Abstract
In New Zealand, and globally, the incidence of patients developing chronic kidney disease and entering the pre-dialysis phase is increasing at approximately 6% per year. The specialist pre-dialysis nurse plays a key role in providing care to this complex group of chronically ill people, but as yet no literature indicates what constitutes effective pre-dialysis nursing care. This paper reports on qualitative research that asked a group of New Zealand specialist renal nurses what they believed comprised effective pre-dialysis nursing care. Semi-structured phone interviews were undertaken with eleven pre-dialysis nurses from throughout the country. Through inductive analysis a number of key themes were identified. These were; a strong nurse patient relationship, a comprehensive holistic nursing assessment and timely and appropriate patient education. Commonly used measurable indicators, timely initiation of dialysis and formation of dialysis access prior to treatment, were also considered important but essentially seen as out of the nurse’s control. We argue that to ensure pre-dialysis care is effective it is important to not only measure quantifiable parameters but also consider the qualitative elements identified as being at the heart of effective pre-dialysis nursing practice.

Keywords
Pre-dialysis nursing, effective care, qualitative research, nurses’ perceptions

Introduction
In New Zealand the incidence of patients entering renal failure programmes is increasing at a rate of 6% per annum. In 2008, 492 patients commenced renal replacement therapy, a rate of 115 per million population (Australia and New Zealand Dialysis and Transplant Registry, 2009). Patients with chronic kidney disease (CKD) who are expected to progress to end stage renal failure are classified as pre-dialysis. They need a high level of educational, social, psychological and emotional support in order to prepare them for this transition and often have a number of complex needs and complications which influence their care (Crowley, 2003). Although there is no New Zealand literature on this topic, international literature demonstrates that multi-disciplinary pre-dialysis care and education are effective in extending time to dialysis as well as improving quality of life, clinical outcomes and patient acceptance and treatment choice (Devins, Mendelssohn, Barre, & Binik, 2003; Devins, Mendelssohn, Barre, Taub, & Binik, 2005; Levin, Lewis, Mortiboy, Faber, Hare, Porter et al., 1997; Levin, 2003; White, Pilkey, Lam, & Holland, 2002). In New Zealand an estimated 350,000 people are classified ........................