Catherine Fielding

Background: Haemodialysis is a life-sustaining procedure for people with kidney failure, requiring cannulation with two needles before each treatment. Individuals undergo haemodialysis at least three times a week, leading to at least 312 cannulations each year. Some people find cannulation distressing and associated with noxious symptoms. Aim: This study aimed to explore what influences patients’ experiences of cannulation for haemodialysis as undertaken by nursing staff, generating understanding about improvements in procedure. Methods: Thirty participants ( n = 30) from two renal centres in the United Kingdom completed semi-structured interviews. Intensive interviewing, constant comparison analysis and theoretical sampling from grounded theory were employed to meet the study aims. Results: Three categories describe the components that influence patients’ experiences of cannulation for haemodialysis: ‘Trying to make cannulation more comfortable’; ‘Preserving humanity and individuality’; and ‘The necessity of cannulation for haemodialysis forces coping’. Conclusion: Coping with cannulation for haemodialysis is dynamic with various facilitative components. Patients require strategies to make cannulation more comfortable, trust and empathy, and understanding and support to navigate and accept the challenges of cannulation.

Introduction Maintaining normal fluid status is critical to health and well-being. Older people are vulnerable to abnormal fluid status and associated complications, morbidity and mortality. Care home residents are especially vulnerable due to dependence on care home staff, frailty and multiple comorbidities. However, it is unclear what evidence-based assessments and interventions are available to support effective fluid-status management in care homes. Methods and analysis This article describes a protocol for a scoping review aiming to explore current evidence on assessment and maintenance of normal fluid status in older people living in care homes. It is written in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Reviews guidelines. The literature search will cover 10 clinical databases and include research registries and grey literature, and reference lists of included articles. Screening of sources will comprise two stages: title and abstract and full-text screening. Articles will be managed in Covidence and data charting will use bespoke data extraction forms used to generate a narrative synthesis of results. Screening and data extraction will be completed by two coauthors, blinded to each other’s results, with discrepancies adjudicated by a third author when required. Ethics and dissemination As a scoping review of existing evidence, rather than conducting new research, ethical approval is not required. Dissemination will comprise a peer-reviewed publication, presentation at a national conference focused on care of older people, and local patient and public involvement and engagement groups. We will explore opportunities to develop care home-facing education materials working with our local Applied Research Collaboration. Registration Open Science Framework: https://doi.org/10.17605/OSF.IO/AVS5B.

Background: Cannulation of vascular access for haemodialysis is essential when using arteriovenous access. However, this can be a painful and distressing procedure for patients. There is no current measure that enables inclusion of patients’ experiences of cannulation as an outcome in research comparing interventions to improve cannulation. This study aimed to develop a patient reported outcome measure of cannulation for haemodialysis, focusing on the physical and psychological experiences of patients. This was named the ‘Patient’s Perspective of Needling’ (PPN) questionnaire. Methodology: The PPN was developed with six patient representatives. Face validity assessed understandability, relevance and comprehensiveness of the PPN. Convergent validity assessed the correlation of the PPN results to the Short-Form Vascular Access Questionnaire (SF-VAQ). Internal consistency and test-retest reliability tested the reliability of the PPN. Floor and ceiling effects were examined and the interpretation of the results of the PPN were explored by: (a) using an item discrimination index; (b) calculating the smallest detectable change. Free text comments were analysed using basic thematic analysis. Results: The first version of the PPN underwent face validity testing with 12 participants from two renal centres, which led to further amendments of the PPN. The final PPN contained three sections with 17 questions, on pain, worry and problems. Internal consistency of the final PPN was 0.937 ( n = 98, 95% CI 0.917–0.954, p < 0.0001). For convergent validity, a correlation to Question 3 of SF-VAQ was − 0.347 (95% CI -0.146 - -0.521, p < 0.001) and Question 4–15 of SF-VAQ was 0.613 (95% CI 0.450–0.736, p < 0.001). Test-retest reliability was 0.856 (95% CI 0.788–0.904, p < 0.001). The smallest detectable change was 0.135. The Pain section of the PPN scored the highest, with the Worry and Problems sections scoring lower. Free text comments from the PPN expanded on difficulties with cannulation, showing that cannulation experience varied over time and how patients cope with cannulation. Conclusions: The PPN behaved in a valid and reliable manner for the tests completed, enabling patients’ experiences of cannulation to be included as an outcome in research studies into cannulation for haemodialysis.

Background: Needling is a key step in haemodialysis. Research suggests that needling experience is sub-optimal; however, no validated measure exists to inform improvements. We addressed this by developing the Needling Patient Reported Experience Measure (NPREM). Methods: We used mixed methods and co-production. All participants were adults with working fistulas/grafts from eight UK kidney centres. Phase 1 involved developing concepts and items: in interviews (n = 41), we explored patients’ needling experience and identified key aspects of needling using thematic analysis. This informed the 98-item NPREM(v0.1). Phase 2 was piloting the measure: cognitive interviews (n = 16) assessed face validity. Items were amended or removed, yielding a 48-item NPREM(v0.2). A pilot survey (n = 183) examined initial psychometric properties. NPREM(v0.2) showed good internal consistency (Cronbach's alpha = 0.95). Review of analyses resulted in a 35-item NPREM(v0.3). Phase 3 involved evaluating the measure's dimensionality, validity and reliability: patients (n = 468) completed the NPREM(v0.3), Vascular Access Quality of Life (VASQoL), EuroQol 5-Dimension-5-Level (EQ-5D-5L) and Patient Activation Measure (PAM), with a sub-set completing a follow-up NPREM (n = 99). Items were evaluated with 28 items retained in the NPREM(v1.0). Confirmatory factor analysis confirmed a unidimensional model fit (comparative fit index = 0.899). Validity of the NPREM(v1.0) was good [convergent: VASQoL (r = 0.60) and overall experience (r = 0.79); divergent: EQ-5D (r = –0.31), EQ-5D visul analogue scale (r = 0.24) and PAM (r = 0.17)]. Test–retest scores were strongly correlated (r = 0.88), demonstrating high reliability. Known-groups validity was demonstrated between centre scores [range 5.21 (standard deviation 1.20) to 5.94 (0.75)]. Conclusion: The NPREM measures patient experience of needling for haemodialysis. It offers kidney services a means of assessing needling experience, informing patient-focused clinical and service improvements.

Background: For many patients, cannulation (‘needling’) is essential for haemodialysis. It is associated with anxiety and fear and contributes to the overall burden of treatment. Limited research exists on patient experience of needling and how this might vary by individual and clinical characteristics.Objectives: To explore and identify key aspects of needling impacting patients' experiences.Design: Qualitative, multicentre, cross‐sectional, co‐produced.Participants: Adults on haemodialysis with working fistulae or grafts (n = 41).Approach: We used interviews to explore patients' experiences of needling and key aspects contributing to this. Interviews were conducted in two sets: unstructured (n = 24, broadly investigated needling experience) and semistructured (n = 17, refined themes and assessed cultural relevance). Thematic analysis was used to identify themes driving experience and examine variation. A Patient Steering Group comprising people with lived experience of needling was integral to the study.Findings: A thematic framework capturing patients' view of needling was developed. It defined a core theme (The Nature of needling) and five foundational aspects of needling (Health of the fistula or graft, Steps in needling, The needler, The patient, Organisational context). We identified two further themes important to overall experience, Learning from needling experience and Reciprocity (the two‐way interaction between patient and needler). Both interrelated across themes, highlighting the complexity of needling and junctures where patient experience can be influenced.Conclusions: Needling is shaped by multiple psychological and relational influences. These findings provide healthcare professionals with a basis to improve patient experience as part of a broader drive to enhance quality in healthcare delivery.

Background: Utilising point‐of‐care ultrasound for assessment and cannulation of vascular access in people receiving haemodialysis has shown positive clinical results. Nonetheless, there is variation in how renal health care professionals worldwide embrace this method, and there's a lack of research on the factors that promote or hinder its adoption.Objectives: To explore regional differences, and barriers and facilitators, to the use of point‐of‐care ultrasound for assessment and cannulation of vascular access in haemodialysis.Design: Exploratory descriptive cross‐sectional web‐based survey.Participants: Healthcare clinicians working in haemodialysis responsible for cannulation of arteriovenous fistula or grafts.Results: The survey was completed by 645 health care clinicians from 38 countries. 75% to 93% of respondents from Australia/New Zealand, Canada, Europe and United Kingdom/Ireland reported access to ultrasound, compared to 26% (n = 43/167) from the United States. United States respondent's reported lower levels of ultrasound training than other regions. Facilitators for using ultrasound were: the availability of ultrasound training (87%, n = 558), to reduce miscannulations (76%, n = 255/336) and to improve patient outcomes (73%, n = 246/336). Point‐of‐care ultrasound barriers were lack of access to ultrasound education (82%, n = 196/239), lack of ultrasound machines (33%, n = 212/645) or believing that ultrasound was someone else's role (38%, n = 29/86).Conclusions: This study revealed national and regional differences related to haemodialysis point‐of‐care ultrasound. Understanding the regions requiring more education and implementation of ultrasound and what motivates staff, or deters from using ultrasound, is crucial for effectiveness of future implementation and workplace change initiatives.

Introduction: Cannulation is an essential part of haemodialysis with arteriovenous access. Patients’ experiences of cannulation for haemodialysis are problematic but poorly understood. This review aims to synthesise findings related to patients’ experiences of cannulation for haemodialysis from qualitative studies, providing a fuller description of this phenomenon. Methods: Eligibility criteria defined the inclusion of studies with a population of patients with end-stage kidney disease on haemodialysis. The phenomena of interest was findings related to patients’ experiences of cannulation for haemodialysis and the context was both in-centre and home haemodialysis. MedLine, CINAHL, EMBASE, EMCARE, BNI, PsycInfo and PubMed were last searched between 20/05/2019 and 23/05/2019. The quality of studies was assessed using the using Joanna Briggs Critical Appraisal Checklist for Qualitative Research. Meta-aggregation was used to synthesise findings and CERQual to assess the strength of accumulated findings. Results: This review included 26 studies. The subject of included studies covered cannulation, pain, experiences of vascular access, experiences of haemodialysis and a research priority setting exercise. From these studies, three themes were meta-aggregated: (1) Cannulation for haemodialysis is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability and dependency. (2) The necessity of cannulation for haemodialysis emphasises the unpleasantness of the procedure. Success had multiple meanings for patients and patients worry about whether the needle insertion will be successful. (3) Patients survive unpleasant, necessary and repetitive cannulation by learning to tolerate cannulation and exerting control over the procedure. Feeling safe can help them tolerate cannulation better and the cannulator can invoke feeling safe. However, some patients still avoid cannulation, due to its unpleasantness. Conclusions: Cannulation is a pervasive procedure that impacts on patients’ experiences of haemodialysis. This review illuminates further patients’ experiences of cannulation for haemodialysis, indicating how improvements can be made to cannulation. Registration: PROSPERO (CRD42019134583).

Background: Cannulation of arteriovenous access for haemodialysis affects longevity of the access, associates with complications and affects patients’ experiences of haemodialysis. Buttonhole and rope ladder techniques were developed to reduce complications. However, studies that compare these two techniques report disparate results. This systematic review performs an in-depth exploration of RCTs, with a specific focus on cannulation as a complex intervention. Methods: A PICO question and protocol was developed as per PRISMA-P guidance and registered on PROSPERO (CRD42018094656 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=112895 ). The systematic review included any RCT performed on adult patients with end-stage kidney disease undergoing cannulation of arteriovenous fistulae or grafts for in-centre haemodialysis, as performed by healthcare staff. Assessment of quality of RCTs and data extraction were performed by two co-authors independently. Data were extracted on the study design, intervention and comparator and outcomes, including patency, infection and patients’ experiences. Results: The literature search identified 241 records. Ten records met inclusion criteria, which described five different RCTs that compared buttonhole to either rope ladder or usual practice. Results were disparate, with patency and infection results varying. Pain Visual Analogue scores were the only measure used to capture patients’ experiences and results were inconclusive. All RCTs had differences and limitations in study design that could explain the disparity in results. Conclusion: Current evidence does not allow definitive conclusions as to whether buttonhole or rope ladder needling technique is superior. Future RCTs should describe interventions and comparators with adequate detail, embed process evaluation, use standardised outcome measures and build on feasibility studies to produce definitive results.