When nephrology emerged as a new speciality in the early 1960s, it entered a clinical world in hospital very different from that we know now. Consultants were in charge of everything, nurses mostly undertook routine care tasks. Relationships were formal – the use of first names at work was unthinkable. The commonest attitude was that doctors knew best; they were the specialists. Nurses gained specific expertise through experience – by working for example in medical or surgical wards, or in theatre. But there were no defined specialist training pathways for nurses – thus no mechanism for being trained or identified as a ‘renal nurse’, let alone being appointed as a nurse specialist or a consultant nurse. Other allied health professionals – for example pharmacists and dietitians – were also ‘generalists’ .
Renal units led the way in many of the transformational changes which are now so familiar in UK clinical practice. Renal units from the beginning gave nurses much increased responsibility and autonomy, and developed other specialist roles – renal pharmacists, renal dietitians, and so on. Entirely new roles were created – for example renal technicians, artificial kidney assistants. Renal units incorporated these roles into the new concept of a multiprofessional clinical team which often also included a social worker, a clinical psychologist, a physiotherapist.
Nephrology was the first speciality in which these things happened – and others soon followed. Among other ‘early adopters’ were intensive care units, where high degrees of nurse empowerment were seen as necessary and effective. It is probably no coincidence that nephrologists were much involved in the development of intensive care in some centres. These innovations in renal units did not however come through carefully reasoned professional development planning , but at first through practical necessity.
As Stewart Cameron (nephrologist, Guy’s Hospital) recalled in a 2018 interview: It’s difficult to remember that in the 1960s it was a radical idea to have a team of physicians, surgeons, dieticians, physiotherapists, pharmacists and so on. But we had all that running by the end of the 1960s. Of course now it’s totally routine, and nobody would think of doing it otherwise. But we didn’t design it – it happened.
Building these teams had many strands, but informality was one outward sign of the mutual respect needed within the team. Doctors and nurses calling each other by first names at work was unconventional to say the least in 1960s hospitals.
Cameron again: We got caned for it! When we started calling all the nurses by their first names, and they called us by ours, I was called in by matron and reprimanded and told absolutely we must not do this. Well, we hummed and hawed and I said ’yes, we’d be good boys’. But we went on doing the same thing!
The changing roles for nurses
Within a very short time, maintenance haemodialysis became a nurse-delivered clinical task.
Cameron again: One thing we did push purely for practical reasons was nurse empowerment. There was simply more than the two or three doctors we had could possibly handle, so the nurses had to do all these things they weren’t allowed to do. ……. it was purely practical … we didn’t have any permission. We basically started a nurse run dialysis unit, because there was no possibility of having it any other way. I used to say to the new doctors – this is a nurse run unit; if you want to know about dialysis, don’t ask me. So we were down seeing matron again, who was asking ‘Why were the nurses in the unit taking blood, and putting needles into places matron didn’t even know existed (AV fistulas)’.
This new sort of nursing undoubtedly attracted those who enjoyed the different environment, the complexity of care, the sense of innovation. Ann Eady worked on the recently opened dialysis unit at the Royal Free as a student nurse in 1964, and later as a renal nurse at Guy’s : My friend Joy went to work there and said to me, “It’s very exciting. Half the time, we don’t wear a uniform, and you do all sorts of different things”. I thought that sounded all right, different to being just an ordinary nurse. It wasn’t like a traditional ward, we had these enormous great tanks that we would fill with all the different things that make up the dialysate and we would literally stir it with a paddle.
You got very little formal training, really, you learnt it as you went along. We learned to get rid of air locks, and do technical stuff, and change fuses. It was a very unconventional setup; the two women who built the Kiil dialysers had been ward orderlies. Stanley Shaldon[1] had taught them what to do, they did it, they taught us, and then we taught the people who were going to be on home dialysis and the people helping to look after them.
I think a lot of others in the hospital were rather scathing about it. ‘What were we doing up there? We weren’t properly dressed!’ … meaning we didn’t wear nurse’s hats. We were definitely unconventional. I was asked ‘Don’t you want to go and do a proper profession?’, ‘Don’t you want to be a Sister on a ward?’ No, not for me.
Needling fistulas
Ann Eady: The patients started to have fistulas. I remember one day at Guy’s, I think there were probably about eight patients all waiting to go on dialysis – I and another nurse couldn’t yet needle fistulas. The consultants came down and said, ‘Right. Do you want to learn how to do this?’ So we said, ‘Yes, please.’ So they said: ‘Come on then’. And that was it, they taught us. There was no going on a special course and getting a certificate and getting mandatory training, we just learned.
Although the dialysis units were nurse-led, some conventions were curiously maintained. When there was a difficult fistula which the expert nurses could not needle, the registrar or consultant would be called to the unit to troubleshoot. Cameron: The joke was that when there were really difficult fistulas to needle we would get called down. And having not put a needle in for a month, we would somehow almost always get a needle in where these experts had failed. It shouldn’t work like that! But I suppose it was just a question of somebody getting down and feeling low after several attempts, and somebody new can whizz in and do it.
This early move to nurse-led dialysis units became the norm across the UK – and developed faster and further than in many other countries which did not face the UK’s severe shortage of doctors. Cameron again: I only realised quite how unusual this was when people came to visit our unit from abroad. They came to our weekly meeting on the dialysis patients which was always chaired by the senior nurse. And of course these people have never seen a nurse telling doctors what to do.
Renal units attracted nurses who wanted responsibility. Cameron: When the senior nurses were interviewing people, I knew that they were looking for people who responded well to challenges – responsibility was all. Those who enjoyed the responsibility, the complexity, the innovation, the teamwork, found it addictive; nurse leaders on renal units often stayed for many years. In my career at Guy’s I think we only four senior nurses, and one of them stayed over 25 years (Cameron).
Netar Mallick recalled in 2018 the early years of the unit at Manchester Royal Infirmary (MRI). I found the nurses inspiring because they put in an enormous amount of time and effort in; and I never remember one complaining. I was working with people who were both courageous , and unstinting in what they would do. They’d taken on dangerous jobs – it was dangerous being a nurse in a renal unit then (MRI was the first of several UK renal units to have an outbreak of hepatitis B in the dialysis unit in the 1960s and 1970s which causes some staff fatalities) (see Hepatitis). In those days student nurses would join morning and afternoon rounds on the wards across the hospital. And normally they would come in through the ward door and walk around the ward with the sister. But when they came to the renal unit they stopped at the door, they wouldn’t come in, they were scared about hepatitis.
There was growing responsibility and empowerment for nurses in the renal team. But for some change did not come fast enough. Netar Mallick: Some of the nurses felt that they ought to be given more status and authority. We had a couple of sisters who were up in arms about this, and I managed to negotiate that they could order tests, although they could not prescribe.
Nurse prescribing – now widespread and carefully regulated – was not a role which those involved in the early days of renal units recall being an issue. Cameron: Well of course all of them had been trained in the British system where what a nurse could do was fairly well laid down. There were whole books of what you could do and what you couldn’t do. But I don’t think there was anything which the nurses asked to do that we said ‘no’ to. Maybe they still as it were ‘knew their place’. Maybe this reflects the ‘family’ strength we had created, or that they were hanging on by their toenails anyway, just to keep up with everything was being thrown at them.
Although the size of modern renal units – patients and staff – mean that the close family environment of those early days has inevitably been somewhat dissipated, the culture they established of teamwork and holistic care continues to hold sway in modern renal units in the UK over fifty years later. Nurses played a particular role in holistic patient care because of the amount of time they spent with dialysis patients, getting to know well the many issues which could challenge the effective rehabilitation of people with kidney failure. Even more so in the early days of dialysis when treatment times were longer, and patients were fewer, nurses were able to spend more time with each patient. Compared to contemporary dialysis schedules, which are typically four hours three times a week, those using the less efficient Kiil dialysers were usually dialysing for eight hours three times a week, or even twelve hours twice weekly.
Nurses soon became much more expert about dialysis than most doctors. Mallick: When I started, I knew I had to be able to take a Lucas machine apart and put it together because if I couldn’t, who else was going to do it. But it was not long before the nurses would tell the doctors; ‘just leave me to it’. It is the people who are doing the job on the ground and doing it day after day after day who really get the expertise.
Netar Mallick was not unusual in being a single handed consultant in the early years of the MRI unit. It meant you had to leave the registrar to do quite a lot of the work if you went away, so you were very dependent on the nurses because it was such a small team. It helped the team to develop – they knew they were needed, but in turn they also needed the doctors who had the knowledge.
The multiprofessional team
The extended roles for nurses were the first sign of the radical overhaul of clinical practice being led by renal units. Other specialists were needed, and were welcomed into the team as renal units developed in size and scope.
In paediatric as well as adult renal units the team became the basis for care. Cyril Chantler recalled in 2018 the development of the paediatric renal team he led at Guys from 1970: We always were a very close knit team, and the nurses were often more important than the doctors. We had our particular skills, but the caring part of this is very much nursing territory. The senior nurses …… were just wonderful; so the families would talk to them. And the nurses saw (the issues) much more than the doctors because they were there all the time. But there was a whole team – including the social worker, the child psychiatrist working with us.
Netar Mallick: There was a core of people who stayed with it, who got into it. It just developed a momentum of its own. You knew each other, you knew you were all trying to do the same job. And it gradually attracted people who became very experienced, were inherently very good, and there was mutual respect.
Nephrology was the first clinical speciality to develop a multiprofessional team. The model was unique but soon spread – first to intensive care, where in many centres nephrologists were significantly involved in setting the culture. The same sense of a team of doctors and nurses working together, putting in all hours, as nephrology teams did, and not stinting.
Dietitians, pharmacists, technicians, artificial kidney assistants, medical social workers, clinical psychologists all played their part and many were attracted the by the egalitarian, non-hierarchical culture which pervaded most renal teams. They also were of necessity committed to the holistic and lifelong care that renal units were offering. The unit became a family – not just a professional family but a family involving the patients. This could be rewarding but was certainly demanding work. Hours were long, volunteers were need for additional shifts to ensure dialysis sessions were not missed. The teams socialised as well – there were dinners and evenings out together. There were patients’ Christmas parties at which consultants and senior nurses and other staff were often to be seen serving and clearing. Consultants and senior nurses often attended fundraising events at evenings and weekends.
The work was stressful but exciting. Some tried it and found it was not for them, many others stayed – finding it rewarding, though exhausting, and satisfying. It was pretty stressful sort of work. But we somehow didn’t feel the stress because we were very supportive of each other. We socialised together as a team and so forth. It was a good time. (Cyril Chantler)
As well as the nurses and doctors there were other key members of the multiprofessional team.
Artificial kidney assistants
Stanley Shaldon had invented the role of artificial kidney assistant (AKA) at the Royal Free in the 1960s. It was a very unconventional setup; he trained two unqualified women who had been ward orderlies to build the Kiil dialysers. They in turn taught the nurses, who then taught the people who were going to be on home dialysis and the people helping to look after them.
Sally Taber was a senior renal nurse in Cambridge in the 1970s: We had an excellent team of artificial kidney assistants, they set up the dialysis machines, and built the Kiil dialysers for each treatment. They were very practical competent people, but their role had clear limits – for example only doctors and nurses were allowed to needle. The AKA was a unique role in the NHS – I remember telling the Department of Health we need to have a staff category for them. But the role was short lived as the dialysers became disposable, and the newer machines became simpler to clean and set up.
Dietitians
Dietitians needed specialist expertise and a substantial workforce to deal with the nutritional demands of the growing numbers of people attending renal units with advanced kidney disease – for example dietetic control of sodium, phosphate and protein intake. Every clinical renal team included one or more dietitians. They quickly coalesced into a Renal Nutrition Group, the first specialist group within the British Dietetic Association, established in 1970. Their increasing expertise meant dietitians soon took on wider leadership roles in specialist areas – for example leading policy and practice for all aspects of phosphate control, well beyond traditional dietetic expertise.
Pharmacists
Pharmacists became a crucial part of the team for their expertise in preventing avoidable patient risks from ill-informed prescribing through the many drug interactions to which those with impaired kidney function are susceptible. They quickly became expert in each new generation of immunosuppressive agents introduced for transplantation, and then in Epo. They then became engaged in the budget challenges of diverting renal patients drug costs to general practice and then repatriating those costs to the renal unit budget as national policy fluctuated. In some centres their clinical contact extended further and they began to work in clinic seeing transplant patients under long term follow up.
Technicians
The central role that machines played in dialysis treatment required technical engineering expertise to service and troubleshoot them. This needed to be immediately available ‘in-house’, and from the beginning it was clear that this role could not be fulfilled by the general technical and facilities resources of the hospitals. So renal technicians became an integral part of the renal team. Their work included the maintenance of machines used by home dialysis facilities, and an on-call rota was needed to provide 24 hour cover and ensure home therapy was not interrupted; this was no mean task with the very rapid growth of home dialysis in the 1970s – many renal units had from fifty up to one hundred and fifty home dialysis patients or more at any one time. The technicians often became encouragers and advisers for home patients, since they were the renal unit staff most often in patients homes, and patients and their carers would share their concerns with them.
Social workers
Social workers became an invaluable part of the team. It was particularly difficult for dialysis patients to return to work in the early days. In part because of the very long hours of dialysis treatment at that time, in part because employers knew nothing about the implications of the treatment. Social workers could be patient advocates in employer discussions, as well as helping patients work their way through the complexities of the benefits system. Social workers also provided assessments of home and family circumstances which informed decisions about suitability for home dialysis.
Those working in these new specialist roles soon saw the value of meeting with their counterparts across the country. The 1970s saw national specialties groups established for dietitians, pharmacists, and technicians. (link to Professional Organisations). Interestingly no such organisation developed at that time for renal nurses, although many attended the European Dialysis & Transplant Nursing Association (EDTNA) and some became involved in EDTNA leadership.
Transplant Coordinator
The role of transplant coordinator was another novel development. Sally Taber, senior renal nurse in Cambridge from the early 1970s: I really enjoyed the transplant side. I got heavily involved in in the liver transplants and also the live kidney donor transplant programme. I looked into the role of the transplant coordinator in 1978. I had cousins in the States and went to a conference where they were talking about it. Soon after that the Minister of Health invited kidney units to a meeting at London Zoo with some of the children and young adults who had been transplanted. During question time I said to him it would be an idea to develop the role of the transplant coordinator in this country, and I was next called to his office and Roy Calne agreed for me to do a pilot in Cambridge (a transplant coordinator also started in Liverpool around the same time). I visited 17 units in the States, looking at the role of the transplant coordinator, developed it and became one myself.
It was not always straightforward to convince others that a transplant coordinator would be valuable. Taber again: In the beginning we weren’t accepted when we went to the intensive care units. I remember feeling a bit like a drug rep, being told to stay behind the mark on the floor beyond which only clinical people can go. No, it was tough getting it accepted. Mick Bewick (transplant surgeon at Guy’s) was influential and did not like the role of the transplant coordinator. Unbeknown to me, he made an anonymous call, phoning my bleep about a possible donor, and said I’d taken 20 minutes to answer it, whereas he would have answered it straight away. He said, ‘the transplant coordinator is nothing more than a rep going around giving out pens and donor cards’. So some doctors were very much against it, but gradually people appreciated what I did when I was on-call, and when I was off realised: ‘Gosh, it’s pity that she isn’t here’. So, I was accepted then.
Geographical sites for renal units
The empowerment of the multiprofessional team and particularly the nursing staff was also driven by the relative isolation of some dialysis units, which were not always allocated space in the main hospital (a reflection of the sceptical attitudes to dialysis of senior clinical staff outside nephrology as well as some managers). In Cambridge for example the dialysis unit and transplant unit were initially sited at Douglas House, an NHS building a couple of miles from the main hospital site, which also contained a psychiatry in-patient unit and an animal research facility. Although the transplant unit soon moved to the main Addenbrooke’s Hospital, dialysis remained at Douglas House.
Geographical isolation afforded more opportunity for nurse empowerment and leadership.
Sally Taber: The senior renal nurses from my age range – they’re all quite assertive. We were the first type of nurses to be given that responsibility, and for those of us that wanted it, we enjoyed it. Yes, we were isolated at Douglas House, so we just got on with it. We developed the team, we looked at all their roles and told the doctors, this is what we’re doing. We had to have good communications between the dialysis and transplant unit when they were on different sites, I did a middle management course because it wasn’t easy to know how we actually managed with the staffing we had. And frankly, if people didn’t work extra time, the patients wouldn’t have survived.
Surprisingly, nursing staff had even become involved in animal care. Sally Taber: When I first came to Douglas House I realised, through talking to the night staff, that their additional duty was to go down and see the pigs in the Animal House. The animals sometimes required an injection during the night, which the nurses were taught to do. I soon put a stop to that!
[1] Stanley Shaldon, founder of the haemodialysis programme at Royal Free Hospital, the first in the UK to develop home dialysis.
Last Updated on March 29, 2023 by John Feehally