Northern Initiative for Social Action (NISA) is a consumer-run, occupation-based, nonprofit organization located in northeastern Ontario, Canada. The NISA organization has grown in response to research revealing few opportunities for participation in personally meaningful and socially valued occupation for persons with mental illness living in the community of study. This article describes a mixed-design research study conducted by the ParNorth Research Unit of NISA and an occupational therapist. The study purposes were to (a) better understand the emerging characteristics of the NISA program and identify which the participants found helpful; (b) evaluate whether participation in NISA improved members' quality of life; and (c) ascertain whether participation reduced members' need for more traditional and costly methods of care (e.g., hospitalization, crisis services). Focus groups, daily participant observation, a quality of life interview, a consumer member survey and objective review of hospitalization data were used for data collection. Qualitative results indicated that NISA helped to meet participants' being, belonging, and becoming needs. Quantitative data indicated that overall, NISA members perceive an improvement in their subjective quality of life and sense of well-being. Their perceptions are supported by minimal use of crisis services and hospitalization, improved socioeconomic status, and several members' success in obtaining paid employment either within or outside NISA. Future challenges include the need to clearly describe the evolving NISA model and to ensure that the growth of this new organization does not exceed secured human or fiscal resources.

Depression in patients with end-state renal disease (ESRD) is both underdiagnosed and treated, which may contribute to an increase in morbidity and mortality. Efforts aimed at screening, diagnosing, and treating depression could potentially modify outcomes in this population. The purpose of this study was to compare the prevalence of depression, as measured by the Beck Depression Inventory (BDI-II), the primary nurse, and nephrology team, among a cohort of patients receiving chronic hemodialysis (HD). A secondary objective was to identify patient variables associated with depression. Patients were screened for depression at the same time point, using the BDI-II, the primary nurse and the nephrology team. Depression was defined as a BDI-II score > or =14. Agreement between the BDI-II score, nurse, and nephrology team assessment of depression was compared using a kappa score and receiver-operating characteristic (ROC) curves were generated. One hundred and twenty-four of an eligible 154 patients completed the study. Depression as measured by a BDI-II> or =14, the nurse and the team was diagnosed in 38.7%, 41.9%, and 24.2% of patients, respectively. With the BDI-II as the gold standard, the nurses' diagnosis of depression had an agreement of 74.6% vs. only 24.2% agreement with the nephrology team. A previous history of malignancy was the only variable associated with the diagnosis of depression. Depression is common among patients on HD, supporting the need for a routine depression-screening program. The primary dialysis nurse is in a key position to identify patients with depression and should be considered as an integral part of the nephrology team.

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.

BackgroundArteriovenous fistulas (AVFs) are the preferred access for hemodialysis (HD) yet they are underutilized. Cannulation of the fistula is a procedure requiring significant skill development and refinement and if not done well can have negative consequences for patients. The nurses' approach, attitude and skill with cannulation impacts greatly on the patient experience. Complications from miscannulation or an inability to needle fistulas can result in the increased use of central venous catheters. Some nurses remain in a state of a ‘perpetual novice’ resulting in a viscous cycle of negative patient consequences (bruising, pain), further influencing patients' decisions not to pursue a fistula or abandon cannulation.MethodThis qualitative study used organizational development theory (appreciative inquiry) and research method to determine what attributes/activities contribute to successful cannulation. This can be applied to interventions to promote change and skill development in staff members who have not advanced their proficiency. Eighteen HD nurses who self-identified with performing successful cannulation participated in audio-recorded interviews. The recordings were transcribed verbatim. The data were analyzed using content analysis.ResultsFour common themes, including patient-centered care, teamwork, opportunity and skill and nurse self-awareness, represented successful fistula cannulation. Successful cannulation is more than a learned technique to correctly insert a needle, but rather represents contextual influences and interplay between the practice environment and personal attributes.ConclusionsPractice changes based on these results may improve cannulation, decrease complications and result in better outcomes for patients. Efforts to nurture positive patient experiences around cannulation may influence patient decision-making regarding fistula use.