Background
Methods
Study design
Participants and setting
Data collection
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- Describe how you use bioimpedance in your everyday practice – is it as you planned for?
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- What advantages or barriers have you experienced in practice?
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- How could use of bioimpedance be improved in your clinic?
Analysis
Results
Level 1–5 | Categories: |
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Type of Determinant | Barriers (−) or Facilitators (+) |
1. Innovation | |
Credibility | − Measurement is dismissed if it is not supported by user’s perception |
− Difficult to interpret measurement of patients with abnormalities | |
Attractiveness | + Feelings of curiosity, satisfaction, excitement |
Advantages in practice | + Has aroused an interest in hydration status in the team, and has given new insights |
+ Software facilitates interpretation of measurement and communication with the patient | |
2. Individual professional | |
Awareness | − The intervention has not been introduced systematically or strategically |
− Continuing education system is insufficient or missing | |
Knowledge | − Insufficient clarity in recommendation (about limitations and restrictions of utilization) − Lack of pre-existing knowledge or expertise about assessment of hydration status (among nurses) |
Motivation | + Users feel ownership over the initiative and are motivated to develop strategies for use |
− Some are not convinced about the benefits | |
Self-efficacy | − Concerns about misjudgment – due to lack of skills, experience and decision aids |
3. Patient input | |
Knowledge | − Patients do not believe in the method |
Preferences | − Patients do not want to change routines |
Motivation | + Patients with limited care initiate measurement |
4. Social context | |
Collaboration | + Dieticians can contribute knowledge |
Team processes | + Nurses take initiative to measure, then consult the physician to discuss the dry weight |
− Physicians do not trust or follow up results | |
5. Organizational context | |
Capacities | + In small units the use of bioimpedance has been implemented successfully on oral agreement |
− High workload and shortage of trained staff | |
Care processes | − The need to wait for the device if someone else is using it interrupts work flow |
Structures | − Lack of routine or large variations in routines between units |
Regulations | − Isolation of patient with multi-drug resistant infection |
Dieticians | Nephrologists | Nurses | All participants | |
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N | 4 | 4 | 16 | 24 |
Proportion of represented study population | 36% | 14% | 7% | 8% |
Men | 0% | 75% (n = 3) | 13% (n = 2) | 21% (n = 5) |
Age (years) | 32 [28,36] | 60 [52,63] | 44 [37,54] | 44 [35,56] |
Years in profession | 8 [4,11] | 31 [25,37] | 14 [9,19] | 15 [8,26] |
Years in current clinic | 4 [1,9] | 19 [12,25] | 10 [3,16] | 11 [3,16] |
Innovation
Barriers
In the beginning we had great faith in it [bioimpedance], and we adjusted the dry weight almost to the hectogram on what it showed, but then reality caught up with us. It turned out it didn’t fit so well [...]. It hasn’t been very useful recently. When a measurement is consistent with our assessment, we think it’s correct, but when it isn’t consistent with our perception, we don’t rely on it. [Nephrologist, CHU]
Some people may have very skinny legs and a corpulent upper body, and then it [bioimpedance] doesn’t work. One must always consider: who is in front of me? Is this really plausible? [Nurse, CHU]
For some, particularly bodybuilders, it’s difficult to get anything out of the bioimpedance measurement. That it doesn’t give any results at all, for example. [Nurse, UHU]
We’ve tried to use it to measure fat mass and fat-free mass, but we’ve found the reliability insufficient, so it hasn’t been of any value. [Dietician, CHU]
Facilitators
You don’t always have to reach absolute dry weight, but you can stay at plus one and a half [liter] and just go on, if the patient is well. So, from that point of view it has of course been useful, and yes it may have given a little more insight into dry weight management, and how to determine, and also the possibility to customize. [Nephrologist, CHU]
Nurses have become much more involved in dry weight. They measure on their own initiative before asking the doctor. Since the machine arrived, discussions regarding dry weight have become much more active. [Nephrologist, CHU]
It also allows us to assess nutritional status and muscle mass, and in some cases it is very important, to see: ‘the patient is keeping weight but losing muscle mass’, and that is a very early warning sign that something is not right. And that is very positive and cannot be done in any other way. [Nephrologist, CHU]
I've actually used it for another purpose too; there’s a patient who's always getting depleted all the time. You cannot have a good discussion with him. But when I do this [bioimpedance measurement], I can show on paper: ‘this muscle mass exists, this fat mass is present, and no water almost.’ Then it may be easier to […] make him understand […] that you cannot lose weight by removing fluids. [Nurse, CHU]
[…] One previous patient, a tall, thin young man, had high blood pressure. We couldn’t understand why […] and he received various drugs, because he had no edema [...]. But then, according to bioimpedance, he had eight liters of fluid overload [...]. When we were gradually able to reduce his weight, he could stop taking many of his blood pressure medications, which is very welcome!. [Nurse, UHU]
Individual professional
Barriers
I attended a lecture about these measurements, but then it had only been performed on non-kidney patients, but so I don’t know if research has been performed in individuals with kidney disease. [Nephrologist, CHU]
We have had someone from [the company], but I don’t know if I got much wiser afterwards, because you want to talk to, you would like to learn from a nurse, who works with patients, with case reports, someone who speaks the same language. [Nurse, UHU]
We’ll write it down [ICV / ECV] but then if we can all interpret it or even have a look at it that is something different. [Nurse, UHU]
We’re not allowed to measure on anyone who has a pacemaker, regardless of what kind, just so there won’t be any mistakes. And we don’t measure amputated patients unless it’s absolutely necessary; in those cases, we’ve measured and used this table [for correction] in order to find the right dry weight, but it feels a little less reliable. [Nurse, UHU]
Of course, you could do it more regularly, but we haven’t really felt the need. [Dietician, CHU]
Then I think, maybe there has been an uncertainty too, with the device itself that, some may not feel confident, and then maybe they don’t bother to measure. [Nurse, UHU]
[...] You might do a measurement one week, and then the next week the patient may have lost four kilograms, and then the third week it’s completely off the rails. [...] That’s a little hard to know how to deal with. If you should adjust the dry weight, [...] which measurement should you trust?. [Nurse, SU]
Facilitators
There’s so much more to develop. In addition to determining dry weight, you could use it for nutritional status. And then there are several other groups of patients who would benefit from a measurement. [Nephrologist, CHU]
I’ve noticed that many new [nurses] like to use it because it’s easy. Maybe they haven’t been working for a long time, and thus have less experience using other methods to assess dry weight. [Nurse, UHU]
Patients’ input
Barriers
Some patients say no. They don’t want to see it; they don’t believe in it. They have their own idea [about dry weight]. [Nurse, CHU]
Some patients react to the recommendation to rest [before measurement]. They come and want to be connected to dialysis straight away. [Nurse, CHU]
Then you should lie down and rest for 15 to 20 minutes before [...] Try to make a dialysis patient to do that. [Dietician, SU]
Facilitators
In the self-dialysis unit there is often [...] a difference of opinion between patients and physicians regarding ultrafiltration, and then patients themselves might suggest: ‘can’t you do that measurement?’ And often, the patient is actually right. [Nurse, UHU]
My patients may ask, at times, then: What does it [fluid management graph] look like? [Nurse, CHU]
Social context
Barriers
Since it’s not followed up, why bother measuring? Some doctors don’t understand it and then they don’t trust the results, and it’s not followed up. So we [the nurses] do measurements, but nothing changes and then it feels meaningless. [Nurse, UHU]
The entire team should be involved, including the physicians, those who... It should not depend on the interest of a few professionals; it's supposed to be the same for all patients, an opportunity to get the best care possible – if you believe this is an improvement. [Nurse, CHU]
Facilitators
We have a very experienced dietician, who helps us, and she’s tested [...] in patients with prostheses and with various electrodes; we get a lot of support from her. So we know when to expect errors too, and that helps a lot. [Nephrologist, CHU]
In our unit, it is usually the nurses who measure on their own initiative. They are quite independent, determine dry weights and such, they consult us, the physicians only if they feel uncertain. And if they are uncertain, they usually run a BCM and then discuss with us, so it's usually their initiative. [Nephrologist, CHU]
Usually, we the nurses initiate measurements. Confidence among physicians varies, of course. We have one physician who’s fond of and may prescribe bioimpedance measurements [...]. But it’s mostly us, the nurses, who want the aid, for dry weight determination. [Nurse, CHU]
We always consult the physician and tell what it [the bioimpedance device] has shown, and then you can see how the patient […], what the other parameters for the assessment of dry weight, you can discuss it. It is not always that we determine dry weight after what the BCM shows, but it may indicate that it should be higher and then the physician may increase it. [Nurse, UHU]
Organizational context
Barriers
We [the nurses] may have different ways of doing it. [...] We have no guidelines or so on how to do. No follow-up system. [Nurse, UHU]
Since there’s no routine to measure regularly, it’s up to individual nurses [...], those who are a little more alert and interested. [Nephrologist, UHU]
The problem is when nurses quit and are replaced; there will be new nurses. To do measurements, it takes some commitment and motivation, for it to be of any benefit. [Nephrologist, UHU]
Some people prioritize other things. Going and getting a machine to measure might sometimes be met with resistance. As for now, with 24 extra patients and a shortage of six staff members, you have to set priorities, and it’s not going to be bioimpedance measurement. [Nurse, UHU]
In our unit, sometimes - in the morning when starting the treatments it's quite hectic – the device is occupied, because it’s used every day. So it's always in another room, and sometimes you may not want to wait the extra five minutes, so you start the treatment and you'll do the measurement the next time. That may be a reason why you skip it. [Nurse, CHU
A patient was kept isolated due to a multi-drug resistant infection. He - without any known new infarction or so - began to develop pulmonary edema. It has been ten to twenty years since I experienced dialysis patients in that situation, but he had not been measured then. [Nephrologist, UHU]
Facilitators
Our unit’s pretty small [...]. If there’s a note in the record that says ‘today it’s time for bioimpedance measurement,’ then the person taking care of the patient will perform the bioimpedance measurement. [Nurse, SU]
I'm in a small unit [PD-unit]. It's easier for us to standardize than it is in the blood dialysis unit. [Nurse, CHU]
Considering those [patients] who are very stressed and want their dialysis treatment to get started. If we absolutely want to measure bioimpedance, we usually ask them to come a little earlier, then they can start their dialysis session at the same time as usual, and that usually works. [Nurse, UHU]