Breaking Through the Glass Ceiling—Having <i>That</i> Conversation: A Constructivist Grounded Theory Study Exploring the Experiences of Nephrology Nurses’ Practice in Kidney Supportive Care in Canada

BackgroundDialysis as treatment for kidney failure can result in significant physical and psychosocial symptom burden. Kidney supportive care (KSC), encompassing advance care planning (ACP), is an approach to care involving early identification and treatment of symptoms that improves the quality of life of people receiving dialysis. However, ACP is underused and often initiated late in the illness. The delay or lack of engagement in KSC by nephrology nurses until near the end of life may result in people receiving care that is discordant with their values, wishes, and preferences.PurposeThe purpose of our study was to construct a substantive theory about the process of engagement in KSC by nurses in Canadian dialysis settings.MethodsUsing Charmaz's constructivist grounded theory method, 23 registered nurses working in hemodialysis and peritoneal dialysis were recruited to participate in two intensive interviews. Concurrent data collection and analysis were undertaken, with constant comparative analysis of codes until the attainment of theoretical saturation, as well as memo-writing and researcher reflexivity, to aid the emergence of categories and concepts.FindingsIn the substantive theory "Breaking Through the Glass Ceiling of Engagement-Having <i>That</i> Conversation," three stages of engagement (Transactional, Intentional, Actional) are identified that describe nurses' practice patterns of engagement in communication about goals of care with patients. This engagement is modulated by a boundary of professionalism and familiarity with patients, amid multi-dimensional contextual barriers.ConclusionNephrology nurses have a vital role in discussions about goals of care and require training to enhance their communication skills.