulk of the nation's actively practicing registered nurses are products of an educational system in nursing which has been procedure and diagnostic-centered and geared to the service needs of hospitals rather than to patients' needs" (p. 2). Using the language of McManus, she proposed the practice of comprehensive nursing based on the identification of overt and covert patient problems.
By the early 1960s, it was foreseeable that nurses would be increasingly involved with technical procedures and treatments. Peplau (1962) responded directly to the challenges facing nurses:
Each nurse will have to use judgment in local situations to determine whether each new device has a...
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