Becoming proficient : knowledge and practice of hemodialysis nurses

Objective: To describe the attitudes and practices of nurses in hemodialysis in the course of reaching their specialty. Methods: Qualitative study using grounded theory conducted in a nephrology service of a public hospital in Rio de Janeiro, RJ, Brazil. A total of nine nurses participated. Semi-structured interviews and participant observation were used. Data analysis was performed considering the basic procedures of grounded theory. Results: The phenomenon "Becoming proficient: knowledge and practice of hemodialysis nurses" emerged from the analysis, which was formed based on the categories: "(Re) establishing practice in hemodialysis" and "Mastering technology". Conclusion: The deepened and updated knowledge nurses acquire leads to the conscientious practice of nursing considering the complexity involved in practical learning.


INTRODUCTION
The interest in studying the trajectory of hemodialysis nurses seeking proficient practice emerged from concerns that are inherent to the process since nurses often arrive in this specialized sector, which is usually a highly technological service, with little or no knowledge 1 and/or ability as required for productive work 2 .
Historically, nursing professionals began to integrate into the dialysis team in the 1970s when governments assumed the costs of renal replacement therapies, promoting the expansion of dialysis centers.At this time, this therapy became a responsibility of nurses and Nephrology became a specialized field in nursing 3 .
Still in the 20 th century, in the 1990s, the field received an important contribution in terms of technological progress, which made the procedure safer and enabled greater control over the treatment's adverse effects, significantly improving the patients' quality of life.At this time, the procedure became almost exclusively performed by nursing professionals 3,4 .
It is worth noting that such innovations incorporated into the practice of hemodialysis intensified the possibilities of the rationalization of the productive process and make it imperative for professionals to be endowed with extensive theoretical and practical knowledge in order to implement actions without losing sight of the totality 2 .At this point, we ask what the experience of hemodialysis nurses is in terms of attitudes and practices implemented and experienced in the search for expertise.
Therefore, discussing the trajectory, as well as the qualification, of nursing experts in the field reflects the advancement and consolidation of the profession's science and technology and contributes to the improvement of healthcare 5 .Hence, this study's objective was to describe the attitudes and practice of nurses providing care in the field of hemodialysis.
Nurses' care practices in the field of hemodialysis "requiresone to consider that each person presents a response to the same stressful situation.For this reason, nursing planning should be based on the acknowledgment of manifestations of coping with the situation patients experience" 6 .
Nephrology is a complex field in nursing practice considering the specificity of its patients, the different renal replacement therapies, the technological apparatus required in the process, and the increasing incidence of Chronic Kidney Disease as a public health problem [7][8][9][10] .

THEORETICAL-METHODOLOGICAL APPROACH
Symbolic Interactionism (SI) was adopted as the theoretical framework in this study.SI attributes great importance to the meanings of things for human behavior, while human behavior is considered to be a result of the interactive process individuals have with themselves and with others 11 , and is used to deal with situations individuals have to face 2,10 .This is a descriptive study with a qualitative approach using Grounded Theory, which is a systematic method of interpretative research designed to generate theoretical constructs that explain a phenomenon present in reality 2,10,12,13 .The study's setting was the nephrology service of a large university hospital located in Rio de Janeiro, RJ, Brazil.Data were collected through semi-structured interviews and participant observation using an instrument with open questions with the objective to establish close interaction with the participants -nurses working in the facility's hemodialysis unit.Generalist and/or specialist nurses working in the hemodialysis unit and 2 nd year residents were included in the study.Each interview was digitally recorded, transcribed and coded up to the point of data saturation.
Then we proceeded to the analysis, as recommended by grounded theory with open code, axial coding and selective coding 12,13 .The sample was composed of nine individuals: six women and four men.Five were 2 nd year residents, three were nurse specialists in nephrology and one was a generalist nurse.Saturation of data was achieved when no new codes emerged during analysis 12 .
The study was submitted to and approved by the Institutional Review Board (process nº 2817/2010).All the participants consented to the study's objectives and signed free and informed consent forms.The participants' confidentiality was preserved by using the following pseudonyms 12 : Mercury, Venus, Earth, Mars, Jupiter, Saturn, Neptune, Uranus, and Moon.

RESULTS AND DISCUSSION
The trajectory to proficient practice for nurses as they start their practice in hemodialysis includes: coping with new knowledge when entering the service; acknowledging actions that are inherent to the field of hemodialysis; becoming familiar with the patients and perceiving their specificities; and identifying the technology involved in the entire process.Therefore, we consider "nurses experiencing a field of practice in which they have no previous experience with patients and have not masteredthe tools used to provide care, to be beginners even if they have experience in another field" 2 .
This movement leads nurses to acknowledge the therapeutictechnological context of hemodialysis and enables them to devise strategies of action/interaction for their development.Hence, the phenomenon Becoming proficient: knowledge and practice of hemodialysis nurses, which emerged from the analysis according to grounded theory, represents the consequence of movements of nurses from the time they are inserted into the hemodialysis service (beginner) up to the acquisition of skills moving toward a fruitful and specialist (proficient) practice and describes the effects of action/interaction strategies that are adopted in the process.The phenomenon was revealed based on the grouping of the categories (Re) establishing practice in hemodialysis and Mastering technology.

(Re) Establishing practice in hemodialysis
The social scene, each individual's view of the world, as well as factors such as principles, values and beliefs, enables each person to confer a different definition onto healthcare, since the meaning attributed to it is a result of the way individuals

Knowledge and practice of hemodialysis nurses
Barbosa GS, Valadares GV perceive the sign, interact with it and assign meaning based on this interaction.As a result, after the beginner nurse has contact with and establishes her/his first interactions within the service, s/he starts to suggest new practices in hemodialysis, as the following excerpt shows: For instance, I already think that there should be interest groups to discuss with patients those themes that interest them.I also think that guidance is not sufficient; it should be more comprehensive, you know?EARTH I always say there should be a nursing consultation for hemodialysis patients, too.A lot of things could be clarified to patients and it would certainly be beneficial.MERCURY Critical thinking is basedon interaction with the context, professionals and patients.In this sense, the context in which nurses are inserted is permeated by factors that can change care practice, since its meaning is changed within and through defining activities of people when interacting 11 .
The interactive process between nurse-context encourages reflection upon practice, suggesting new elements that enable redefining it to confer greater quality.In regard to this process, we highlight nursing consultations.These enable nurses to monitor changes in lifestyle and reinforce self-care guidance based on the Nursing Process 14,15 .We also stress the need to change hemodialysis nurses' practices in order to reinforce professional identity in the specialist practice.

[...] you also need to re-think the role of nursing in the multidisciplinary team. It seems, sometimes, that we're only doing what is prescribed and this fragmented care shows it. We know very clearly what the role of the nutritionist is, of the physician [...] and even the role of the psychologist, but nurses are seen as 'machine operators'. This has to change. NEPTUNE
Therefore, new practices emerge and already existing actions can be adapted.Nurses continue analyzing their own care practices in an interactive exercise, in which technique can be re-signified.

[...] we become critical, want to change one or another action. Start rethinking and assessing our way of doing things to see what is ideal. SATURN
It is worth noting that practical learning has a singular complexity and comprehends multiple aspects of reality, and that an enlarged view about things is necessary in terms of seeking emotional balance and valuing human co-existence 16 .
We don't know nephrology when we graduate.We got here without knowing much and learned day-by-day, hands-on.VENUS

The process of learning and working with hemodialysis is not easy. It's not only because of its complexity per se, but there's a lot of things involved. We start working with it without knowing exactly, if you're not humble and don't know how to behave, things get more complicated, because you depend on others to teach you everything. MARS
We got here without knowing much and learned day-by-day, putting our hands on, really.VENUS In this sense, the movement of nurses toward specialization is highlighted, since it is important to ally technical and scientific knowledge, necessary to work in this field, with the sensitivity that is inherent to the "nursing being" focused on the patient as a systemic being 15 , as shown in this except: I went sought theoretical knowledge, which I needed, I thought that I had a gap to fill in, a specialization program in nephrology.It helped a lot.EARTH [...] I was learning to do but I needed more.I needed theory.So, I started a specialization program.SATURN I started a specialization as soon as I got here.I thought that it was important to ally theoretical knowledge acquired in a specialization program with the practice I had here.MOON Advancement in theoretical and practice knowledge, especially with scientific development, adds quality to the work and provides important support to specialized practice since the professionals involved in the research process contribute to more qualified care and research can be a great strategy in strengthening nursing in both generalist and specialist terms 5 .

Such is strategy is indicated in what follows:
I'm getting a specializationand don't want to stop.I guess that patient nurse, have to improve practice, more than in other fields, and for this reason, should do research and implement findings in their routines.JUPITER In this sense, practical knowledge that permits nurses to implement care actions in a fruitful manner, allied with experience, and based on this experience, interactions that guide meanings attributed to practice, collaborate with nurses' self-assured practice to master the demands of the service and of hemodialysis patients.

Mastering technology
This category proposes that nurses adapt to the technological context and be ready to meet the requirements it presents.Once the nurse is familiar with the equipment, s/he can dedicate activities to providing care that resolve more problems, heeding the needs of the patients under his/her care.This is based on the premise that knowledge is collectively constructed and reconstructed.People make a difference, considering the fact they can either cooperate or do not for a healthy environment since Knowledge and practice of hemodialysis nurses Barbosa GS, Valadares GV their attitudes are essential to the institutional environment 17  At this point, nurses have knowledge and understanding and feel more self-assured to implement actions in the hemodialysis service, allowing themselves to reflect upon their practice, adopting new actions or reaffirming other ways of implementing their own actions, in which attitudes intended to establish an effective interaction with other professionals from the multidisciplinary team promote good outcomes.
Collaborating, interacting and congregating are interesting practices through which to achieve good performance in the field.In this line of reasoning, teamwork can be a strategy to redefine work processes aggregating new values and gaining greater quality service 18 .

FINAL CONSIDERATIONS
Being familiar with the technological context enables nurses to establish new ways to work with hemodialysis.This movement occurs based on the professional's adaptation to the technological apparatus involved in the work process.When professionals are comfortable with the technology, they can focus their effort on improving their practice, assessing and reassessing their own attitudes.
Hence, the knowledge acquired, deepened and updated leads to conscientious practice in light of the complexity involved in the process of learning while doing.Interaction with the context and the team produces a beneficial effect on the meaning attributed by nurses to hemodialysis, serving as a basis for the strategies adopted.
, as shown in the following: As soon as we get to the sector we think we won't be able to deal with all that technology.Learn how to program, adjust and turn off alarms that go off during sessions.But over time, we perceive that we're becoming familiar with it [...] learning to solve it all [...] become more self-assured when wemaster [the machine].NEPTUNE