The development of kidney transplant nursing.
Initial Experiments in Kidney Transplantation
The earliest reported successful kidney transplant resulted from a surgeon's interest in improving vascular suturing techniques (1). In 1902 in Vienna, Austria, Emerich Ullmann performed an autotransplant in which a dog's kidney was moved from the abdominal cavity to the neck. The kidney produced some urine and the dog lived a few days (Hamilton, 1988). Subsequent animal kidney transplants, including autografts, allografts (between animals of the same species), and xenografts (between animals of different species) were performed between 1902 and 1912 by Ullmann, Alfred von Decastello (also of Austria), and a French physician, Alexis Carrel. Carrel later immigrated to the United States and performed many successful autografts in cats and dogs (Hamilton, 1988) (2). These animal kidney transplants established the technical feasibility of resecting a kidney from one location and reattaching it in another part of the body.
Mathieu Jaboulay, a French surgeon, reported the first kidney transplants into humans in 1906. He performed two xenografts using organs from a pig and a goat; each transplanted kidney functioned for only an hour (Hamilton, 1988). Next, a Ukrainian surgeon, Yu. Yu. Voronoy, performed six human kidney allografts between 1933 and 1949. His first transplant was in a woman who had attempted suicide by ingesting a substance that led to acute renal failure. The donor kidney came from a patient who had sustained a fracture at the base of his skull and died upon arrival at the hospital. The kidney was placed in the woman's thigh with the renal arteries and veins anastomosed to the femoral arteries and veins. Skin flaps were used to cover the kidney and the ureter was pulled to the surface of the thigh and sutured in place. Although the woman lived two days after the transplant, the kidney showed no signs of function (Hamilton & Reid, 1984). Voronoy's later allograft attempts also were unsuccessful.
These earliest reports of human transplants provided considerable detail about the patients and surgical procedure; however, involvement of nurses was not described. One can speculate that due to the patients' short survival, nursing involvement, if any, would have been limited to assisting the surgeon as directed, preparing equipment, and cleaning up afterward because these were common nursing functions during that period.
Experiments with Human Kidney Transplantation after World War II
After World War II, scientific research on disease mechanisms and treatments grew rapidly and laid groundwork for surgeons to pursue research on kidney transplantation. Beginning in 1947, sustained efforts to achieve successful transplants were initiated at the Peter Bent Brigham Hospital ("the Brigham") in Boston (3). The first transplant at the hospital was performed by Doctors David Hume, Charles Hufnagel, and Ernest Landsteiner to treat a young woman who developed acute renal failure after obstetrical complications. A kidney from a recently deceased patient was transplanted into her thigh. The transplanted kidney produced urine immediately, and the woman began showing signs of recovery. Two days later, the kidney was removed because it was no longer producing urine. The patient recovered and was discharged. The transplanted organ had likely served as a temporary "bridge" while her native kidneys recovered (Tilney, 2003).
More transplants were performed over the next few years, but with minimal or no success. Dr. Joseph E. Murray joined the Brigham Hospital staff in 1949 and began working with Hume and others in the laboratory experimenting with transplant. When Hume left in 1953, Murray took over in the transplant research laboratory and became the lead kidney transplant surgeon (4). At that point, the Brigham's renal physicians were collaborating with Murray on kidney research and testing other treatments for kidney disease (Murray, 2001; Tilney, 2003). Their interest in transplant was encouraged by a 1951 report from Richard Lawler and colleagues in Chicago, who performed a transplant in a woman suffering from polycystic kidney disease. One of her diseased kidneys was removed and replaced with a kidney from a deceased donor. The new kidney produced urine, her condition improved, and she was discharged two months after the transplant (Lawler, West, McNulty, Clancy, & Murphy, 1951). Ten months later, the transplanted kidney had ceased functioning, yet the patient lived five more years. This transplanted organ, like that in the Brigham's 1947 case, had likely served as a bridge while her remaining native kidney recovered partial function (Tilney, 2003).
By 1954, 16 transplants had been performed at the Brigham. Of these, 10 patients died, 5 kidneys showed "measurable but short-term function," and 1 kidney functioned for 5 months (5). In October 1954, a development that presaged future successes occurred. The Brigham had a reputation for its research on kidney disease, and physicians at other hospitals often referred patients with renal failure (6). Richard Herrick (7), a 23-year old man with severe renal failure, was sent to the Brigham from a nearby Boston hospital. The referring physician suggested that because the patient had a healthy twin brother, Ronald, it might be possible to perform a kidney transplant (Merrill, Murray, Harrison, & Guild, 1956). By this time, physician researchers had observed that the body rejected grafted tissues except when the graft was between identical twins. Thus, if the Herrick twins were identical, a successful transplant might be possible.
On admission, Richard Herrick presented with hypertension, persistent nausea and vomiting, disorientation, erratic behavior, and biochemical indicators of uremia. Over a two-month period, the renal team treated his symptoms, including use of two dialysis treatments. Some symptoms were resolved, yet he continued to decline. During these two months, Ronald was evaluated to assure he was healthy and to assess his willingness to donate a kidney. The transplant team performed a number of procedures to verily that the brothers were identical twins. Most important were full thickness skin grafts between them. Murray explained in his autobiography that this two-month period was also used to weigh the moral and ethical ramifications of moving forward with the transplant. No one had ever removed a kidney from a healthy human for transplantation into another individual; the unknowns were great. The renal team sought consultation from other physicians and psychiatrists, clergy, and legal counsel. Subsequent to these consultations and team discussions, they presented what they knew about the procedure, the risks, and the probable benefits to Richard, Ronald, and their family so they could make a decision about whether or not to proceed. When the family asked about risks Ronald might encounter in living with only one kidney, the renal team even approached insurance companies to obtain actuarial data. They learned that people who had only one kidney had no increased risk of death. Ronald decided to donate his kidney (Murray, 2001).
The transplant was scheduled for December 23, 1954. A few days prior to this, Murray carried out a "test run" on a cadaver using surgical techniques he had perfected on dogs in the laboratory (8). The donated kidney was placed into Richard's abdominal cavity; the renal artery and vein were anastomosed to the external iliac artery and vein, respectively, and the end of the ureter implanted into the bladder. The kidney functioned immediately (9). Ronald's post-operative course was uneventful, and he was discharged on the 14th hospital day. Richard's post operative course was also relatively uneventful, and he was discharged on the 37th post- operative day. He had gained 11 lbs, his blood urea nitrogen had dropped to 14 mg/100 cc, and his blood pressure was 120/60 mmHg (Merrill et al., 1956). Over the next few months, his blood pressure rose, despite otherwise good functioning of the transplanted kidney. The rise was attributed to his native kidneys so they were removed in two subsequent surgeries. The hypertension resolved, and Richard returned to full-time work, married, and became a father (Murray, 2001). He lived until 1963, when he died from renal failure. The disease that caused his initial kidney failure, chronic glomerulonephritis, had recurred in the transplanted kidney (10).
Clare Burta was one of the nurses involved in the care of Richard Herrick (11). She was a 1952 graduate of the Peter Bent Brigham Nursing School, and in 1954, she was working in the recovery room at the Brigham. She first took care of Richard in the recovery room, then was one of the nurses who worked private duty shifts to take care of him on the surgical floor. Due to a national shortage of nurses at that time, staffing on hospital floors was insufficient to care for patients who needed close monitoring. Other patients who were likely to have private duty nurses were those who underwent cardiac surgery. Burta recalls that the nursing care for Herrick was much the same as it was for other post-surgical patients: check vital signs frequently, check surgical site for bleeding, closely monitor intake and output, and keep him comfortable. Burta worked many years before retiring, but she never provided nursing care to another transplant patient.
Herrick's successful transplant was the motivation for the Brigham surgeons and renal physicians to attempt more transplants as identical twin cases were referred. Four years later Murray, Merrill, and Harrison (1958) published results from 8 identical twin transplants, most between the ages of 14 to 26 years, although one was 42 years old (12). At the time the report was written, 6 of the transplanted kidneys were functioning, with the time since transplant ranging from 3 to 42 months. One patient had died as a result of rapid recurrence of her original renal disease and another due to anatomic anomalies encountered during the surgical procedure. Because there was not yet a technique for sustained access to the bloodstream, chronic dialysis was not an option for patients when a transplant failed.
A photograph (c. 1957) of a Brigham "private nurse" shown interacting with a teenage recipient and donor provides evidence that the hospital continued to use private duty nurses to care for transplant recipients (13). Available information suggests that the few hospitals doing transplants in the 1950s probably all used private duty nurses to care for patients who received transplants. The first nursing publication about kidney transplantation was written by Shirley Harris, a private duty nurse at the Royal Victoria Hospital in Montreal, where she cared for Moira, a 15-year old girl who received a kidney from her identical twin (Harris & Dossetor, 1959).
Three private duty nurses were assigned to care for Moira before the transplant so they could become acquainted with her and her condition. They received instruction about her condition, the operation, and post-operative care from a surgeon (presumably Dossetor). Post-operative care was planned based on "I) anticipated developments in Moira's condition, 2) understanding of the effect of such surgery on total body function, [and] 3) the laboratory investigation required in estimating the body's return to normal function" (Harris & Dossetor, 1959, p. 508). After the transplant surgery, Moira returned from the operating room to an aseptically prepared room. The few staff and family members who entered the room donned full surgical attire. Many aspects of the post-operative care were consistent with standard practices: vital signs, bladder irrigations, wound care, pain medications, deep breathing and coughing, leg exercises, and positioning. Other aspects of care were precisely described "meticulously accurate estimation" (Harris & Dossetor, 1959, p. 509) of intake and output, biochemical analyses of all body fluids, and management of a variety of tubes (nasogastric, cystostomy, ureteral catheter, Foley catheter, and two intravenous lines).
Moira showed signs of depression, so the nurses were responsible for "cheering [her] up" (Harris & Dossetor, 1959, p. 511). Because many consultants saw the patient throughout her stay, the nurses were to "channel" all orders through one "specific authority" (presumably the transplant surgeon) to avoid conflict of ideas. Finally, all information about the patient was entered onto "wall charts ... [which] gave a graphic picture on Moira's condition at any specific time" (Harris & Dossetor, 1959, p. 509). Moira was discharged with a functioning kidney five weeks after surgery.
New Kidney Transplant Experiments and Recipients
Total Body Irradiation
As word spread about the success of the identical twin transplants at the Brigham, they received referrals of non-twin patients who suffered from kidney failure. This presented an opportunity to begin transferring laboratory work related to the immune barrier into the clinical setting. Researchers in earlier decades had demonstrated that x-irradiation caused immune suppression, and in the 1950s, experiments on total body irradiation (TBI) followed by bone marrow infusions were being conducted in animals (Tilney, 2003). This approach was applied for the first time at the Brigham in 1957 to a woman who had undergone emergency surgery at another hospital to remove an infected appendix. It was soon discovered that the infectious mass was her only kidney, so she was referred for possible transplant. She was subjected to whole-body irradiation, received three hemodialysis treatments, and was given bone marrow infusions, all while she was being kept in a sterile operating room to protect her from infectious organisms. The "free" kidney (14) she received began excreting urine two weeks after transplant, but within a month, the woman succumbed to infection (Murray, 2001).
The only successful use of TBI at the Brigham was in 1959 in a set of fraternal twins, John and Andrew Riteris. After a difficult first month, John's new kidney began functioning. Nine months after the transplant, he developed rejection, which was reversed by cortisone and additional irradiation (Merrill et al., 1963). John Riteris lived 29 years with his transplanted kidney (Murray, 2001). Other centers also ran trials with TBI or combined TBI-bone marrow infusion, but Riteris was one of the few who achieved a successful outcome. Because of the inability to prevent fatal infections, TBI was abandoned.
Although TBI was short-lived, it was a driving force in the design of the first dedicated kidney transplant units and the first iteration of kidney transplant nursing responsibilities. The term "sterile room" was associated with dramatic images, as illustrated by a Newsweek report, "The powerful radiation ... left him vulnerable to invasion from any germ. During this crisis, John Riteris lived in a completely sterilized hospital room, protected from germs by a 'curtain' of ultraviolet rays flickering across the entrance (15)."
In 1960, the Medical College of Virginia (MCV) Hospital in Richmond began planning its five-room transplant suite. The suite and the nursing procedures (16) used in the suite were modeled after operating room procedures and the U.S. Navy Nurse Corps nuclear nursing curriculum (Hoffart, 1989a). A circulating nurse worked in the anteroom and supported a scrub nurse, an RN or LPN, who entered the sterile room to care for the patient. The circulating nurse assisted the scrub nurse by passing sterile equipment into the sterile room and accepting contaminated materials for removal. Both nurses were responsible for routine cleaning of equipment, work surfaces, floor, and walls of their respective work area. Operating the transplant suite required several other hospital staff. The nurse in charge of the unit where the transplant suite was housed prepared and administered medications (or supervised the scrub nurse who administered them) and checked sterile supplies to assure they had not expired. Hospital aides prepared packs and supplies for autoclaving. Then the aides or hospital attendants transported the packs to and from the central supply room or pharmacy where they were autoclaved.
Two articles about kidney transplant in the United Kingdom were published by Nursing Mirror in 1963 (Shaw, 1963; Walker, 1963). Each author described sterile suites and procedures akin to those developed at MCV. In addition, the suites used positive pressure ventilation to prevent contaminated air from flowing inward.
Shaw (1963) reported that the suite at the Royal Infirmary--Edinburgh had "electronic monitoring equipment which makes it possible for the nurse to observe the patient's pulse, temperature, respiration rate, and blood pressure on an instrument panel in her [ante]room" (p. iv). Other design elements were a glass wall, loudspeaker, and microphone between the clean supply corridor and the patient's room. Thus, physicians, family, and others could communicate with the patient without entering the room, and nurses on both sides of the wall could do the same. This was probably an appreciated design element given that everyone who entered the patient room had to shower, dry with a sterile towel, and don sterile clothing. In another effort to prevent infection, "before and at intervals during their tour of duty, the nurses have nasal, throat, and perineal swabs taken to ensure that they are not carriers of pathogenic bacteria" (Shaw, 1963, p. iv). Like at MCV, staffing was generous; "because of the elaborate techniques required for the successful operation of such a unit, seven senior nurses are needed to look after a single patient" (Shaw, 1963, p. iii).
Walker worked at the General Infirmary at Leeds, which also operated a transplant suite with strict aseptic procedures. She inferred that it was difficult for patients in the isolated environment when she wrote, "Televiewing [is] a pleasant pastime and helps to amuse the patients, but the nurses' and doctors' presence and reassuring approach to him were the greatest morale booster" (p. 513).
During the few years that TBI was the principal means of immunosuppression, a key factor that differentiated transplant post-operative care from general post-operative care was the sterile room. It is likely that most nurses were familiar with the strict sterile room procedures because operating room rotations were a component of most nurse training programs of the day. But the incorporation of new elements, such as ultraviolet lights, remote monitoring devices, and intercom systems, as well as caring for patients undergoing this advanced surgical procedure, were likely to have been exciting for these nurses.
As TBI fell out of favor, transplant teams began experimenting with pharmacologic agents to prevent and treat rejection. In 1958, 6-mercaptopurine (6MP), an anti-metabolite, was shown to induce immunosuppression in dogs. The Brigham transplant team and those at other centers began using it instead of TBI. One patient in Paris survived with a combination of 6MP, irradiation, and intermittent prednisone (Hamilton, 1988), but other programs had little success. Within two years, azathioprine (Imuran), a derivative of 6MP, became available. The Brigham achieved another first--the first successful kidney transplant from a "post-mortem" donor (Merrill et al., 1963, p. 347). This transplant was performed in 1962 using azathioprine as the method of immunosuppression. The patient experienced repeated episodes of rejection during the first five months, which were treated with actinomycin-C (an antibiotic that kills white blood cells) and prednisone. At the time of their report (15 months post-transplant), the patient was considered successfully transplanted, and despite a high blood urea nitrogen (100 to 115 mg%) and low creatinine clearance (8 to 9 mL/ minute), he was working full-time. Eventually, he lost the kidney to rejection and received a second transplant. Other centers' experiments with azathioprine increased the number of successful allografts, yet many patients died due to toxicity (Murray, Tilney, & Wilson, 1976).
Tilney (2003) characterized the 1960s and early 1970s as a period of "innovation and the struggle for legitimacy" (p. 125). Research continued on many fronts--pharmacologic prevention and treatment of rejection, immunogenetics, and organ preservation (17). Tilney (2003) noted that each success, even when outnumbered by multiple failures, was a reason to continue. Advances in hemodialysis, including the development of the external arteriovenous shunt, opening of regional dialysis centers, and availability of home dialysis, allowed patients to be maintained on dialysis while awaiting a transplant or return to dialysis after a failed transplant. Consequently, more hospitals started kidney transplant programs. Tilney (2003) wrote that in 1954 "about 25" people attended the first international transplantation conference, and by 1966, attendance at the seventh conference grew to "several hundred" (p. 126).
In 1962, Dr. Thomas E. Starzl established an active transplant program at the University of Colorado Medical Center in Denver. He performed transplants at both the Veterans' Administration Hospital and Colorado General Hospital. Between November 24, 1962, and March 30, 1964, his team carried out 83 kidney transplants in 75 patients. As of June 1, 1964, 33 patients had died (18). The comprehensive textbook in which he presented his team's results covered many medical and surgical aspects of kidney transplantation (Starzl, 1964). He summarized the status of kidney transplantation in the Introduction:
The employment of renal homografts is still a fundamentally experimental practice, which is attended by a distressingly high incidence of early failure even under the most nearly ideal circumstances ... A stampede of uncontrolled activity at this time will serve no useful purpose, and may discredit the operation before its merits are fully determined...In its present developmental state, homotransplantation requires an institutional effort, since even the studies which are necessary to document the course of a single patient are beyond the knowledge, skill, and time of any individual or small group of physicians (p. xii).
Eight years later, his statement still rang true. The 1972 Human Kidney Transplant Registry (which had data from practically all transplant centers) showed that at 1-year post-transplant, 75% of recipients with kidneys from living related donors had functioning grafts, and only 45% of those with kidneys from cadaveric donors had functioning grafts (Tilney, 2003).
Transplant Nursing Emerges as a Specialty
As the number of transplant programs grew, interested nurses sought opportunities to work in them. The prospect of being involved in something innovative stimulated their interest. Michele Topor (19), who was employed at the Brigham, explained her attraction to the newly established transplant unit (20):
I had worked in the transplant unit when I was a student nurse [at the Brigham], I was very captivated by it. The year I graduated , we couldn't go directly to specialty nursing, so I worked on a regular medical-surgical unit, which was right outside the kidney transplant unit. Whenever they needed help in the transplant unit, I was floated over there. I worked on the med-surg unit for one year and then transferred to the transplant unit.
Dorothy Shebelski (21) was working at the Denver VA Hospital in 1962 when Dr. Starzl performed the first transplant. The patient stayed in the recovery room with one-to-one nursing care until six days before discharge, at which time he was transferred to a general surgical floor. Shebelski was head nurse on that surgical floor, so she was exposed to the patient: "I had a little taste of it then and I really thought it was going to be fun." In 1963, when the hospital decided to establish a designated transplant unit, she volunteered to be head nurse: "I looked at it as a real challenge, but the chief nurse looked at it with jaundiced eyes, and told me if I didn't like it, I would not be able to get my general surgical floor back. But I was ready to go ahead ... I really thought this was going to be a very exciting thing to get into."
Soon Shebelski, Topor, and other nurses began to share their knowledge of transplant by publishing articles and book chapters, and presenting papers at professional conferences. Ten transplant nursing papers were published between 1965 and 1970 (Bois, Barfield, Taylor, & Ross, 1968; Eisendrath, Topor, Misfeldt, Jessiman, 1970; Felix, Marshall, & Rubin, 1969; Fulton, 1968; Juzwiak, 1968; MacDonald, 1967; Rockwell, 1965; Samartino & Preston, 1967; Shebelski, 1966; Stevens, 1969). The information from these papers has been supplemented by the author of this article, with reminiscences gathered through four interviews with transplant nurses of that era to illustrate how clinical practice in transplant nursing developed and how nurses contributed to the legitimacy of kidney transplant as a therapeutic procedure. Combined, the papers and interviews represent seven transplant centers.
The ways in which transplant programs were set up influenced the nursing role. Not all hospitals used the same structure. Some established dedicated transplant units, while others admitted transplant patients to a clinical research unit or a general surgical unit. Some of the dedicated units also included dialysis rooms. Unit admission policies varied. Some accepted only transplant recipients, while others admitted living related donors for the donor work-up or their pre- and post-operative care. Some programs returned patients to the transplant unit or intensive care unit immediately from the operating room without a stop in the recovery room. At MCV, the transplant nurses went to the recovery room to give the immediate post-op care until the patient was ready to return to the transplant unit. Kay Andrews (22), supervisor of the kidney transplant unit at MCV, designed a "self-care unit" for the many patients who came to Richmond from long distances (23). At four weeks post-op, if the patients no longer needed to be hospitalized, they would transfer to the self-care unit for several more weeks of close monitoring (Stevens, 1969) (24). This freed up inpatient beds so the program could accept more patients. The variability in the location of beds and admission policies among transplant programs led to variability in the duties of transplant nurses. For example, if the unit included a room for dialysis, the nurses were trained to perform the dialysis pre- and post-transplant (if needed).
Despite some variations, two aspects of transplant nursing care were addressed in the papers: prevention of infection and prevention, recognition, and treatment of rejection. Since TBI was no longer used, the drama of sterile rooms and the focus on the unyielding procedures for creating aseptic environments lessened. In 1966, Shebelski boldly wrote that at the Denver VA:
We abandoned this elaborate isolation technique [sterile room] in October 1963 because bacteriologic surveys demonstrated that the organisms infecting the patient were invariably endogenous: they were present on the patient's skin, in his pharynx, or in his stool in virtually every case. Thus, the expensive and difficult precautions for asepsis appeared to be directed at the wrong target (p. 2426).
The bibliography for Shebelski's article listed a 1964 medical publication entitled, "Infectious Diseases Associated with Renal Homotransplantations," a likely source for the survey results she referenced. Yet, not all centers adopted the change as quickly; in 1969, Felix et al. included discussion of the need for the sterile room procedures in their textbook chapter. It is important to note that patients were still at high risk for infection because leukopenia was a significant side effect of the newer approaches to immunosuppression. Thus, protective isolation remained in use for a few days immediately post-op and when patients became leukopenic.
Early in the 1960s, transplant centers were experimenting with newer pharmacologic strategies to prevent and treat rejection, including azathioprine and corticosteroids. Experiments with splenectomy, thoracic duct drainage, anti-lymphocyte serum, and localized irradiation were carried out to supplement these medications (25). Topor and Amy Chang (26) both recalled a daunting experiment at the Brigham. Topor described it: "Patients were intentionally given typhoid disease in hopes that the body would get the T-cells off the new kidney because they instead would be busy fending off the typhoid. I can still remember the fevers of 105 [degrees] and the cooling blankets. Frightening! That didn't go on for long." Like the typhoid experiment, most of these approaches were complex to administer and carried significant morbidity. Chang said there was "mystery with each case" because of the uncertainty and complications associated with these therapies. Nurses assisted the physicians and surgeons in carrying out these experimental approaches and generally played the lead role in easing patients' suffering due to complications such as pain, fever, gastrointestinal disturbances and bleeding, fear, and anxiety.
An important component of these transplant nurses' work was giving emotional and psychological support to patients and their families. When asked how she selected nurses to hire, Andrews said, "I felt you needed someone with ... an ability to relate to people ... It didn't have to be a person that had to be continually busy doing something. If they felt they could sit and talk with the patient, they could contribute in ways other than just menial skills of nursing." Andrews' use of the phrase "menial skills of nursing" suggested that relationship building and supportive care may have been more challenging or rewarding than routine post-operative nursing techniques or the previously required sterile room procedures. Several authors indicated that developing a trusting interpersonal relationship with the patient was required for effective transplant nursing:
* Provide psychological support to the patient and his family, ... be available to talk with him or to listen, ... discuss his concerns, ... help him arrive at ways of coping with them (Rockwell, 1965, p. 124).
* The nurse must understand the fear that her patient experiences...his concern over his ill ness, his sense of loss and bewilderment...The patient who is helped to feel at home on the ward and is treated as a member of the team ... will be more cooperative, and therefore, more easily treated (MacDonald, 1967, p. 35).
* The support needed to be given to [the transplant] patient is more demanding because emotional problems are increased...The nurse must give support to each patient on a very personal level. Rapport must be established (Bois et al, 1968, p. 1246).
Hospitalization for transplant ranged from several weeks to months, which further contributed to problems. Uncertainty about the effectiveness of methods being tested to prevent rejection caused patient and family stress.
Nursing interventions to ease patients' and families' emotional and behavioral problems included listening, spending time, encouraging, reassuring, creating an atmosphere that fostered open discussion, answering questions frankly and completely, involving in diversionary activities, giving passes to leave the hospital, and altering routines to break the monotony of hospitalization. Nurses also devised ways to use others in addressing the emotional needs of patients. One approach was to foster interaction between successful transplant recipients and more recent or prospective transplant patients (Bois et al., 1968; Juzwiak, 1968). Stevens (1969) described a "big brother" program for teenage patients and recruited community volunteer groups to offer recreational activities for patients. The nurses also frequently sought the assistance of social workers, psychiatrists, psychologists, and chaplains.
Closely related to the transplant nurses' role in providing emotional support was preparing patients and their families to manage their care after discharge. Teaching was required because of the long-term nature of immunosuppression. Shebelski explained:
I remember Dr. Starzl saying, 'You know these patients are going to be on these medications probably for the rest of their life, so it's going to be up to you to do something about this.' ... It was rather instinctive that I knew they were going to have to know all this stuff, and all the rest of the staff felt the same way. I didn't think anything of it at the time.
Throughout the patient's post-op recovery, the nurses integrated teaching into other aspects of care. Topor described it as "open discussion ... We could talk to patients, we could go over charts. We could go over numbers. Nothing was, 'Oh, the doctor will tell you.'" At MCV, an admission checklist identified what patients needed to know pre-op, and a discharge checklist identified what had to be covered by discharge (Andrews). As medications were given, the nurse explained them to patients and asked them questions to verify their understanding; as laboratory results were written on the wall charts, they were explained to patients; good health habits and dietary regulations were stressed. "Med cards" were given to patients as a teaching aid. Chang told a story that illustrated that nurses were in control of patient teaching. She was rounding with physicians, who disagreed about whether or not a patient was ready for discharge. Dr. Murray asked her if she thought the patient was ready for discharge, and she said, "He has more to learn." Dr. Murray replied, "Then he'll stay."
The seven institutions represented in this analysis were leading transplant research institutions. Consequently, the nurses' work interfaced with the research. Nurses carried out aspects of research protocols: for example, administering experimental drugs and managing drainage bags for thoracic duct drainage. Topor explained that there was "lots of documentation with all of that, documentation in the charts, and graphs everywhere, on all the doors." Starzl (1964) described the importance of using specially designed flow sheets, rather than standard hospital charts, to assure accurate, complete, and organize presentation of patient data; nurses or physicians recorded the data on the flow sheets. Transplant nurses also learned how research findings influenced patient care. Bois et al. (1968) wrote that it was important "for the doctor to keep the nurses informed of the results derived from the continuous research in both patients and experimental animals" (p. 1247) because it helped assure that doctors and nurses were working together. Andrews explained how this was accomplished at MCV:
We had a [team] conference every two weeks with the physicians and all the nurses. There would be a presentation by one of the residents or Dr. Hume himself on some aspects of the transplant program statistics and the research they were doing and why they were doing it. That was extremely interesting and educational to me.
Topor recalled that staff from the research laboratories attended clinical conferences on the Brigham transplant unit, "... and if I wanted to go and see the dogs, I could go over there. I remember going to see the dogs that were given the Imuran." Andrews rotated nurses to the research laboratory where they might help transplant kidneys in the dogs because "it gave them a different scope, and every so often, it got them off the unit to look at something different."
As the new transplant programs developed, nurses entered into relationships with physicians and surgeons that were different than they had experienced in prior work settings. Shebelski said:
It was the first time everybody was on a first-name basis. I think that was unusual in the early '60s. It was not unusual for the surgeons to ask to have meetings with nurses, we would set down and talk about the patients ... It was an extremely close working relationship and ... very gratifying.
Andrews' experience was similar:
Every evening we would make rounds between 5:00 and 5:30 ... Each person would report anything they were aware of on each patient, and we would discuss the plans for their care ... I was the nurse representative, [so] there was input from the people that cared for them everyday--the nursing staff ... It was a team approach ... I feel it was before its time.
Topor described that at the Brigham, "Everybody had something to contribute. We all contributed equally. That was what was exciting about this. Because I don't think that was done on a lot of the other floors."
In spite of the nurses' excitement and their expanding role, knowledge, and collaborative relationships, being a transplant nurse did have its down sides. First, the work environment was intense and stressful. As noted above, patients and families exhibited emotional and behavioral problems; these were compounded by the physical intimacy of units and long hospitalizations. Patients and their families, who spent considerable time at the hospital, became close and supported each other. Nonetheless, as Andrews explained, "Everybody knew what was going on, and you couldn't hide anything," so the problems of one patient raised anxiety for others. Furthermore, because "these patients were your [the nurses'] friends," there was added stress when they developed complications and rejection (Andrews). Bois et al. (1968) emphasized that "the nurse's most demanding need for emotional support comes when a patient is dying" (p. 1247).
Nurses needed support to cope with the stresses. Shebelski (1966) described the importance of in-service training for the nursing staff, as well as formal and informal conferences to plan care to resolve patients' behavioral and interpersonal problems. Bois et al. (1968) advocated for team conferences with "psychiatrically oriented personnel" (p. 1247) to enable nurses to get relief from their frustrations and anxieties. Although nurses' relationships with physicians were viewed as favorable, nurse-physician tensions did arise. Topor and colleagues (Eisendrath et al., 1970) asserted that staff conferences (which they called service meetings) could be used to address problems, such as poor communication among nurses and physicians, confusing lines of decision-making authority, and contradiction of orders among physicians. They concluded:
The nurses had an opportunity to state their suggestions and reservations in the open. Though the idea that the nurse is an unthinking adjunct to the physician has generally been discarded, the facilitating of a greater degree of cooperation cannot really occur on traditional rounds. The service meetings met this need well (p. 56).
Another feature that added stress was the long work hours. Topor explained, "I think those who worked in the program had to be able to work any time of day, night, or overtime. You were there; it was your life. You couldn't float a lot of people from other floors." Shebelski concluded, "It was physically and emotionally draining." As head nurse, she often worked 12-hour days and could be called back because of problems on the unit. Staff nurses also worked long hours because "we covered our own illnesses. No one wanted to come up to relieve us [because] they were afraid; it was the unknown" (Shebelski). She recalled that during her three years as head nurse, only three nurses transferred out of the unit because "they couldn't tolerate being in an area that was really charged at all times."
Transplant nurses also confronted ethical, legal, and moral issues. Samartino and Preston (1967) wrote that nurses questioned how transplant recipients were selected when the resources to transplant all in need did not exist. They noted nurses' conflicted feelings about use of cadaveric donors and asserted that they "should not assume the role of judge and jury" (p. 17) when similar concerns arose from patients. At MCV, the transplant nurses felt some resentment from recovery room nurses, who cared for cadaveric donors before their organs were recovered, and that "a lot of time, the [recovery room] nurses would actually want to fight to keep that patient alive" (Andrews). Fulton (1968) raised questions about determination of death in kidney donors, and how nurses could help overcome the lack of available dialysis machines and transplant facilities when there were so many who needed care. Shebelski recalled staffs concerns and negative attention from the Denver press when baboon kidneys were transplanted into humans. She also recalled a short-lived trial of living-nonrelated transplants using kidneys from prisoners, which raised concerns for staff and public alike. Close relationships among team members and the willingness to discuss and debate such issues were seen as an important means of resolving stress.
Although there were 10 nursing publications on kidney transplantation, there was little or no direct interaction among nurses working in kidney transplant units. Both Andrews and Shebelski acknowledged they knew there was a transplant unit at each other's hospital and both supervised those programs from 1963 to 1965, yet they did not meet or even speak by telephone. For personal reasons, both left their transplant positions before the end of the decade, missing opportunities that materialized when a nucleus of dialysis and transplant nurses began to organize themselves. On October 2829, 1966, Elizabeth Cameron and Barbara Fulton, dialysis nurses at the Brigham, hosted the first conference for nurses and technicians interested in hemodialysis, at the Peter Bent Brigham Hospital (Hoffart, 1989b); 146 registrants attended the symposium (27). Topor presented a paper on kidney transplant at the meeting. Subsequent conferences in 1968 and 1969 also included nursing papers addressing kidney transplant (Fulton, 1968; Stevens, 1969), but records do not indicate how many transplant nurses attended.
Transplant nurses were not without colleagues, however. They perceived themselves as valued members of the transplant team. Formal and informal conferences with the team, discussions of the research being conducted, and daily rounds fostered their learning and professional development. Content about kidney transplantation and hemodialysis most likely would not have been covered in nursing curricula of the day. Thus, the inclusion of content about uremia, principles of dialysis, transplant immunology, and manifestations and diagnosis of rejection in their published papers attests to the extent of learning that occurred "on the job." The published papers also refer to work relationships with transplant fellows, psychologists, dietitians, chaplains, and physical therapists. Nonetheless, the lack of collegial relations with other transplant nurses meant that the nurses in each unit had to draw from their own experience in designing new aspects of clinical care. Furthermore, the lack of nurse-to-nurse interaction delayed the spread of transplant nursing knowledge.
Early Transplant Nursing in a Nursing Context
Because of the many medical advances after World War II, nursing was faced with new demands and opportunities. During the 1960s, there were nursing faculty in university settings who advocated for changes in nursing curricula to strengthen clinical care and prepare clinician specialists (Peplau, 1965; Reiter, 1966). Two papers by nurse educators were presented at the 1968 and 1969 hemodialysis nursing symposia (Hewitt, 1969; Redman, 1968), but it is difficult to determine the extent of interaction and whether or not nursing educators and other nurse leaders had a direct influence on the work of the early transplant nurses. However, from a vantage point almost 45 years later, it is evident that the development of the nursing role in transplant units was parallel to proposals from educational leaders of the day.
Hildegard Peplau was on faculty at Rutgers University School of Nursing in 1965 when she wrote "Specialization in Professional Nursing" (Peplau, 1965). She advocated that the profession deliberately develop specialization in nursing practice and listed 10 possible models that could be used, including "organs and bodily systems," with renal and cardiac nursing as examples (28). While Peplau predicted that at best, organ and body system specialists would become subspecialties in one of the other models, the developments occurring at that time in transplant and dialysis units illustrated the utility of the organ and body systems model (Hoffart, 1989a). Peplau further asserted that specialists must be investigators ready to question and critique what they read; innovators ready to imagine, formulate, and test new approaches to problems; and thinkers able to formulate dynamic patterns rather than "play it safe." The analysis of data about early transplant nurses indicates their inquisitiveness and interest in learning. The technical aspects of transplant care coupled with challenges in providing emotional support and teaching patients required innovation. For example, the first nursing textbooks about patient teaching were not published until 1968 (Hoffart, 1989a), so it is unlikely the transplant nurses had materials to use as models in developing their teaching approaches. Strategies, such as the self-care unit that Andrews developed at MCV, indicate that these nurses came up with creative solutions to meet new patient and program needs.
Another advocate for strengthening clinical nursing practice was Francis Reiter, Dean of the Graduate School of Nursing at New York Medical Center (Reiter, 1966). She argued that clinical nursing competence required depth of understanding in three functions. The first was care using the basic sciences in providing the fundamentals to make patients comfortable. The second was cure tailoring care based on the principles and goals of treatment, clinical data, and medical science. The third was counseling -- emotional, intellectual, and psychological support through therapeutic use of self. In addition to these functions, she argued that another dimension of competency was required because of the increasing breadth of services available to patients. Reiter viewed nurse clinicians as responsible for coordinating the array of professional services for patient welfare, assuring continuity in care from shift to shift and from hospital to home, and collaborating with physicians when providing care.
The work of early kidney transplant nurses can be considered vis a vis the functions and responsibilities Reiter proposed. They carried out basic post-operative care. They cured by using new techniques, knowledge, and clinical data to help overcome rejection and complications of the therapy. They developed interpersonal relationships with patients to support them and teach them how to adapt to their life as transplant recipients. Relative to coordinating services, Bois et al. (1968) included a section in their article entitled, "Coordination of Care." Transplant social workers, however, not nurses, were responsible for helping patients transition to their home communities after discharge. They did note that if a visiting nurse was involved after discharge, transplant nurses would provide training for the nurse. Continuity of care was not addressed in the interviews or papers, but the long hospitalizations on small units may have allowed continuity of care to occur without deliberate planning. The emphasis on the use of flow sheets to follow patient status would have supported continuity. Finally, nurses spoke and wrote about their collaboration with physicians and other professionals.
In the Preface to "Nurses' Work: Issues Across Time and Place," Patricia D'Antonio explains that the historical study of clinical nursing practice can help us understand why nursing care took the form that it did, the reciprocity between assigned tasks and workplace values, common interests among nurses that sustain workplace culture, and the important role of patients in shaping the work of nurses (D'Antonio, Baer, Rinker, & Lynaugh, 2007). Sara Stevens concluded her presentation at the 1969 Dialysis Symposium for Nurses by stating, "The complexity and characteristics of clinical transplantation require the nurse to function on principles of nursing and not necessarily practiced habit" (Steven, 1969, p. 45). The analysis in this article has shown that evolving medical treatment for rejection was an influential factor in why early transplant nursing care took the form it did. Moreover, the participation of transplant nurses in new tasks and activities gave them a venue for learning, and in turn, led to refinements in care. Collegial relations among all members of the transplant team created a culture that sustained them in the face of the uncertainties of transplantation. Finally, transplant nurses interacted with courageous patients who agreed to be subjects in extreme experiments. Nurses sought ways to ease the patients' physical and emotional suffering. Indeed, early transplant nursing was not necessarily practiced habit.
To provide an overview of the development of kidney transplant nursing as a specialized area of practice.
1. Discuss early kidney transplant experiments pre-World War II and into the 1950s.
2. Describe how kidney transplantation evolved during the 1960s and beyond.
3. Identify key changes in post-transplant patient care over the last 60 years.
4. Outline significant events in transplant nursing as recalled by early transplant nurses.
Editor's Note: This article was originally published in the March/April 2009 issue of the Nephrology Nursing Journal.
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(1.) One of the most complete sources on the development of transplantation is Transplant: From Myth to Reality, by Nicholas L. Tilney (2003). In addition to providing an account of transplantation and transplantation biology, Tilney addressed the often skeptical and disapproving reactions to the innovation from the public and healthcare professionals.
(2.) Carrel was awarded the Nobel Prize in Medicine in 1912 for his work on transplantation and vascular suturing techniques that are still used today. His lecture is available at the Nobleprize.org Web site (http:// nobelprize.org/nobel_prizes/medicine/laureates/ 1912/index.html).
(3.) Peter Bent Brigham Hospital was a 250-bed hospital established in 1913 and affiliated with Harvard Medical School. Tilney (2003) characterized the hospital as one that "used each patient as a laboratory, gleaning as much physiological and pathological data as possible," yet due to its small size and some financial struggles was "an unlikely site for innovation and originality" (p. 51). Nonetheless, in 1942, when Dr. George Thorn became physician-in-chief, he steered his Brigham colleagues toward study and treatment of kidney disease, including laboratory work on transplantation in dogs. In 1980, Peter Bent Brigham Hospital merged with other Boston hospitals into what is now Brigham and Women's Hospital.
(4.) Murray shared the Nobel Prize in Medicine in 1990 with E. Donnell Thomas, who led the development of bone marrow transplantation. Murray's Nobel Lecture summarizes the many aspects of medicine and biology that came together to make transplant viable, outlining "three trails" that merged to create a successful transplant program at the Brigham. The lecture and a videotaped interview with Murray conducted in 2000 are available on the Nobleprize.org Web site (http://nobelprize.org/nobel_prizes/medicine/laureates/1990/index.html).
(5.) Transcript of press conference regarding kidney transplants, March 15, 1963. From Public Relations Department, Peter Bent Brigham Hospital (PBBH) Archives, box 8, folder 23, Boston, MA: Francis A. Countway Library of Medicine, Center for the History of Medicine, Harvard Medical School.
(6.) Dr. Willem Kolff developed the artificial kidney in The Netherlands in the 1940s and was invited to visit the Brigham in 1947. Under the leadership of Doctors Carl Walter and John Merrill, modifications were made to Kolff's artificial kidney, and they began using it to treat patients with severe renal failure. The June 1950, Brigham Bulletin, the hospital's newsletter, reported that in two years' time, the "rotating dialyzer" (reflecting its design) had been used 100 times and "has been the difference between life and death" by allowing nature time to heal the kidneys (PBBH Archives, box 8, folder 31). Yet, with no permanent access to the bloodstream, repeated dialysis for chronic renal failure was not available. Only after 1960, when Belding Scribner developed the external arteriovenous shunt as a means of repeated bloodstream access, was it possible to use the artificial kidney for ongoing dialysis (Quinton, Dillard, & Scribner, 1960). The Kolff-Brigham artificial kidney is shown in use in a 1951 film clip available at Voice Expeditions, Nephrology Oral History Project (http://www.voiceexpeditions.com/ index.php?id =273).
(7.) Although the patient and donor identities were not reported in early professional publications, they were identified by name and in photographs by the media before the transplant and in many later publications. Other patient names used in this paper have been published in prior reports.
(8.) Several years later, in response to a reporter's question, Murray stated that he had performed kidney transplants in over 800 dogs (transcript of press conference regarding kidney transplants, March 15, 1963. PBBH Archives, box 8, folder 23). The bibliography of his publications illustrates the extent of this research. He performed transplants in dogs, rabbits, and mice to determine the best location for placement of the grafted organ, means to assess functioning of transplanted kidneys, methods to preserve the graft before transplantation, indicators of graft rejection, and treatments for rejection (Murray, 2001, pp. 237-248). The research that Murray and many others performed in animals was crucial in the development of all types of organ transplantation.
(9.) Murray performed the transplant procedure. Dr. J. Hartwell Harrison, a urologist, performed the donor nephrectomy. In 1996, Joel Marvin Babb, a Boston art historian and painter, was commissioned to portray this historic event on canvas, using photos during the surgery as an aid. In a recent publication, Desai et al. (2007) identified all physician and nurse participants in the surgeries and provided information about their subsequent careers.
(10.) Ronald Herrick remains alive at this writing and has often shared his experience as a kidney donor through various media ("A brother's love saves a life, makes history," USAToday.com, December 19, 2004, http://www.usatoday.com/news/health/2004-12-19transplant_x.htm accessed 2/1/09; and the Best Fie Had to Offer: The Ron Herrick Story, by C.B. Herrick, Rockland, ME: TEA Printers and Publishers, 2004).
(11.) Interview with Clare (nee Burta) Herrick conducted by the author, December 17, 2008. Richard Herrick came back to Boston for frequent check-ups after he was discharged and visited Burta during those trips. They were married in 1955.
(12.) Although the article title references seven transplants, a note added as it went to press reported on an eighth.
(13.) Loose photo. PBBH Archives, box 26, folder 23.
(14.) "Free" kidneys were removed from living patients as part of a therapeutic procedure. A common source of free kidneys included children suffering from hydrocephalus. One treatment approach for these children was to remove a kidney, leaving the ureter so it could be used to create a lumboureteral shunt through which excess cerebrospinal fluid could be diverted to the urinary bladder (Rachel, 1999). The kidney transplanted into this patient was obtained through this procedure.
(15.) Triumph of the surgeon. Newsweek, April 27, 1959, p. 106.
(16.) Sterile Room Procedures, July, 1962, Medical College of Virginia, Hospital Division, Department of Nursing (personal collection of the author). The list of packs and supplies attests to the attention given to comprehensive planning: daily linen pack, bed pan pack, urinal pack, bath and shampoo pack, gown pack, half-gown pack, clean up basin pack, and oral hygiene pack. Supplies included carefully itemized laboratory supplies, needles, syringes, linen, dressings, gloves, instruments, and many pieces of equipment, such as stethoscope, thermometers, suction units, flow meters, medication jars, clamps, mops, scrub buckets, etc.
(17.) Research was also being conducted by sociologists on the sociological response and psychological adjustment of patients, families, and society-at-large to the human transplant enterprise. See Fox, R.C., & Swazey J.P. (1974). The courage to fail: A social view of organ transplants and dialysis. Chicago: University of Chicago Press.
(18.) The kidneys for this series came from 2 identical twins, 51 living related donors, 21 living non-related donors, and 3 cadaveric donors. Most interesting were the 6 xenografts in which kidneys from baboons were used; all of these transplants were unsuccessful (Starzl, 1964). Starzl was not the only surgeon to use simian kidneys for transplant. Hitchcock in Minneapolis conducted one and Reemtsma in New Orleans conducted six. All failed except for one of Reemtsma's efforts, in which a chimpanzee graft functioned for nine months (Tilney, 2003).
(19.) Interview with Michele Topor, conducted by the author, December 30, 2008. Topor worked at the Brigham transplant unit from 1966 to 1971; she then moved to Children's Hospital Medical Center, Boston, and served as the Nursing Co-Ordinator, Dialysis/ Transplant Program, 1971 to 1994.
(20.) Although the Brigham had been performing transplants since 1947, it wasn't until 1965 that a dedicated unit was established. In the hospital's employee newsletter, Murray explained that because of the program's growth, it had become difficult to manage such specialized medical and nursing care when patients were scattered on units throughout the hospital. A 9-bed unit was slated to open in early 1965; an Outpatient Transplant Clinic had already been opened to follow patients after discharge. Brigham Bulletin, vol. 10, no. 3, Fall 1964, PBBH Archives, box 8, folder 34.
(21.) Interview with Dorothy Shebelski, conducted by the author, April 14, 1986. Shebelski was head nurse of the Denver VA Hospital transplant unit from 1963 to 1965. American Nephrology Nurses' Association (ANNA) Oral History Project, 1986 to 1987, MC 7, School of Nursing, University of Pennsylvania, Secret lives we neber knew...Barbara Bates Center for the Study of the History of Nursing, Philadelphia, PA.
(22.) Interview with Kay Andrews conducted by author, April 8, 1986. Andrews was Clinical Transplant Center Supervisor, Medical College of Virginia Hospital, Richmond, 1963 to 1968. ANNA Oral History Project.
(23.) Because there were few transplant centers in the 1960s, patients seeking transplant travelled great distances. The Denver VA was the first VA Hospital to offer kidney transplantation, and Shebelski recalled having patients from states across the country. Andrews and Topor recalled serving patients from across the country as well as international patients.
(24.) The 10-bed self-care unit was located in a former nursing dormitory. Andrews managed the unit and hired house mothers to be the staff presence. Patients were on a self-medication program, ate in a hospital cafeteria, and reported to the transplant unit for blood tests, etc. Andrews made daily rounds to the self-care unit with the physician team, and transplant unit nurses responded to calls for help from the house mother.
(25.) The spleen and thymus are part of the lymph system, so splenectomies and thoracic duct drainage (cannulation of the thoracic duct located in the neck which drained lymph fluid) were performed as means of lessening the presence of immunologically competent lymphocytes. Anti-lymphocyte serum involved inoculating animals (often horses) with human lymphocytes, later harvesting antibodies the animal produced against the foreign cells, then concentrating and purifying these antibodies so they could be administered to human transplant recipients. Radiation aimed at the transplanted kidney was typically used to treat acute rejection. Some centers irradiated blood that was circulating through an extracorporeal circuit. The aim of both approaches was to destroy lymphocytes associated with rejection. The theory behind the use of typhoid antigen was known as antigen competition; it was based on the hypothesis that the body's powerful response to the typhoid bacterium would lessen its response to the transplanted organ and spare the kidney from rejection. Most of these approaches were relatively short-lived but advanced understanding of the immune system (Tilney, 2003).
(26.) Interview with Amy Chang, conducted by the author, January 20, 2009. Chang worked as staff nurse and clinical specialist at the Brigham transplant program from 1970 to 1995.
(27.) Dialysis Symposium, Brigham Bulletin, vol. 11, #2, Winter, 1966. PBBH Archives, box 8, folder 34.
(28.) The other 9 models were area of practice, age of client, degree of illness, length of illness, nurse activities, fields of knowledge, subroles of the work role of staff nurse, professional goal, and clinical services.
Nancy Hoffart, PhD, RN, is a Professor, School of Nursing, Northeastern University, Boston, MA, and a member of ANNA's Mass Bay Chapter. Her interest in the history of nephrology nursing dates to the mid-1980s when she first wrote about the emergence of the nephrology nursing specialty.
Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 587.
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|Title Annotation:||Continuing Nursing Education|
|Publication:||Nephrology Nursing Journal|
|Date:||Nov 1, 2014|
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