What Percentage Of RN Staff In Hemodialysis Units
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 133
Almost 500,000 persons with end stage renal disease (ESRD) in the United States receive hemodialysis as a renal replacement therapy, with 98% receiving their hemodialysis in outpatient dialysis facilities (United States Renal Data System [USRDS], 2019). Even though hemodialysis has transformed from an extraordinary to a commonplace procedure over the past 50 years, hemodial- ysis centers can be uniquely hazardous for patients (Garrick et al., 2012; Holley, 2010). Hemodialysis treat- ment facilities are complex and involve multiple care providers, advanced technologies, and multiple patients with extensive comorbidities. Water quality, dialyzer reuse, infection control, intradialytic hypotension, vascular access complications, medication errors, and miscommunications among staff members and with patients are examples of potential safety risk areas in hemodialysis units (Kliger, 2015). Patient safety is an important foundation of high- quality care, and fostering a culture of safety in hemodial- ysis units is an essential requirement for minimizing patient risks for harm, preventing or reducing errors, and improv- ing the quality of care rendered. According to the Agency for Healthcare Research and Quality (AHRQ) (2019), a culture of safety is a commitment at all levels of the organ- ization, from frontline providers to managers and execu- tives, to minimize adverse patient events in the face of inherently complex and potentially hazardous procedures, such as hemodialysis treatments.
Copyright 2020 American Nephrology Nurses Association. Thomas-Hawkins, C., Flynn, L., & Dillon, J. (2020). Registered
nurse staffing, workload, and nursing care left undone, and their relationships to patient safety in hemodialysis units. Nephrology Nursing Journal, 47(2), 133-142. https://doi.org/10.37526/1526-744X.2020.47.2.133
Patient safety is an important foundation of high-quality care. Yet little is known regarding the effects of nursing indicators on patient safety in dialysis units. The purpose of this study was to examine interrelationships among regis- tered nurse (RN) staffing, workload, nursing care left undone, and patient safety outcomes in hemodialysis set- tings. The sample consisted of 104 staff nurses who worked in hemodialysis facilities and completed a mailed survey. Low RN staffing, high RN workloads, and RN nurs- ing care left undone were significantly associated with unsafe patient shift change periods and low safety ratings. Care left undone was an indirect pathway through which low RN staffing and high workloads impacted safety. Patient safety in hemodialysis units can be enhanced by ensuring adequate RN staffing and reasonable RN work- loads, as well as redesigning responsibilities so RNs can complete necessary care activities.
Key Words: Hemodialysis, nurse staffing, nurse workload, missed care, patient safety.
Charlotte Thomas-Hawkins, PhD, RN, FAAN, is an Associate Professor and Interim Associate Dean, Nursing Science Division, Rutgers University School of Nursing, New Brunswick, NJ, and a member of ANNA’s South Jersey Chapter. Linda Flynn, PhD, RN, FAAN, is Interim Dean and Professor, Rutgers University School of Nursing, New Brunswick, NJ. Jennifer Dillon, MPA, RN-BC, is a PhD Candidate, Rutgers University School of Nursing, New Brunswick, NJ. Acknowledgment of Funding: This study was funded by an American Nephrology Nurses Association Research Grant. Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity. Note: Additional statements of disclosure and instructions for CNE eval- uation can be found on page 143.
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units Charlotte Thomas-Hawkins, PhD, RN, FAAN, Linda Flynn, PhD, RN, FAAN, and Jennifer Dillon, MPA, RN-BC
1.4 contact hours
N e p h r o l o g y N u r s i N g J o u r N a l
Two key indicators of patient safety culture within an organization are 1) patient transitions within and across health care settings, and 2) health care employees’ overall perceptions of patient safety in their work setting (AHRQ, 2019; The Joint Commission [TJC], 2012). Effective patient transitions are characterized by interactive communication, up-to-date accurate information, limited interruptions, a process for verification, and an opportunity to review any relevant patient data (TJC, 2012). Ineffective patient transi- tions, however, are common and have been linked with
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2134
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
adverse patient events (Mardon et al., 2010) and unsafe work environments (Lee et al., 2016). Patient turnover peri- ods in hemodialysis settings, usually referred to as patient shift changes, are common patient transition periods that occur multiple times per day in a single hemodialysis unit. During these turnover periods, cohorts of patients concur- rently transition in and out of the hemodialysis unit before or after their treatments. The goal of a successful patient shift change is to safely terminate hemodialysis treatments for a group of patients while simultaneously safely initiat- ing treatment for the next shift of incoming patients. Patient turnover periods in hemodialysis facilities provide ample opportunity for misinformation, miscommunica- tion, and error. Notably, a previous analysis of patient shift change safety in outpatient hemodialysis settings revealed that only 39% of nurses rated these patient transition peri- ods as safe, and unsafe patient shift change ratings by nurs- es were associated with a higher likelihood of adverse patient events (Thomas-Hawkins & Flynn, 2015).
Employees’ overall perceptions of patient safety in their workplace is an important measure of the extent to which workers perceive the organization’s culture supports and promotes patient safety (AHRQ, 2019). Importantly, an emerging body of research indicates that employees’ nega- tive ratings of patient safety in their hospitals are associated with adverse patient events, such as medication errors, hos- pital-acquired pressure ulcers, and patient dissatisfaction with care (DiCuccio, 2015). In hemodialysis settings, most registered nurses (RNs) rate patient safety on their units as very good to excellent (Thomas-Hawkins & Flynn, 2015; Ulrich & Kear, 2015, 2018). On the other hand, negative ratings by nurses of patient safety in outpatient hemodialy- sis units are associated with a higher likelihood of nurse- reported adverse patient events, such as medication errors, skipped hemodialysis treatments by patients, and vascular access infections (Thomas-Hawkins & Flynn, 2015). As frontline caregivers, RNs play a critical role in patient safe- ty through their ongoing surveillance and monitoring of patients, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing numerous other tasks to ensure high-qual- ity patient care (AHRQ, 2019). Given the current attention on patient safety and quality of care in health care, it is important to gain an understanding of nursing factors asso- ciated with patient safety in hemodialysis settings.
The Nursing Organizations and Outcomes Model pos- tulates that organizational factors, such as RN staffing, RN workload, and the adequacy of nursing care processes, fre- quently operationalized as nursing care left undone, affect not only patient and nurse outcomes, but also organiza- tional outcomes, such as patient safety (Aiken et al., 2002). According to the model, high RN staffing and lower RN workloads facilitate high-quality nursing care processes and enhance positive organizational outcomes. The model also stipulates that the effect of RN staffing and workload on outcomes is direct as well as indirect through their effects on nurses’ ability to adequately complete essential
nursing care. Findings from nurse and patient outcomes studies in outpatient hemodialysis units support the model in that low RN staffing, high RN workloads, and nursing care left undone were significantly associated with nurse burnout and intent to leave (Flynn et al., 2009) and nurse- reported adverse patient events (Thomas-Hawkins et al., 2008). However, little is known regarding the impact of nurse staffing, workload, and nursing care left undone on the state of patient safety in hemodialysis units.
Study Purpose The purpose of this study was to examine the complex
interrelationships among RN staffing, RN workload, nurs- ing care left undone, and patient safety outcomes including patient shift change safety and overall patient safety ratings. The study was designed to address the following research questions: 1. What percentage of RN staff in hemodialysis units
report positive ratings of a) patient shift change safety and b) overall patient safety?
2. What are unadjusted and adjusted effects of RN staffing, RN workload, and nursing care left undone on nurses’ ratings of patient shift change safety in hemodialysis units?
3. What are unadjusted and adjusted effects of RN staffing, RN workload, and nursing care left undone on RNs’ ratings of overall patient safety in hemodialysis units?
4. Does nursing care left undone mediate the relationship between RN staffing and workload and RNs’ ratings of patient safety outcomes in hemodialysis units?
Design and Methods To ensure the protection of participants, this study,
employing a cross-sectional, correlational design, was approved by Rutgers University’s Institutional Review Board prior to data collection. Because RNs are reliable informants regarding hemodialysis unit staffing, nurse workload, and the care they leave undone, the use of nurse survey data has become a key methodological approach in nursing outcome studies (Aiken et al., 2008). Con – sequently, a mailing list of 800 RNs who identified them- selves as nurses in nephrology settings was obtained from the state Board of Nursing in a southern state, and a second mailing list of 400 nephrology nurses was obtained from the United Nurses Association in a western state. A survey packet was mailed to their homes in accordance with a Dillman survey method (Dillman et al., 2014), and follow- up reminders were mailed at scheduled intervals.
Sample Of the 160 nurses with valid responses to the mailed
survey, 104 identified themselves as staff RNs who worked in hemodialysis settings and therefore comprised the ana- lytic sample for this study. Using a moderate effect size (f 2
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 135
= 0.15), power analysis indicated that the sample size for this analysis would yield sufficient power (0.80) at a signif- icance level of less than 0.05 to detect the true effects of the RN staffing, workload, and nursing care left undone on the two patient safety outcomes examined in this study (Cohen, 1988). Demographics of the study sample are pre- sented in Table 1.
Measures Patient safety outcomes. Two scales of the Hospital
Survey on Patient Safety Culture (HSOPS) (Sorra & Nieva, 2014) were used to measure the two patient safety out- comes in this study. The 4-item Handoff and Transitions Scale of the HSOPS was used to measure nurses’ ratings of patient transitions safety during a patient shift change in hemodialysis units. A slight modification was made to the wording of each scale item. The wording “when trans- ferred to another unit” or “shift change” in scale items was replaced with “during patient shift change” to reflect the time of patient transitions in hemodialysis units. Nurses are
asked to rate their level of agreement or disagreement with each item on a scale of 1 = strongly agree to 5 = strongly disagree; higher scores indicate higher ratings of safe patient transitions. The modified scale has been tested in a previous sample of nurses who worked in hemodialysis units, and the alpha reliability for the scale was 0.91 (Thomas-Hawkins & Flynn, 2015). Alpha reliability for the scale in this study was 0.89. A mean score was computed with a possible range from 1 to 5; higher scores reflected higher levels of patient shift change safety.
The patient safety grade single-item rating on the HSOPS (Sorra & Nieva, 2014) was used to measure nurses’ ratings for overall patient safety in their hemodialysis units. Nurses were asked to give their hemodialysis unit a grade on patient safety on a 5-point scale ranging from A = 1 to F = 5. Prior to data analysis, patient safety grade ratings were reverse coded so higher scores reflected higher over- all patient safety ratings by respondents.
RN staffing. RN staffing was measured as nurses’ responses to several items developed and tested in a previ-
Table 1 Sample Demographics (n = 104)
Mean SD
Age (years) 47.6 11.7 Years in current position 6.5 6.2 Years working for current employer 7.1 5.6 Years in nephrology nursing 11.6 7.6
n %
Gender
Female 84 80.8 Male 20 19.2
Race African American/Black 22 21.2 Asian/Pacific Islander 15 14.3 Hispanic 1 1.0 White/Caucasian 61 58.7 Other 4 3.8 Not reported 1 1.0
Nursing Education
Diploma 7 6.7 Associate degree 47 45.2 Baccalaureate degree 40 38.5 Masters degree 9 8.6 Not reported 1 1.0
Unit Type
Chronic hemodialysis unit 84 80.8 Acute hemodialysis unit 20 19.2
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2136
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
ous sample of RNs working in hemodialysis units and used to calculate patient-to-RN ratios (Thomas-Hawkins et al., 2008).
Workload. Recognizing that RNs’ workloads are influ- enced by more than patient ratios, overall RN workload was measured by the 5-item workload subscale of the Individual Workload Perception Scale (Cox et al., 2006). Acceptable psychometric properties of the scale and sub- scales have been established in multiple samples of nurses (Cox et al., 2006). On a 4-point summated rating scale rang- ing from (1) strongly disagree to (4) strongly agree, RNs were asked to rate the extent to which they agreed that the statement reflected their workload conditions. Scores can
range from 5 to 20, with higher scores indicating higher workloads. Sample items include “my workload will cause me to look for a new position” and “my workload has caused me to miss important changes in my patients’ con- ditions.” In the current study, an internal consistency relia- bility coefficient of 0.71 reflected good reliability of the measure in the analytic sample and compares favorably with a published alpha of 0.78. in a previous study of RNs who worked in hemodialysis units (Flynn et al., 2009).
Nursing care left undone. Care left undone was meas- ured using a series of innovative survey items developed and tested in United States and international health care set- tings (Aiken et al., 2001; Ausserhofer et al., 2014; Liu et al.,
Table 2 Descriptive Statistics for Study Variables
Handoffs and Transitions Safety Items Percentage of Sample Who Disagreed (Positive Response) with Scale Item
Things fall between the cracks during patient shift change 27.0% Important patient care information is often lost during patient shift change
31.7%
Patient shift change are often problematic for patients in this hemodialysis unit
35.6%
Problems often occur in the exchange of information during patient shift changes
39.4%
Mean Composite Score (Percent of Sample with Positive Response)
Overall handoffs and transitions safety 33% M (SD) Handoffs and transitions safety score 2.95 (0.97)
Safety Grade Percentage of Respondents
F (Failing) 3.8% D (Poor) 4.8% C (Acceptable) 19.2% B (Very Good) 51.0% A (Excellent) 21.2%
Mean Composite Score (Percent of Sample with Positive Responses)
Overall patient safety 72.2% M (SD) Safety Grade score 3.83 (.92)
Predictor Variables M (SD)
Patient-to-RN ratios 11.4 (8.02) Workload 11.7 (2.71) Nursing care left undone 2.08 (2.00)
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 137
2018). RNs were asked to indicate from a list of seven key nursing care activities which, if any, were necessary but left undone during their last full day of work because they did not have the time to complete them. Higher scores reflect a higher number of nursing care activities that were left undone. The original survey items were reworded slightly to reflect a hemodialysis setting, and construct validity has been demonstrated in a sample of RNs in outpatient hemodialysis units (Thomas-Hawkins et al., 2008).
Data analysis plan. Frequency distributions and descriptive statistics for study variables were computed and examined. Two unadjusted and adjusted linear regression models were estimated to determine the individual and independent effects of patient-to-RN ratios, RN workload, and the number of nursing care activities left undone on each of the two patient safety outcomes examined in this study (i.e., patient shift change safety and RN overall patient safety grade ratings). In the unadjusted models, the three predictors were entered individually. In the adjusted models, all predictors were entered simultaneously. To examine the role of nursing care left undone as a mediator, a series of four ordinary least squares regression analyses were conducted to estimate indirect effects of patient-to-RN ratios and RN workload on patient shift change safety and patient safety grade outcomes (Hayes, 2018). For each sim- ple mediation model, bias-corrected 95% confidence inter- vals using 10,000 bootstrap samples were examined for indirect effects that were statistically significant from zero (i.e., the confidence interval did not include a zero). Nursing care left undone was determined as a mediator of the effects of patient-to-RN ratios and RN workload on patient safety outcomes if the bias-corrected 95% confi- dence interval for indirect effects did not include zero (Hayes, 2018).
Results Descriptive statistics were computed for all study vari-
ables. Nurses’ responses to the four items on the Handoffs and Transitions Scale reflected overall poor patient shift change safety ratings by a majority of participants, as shown in Table 2. Only 34% of RN participants positively endorsed safe patient transitions during a patient shift change in their hemodialysis units. On the other hand, most RNs (72%) positively rated overall patient safety in their hemodialysis unit as either very good or excellent (see Table 2). Patient-to-RN ratios ranged from 1 to 48 (M = 11.04, SD = 8.02), and one out of four nurses (25%) report- ed that they were assigned to more than 12 patients concur- rently on the last day they worked (see Figure 1). RN work- load scores ranged from 5 to 18 (M = 11.7, SD = 2.7), and 40% of nurses reported a workload score of 13 or higher, reflecting moderate to high workloads (see Figure 2). The number of nursing care activities that nurses reported left undone on their last day worked ranged from 0 to 7 (M = 2.07, SD = 2.0), and 34% of nurses reported three or more care activities left undone (see Figure 3). Lastly, there were
no associations between demographic variables and out- come variables of patient transition safety and patient safety grade ratings.
Results of regression analyses for both patient safety out- comes are summarized in Table 3, indicating the unadjust- ed and adjusted linear effects of patient-to-RN ratios, RN workload, and the number of nursing care activities left undone on nurses’ ratings of patient shift change safety and overall patient safety in their hemodialysis units. In the unadjusted models, all three predictors had significant neg- ative effects on both safety outcomes, and a high number of nursing care activities left undone had the largest unadjust- ed negative effect on nurses’ ratings on both patient shift change safety and patient safety grade ratings.
As presented in Table 3, when estimating the adjusted effects of the predictor variables on patient shift change safe- ty, controlling for the effects of the other predictor variables in the model, the significant negative effects of all predictors on RNs’ ratings of patient shift change safety persisted in the adjusted model. Findings in this model indicate that 1) for every one-patient increase in the nurses’ assignment (i.e., patient-to-RN ratio) on the last day worked, patient shift change safety scores decreased by 5%; 2) for every one-unit increase in respondents’ workload scores, patient shift change safety scores decreased by 5.4%; and 3) for every one-unit increase in the number of nursing care activities left undone, respondents’ ratings of patient shift change safety decreased by 5.4%. The three predictors accounted for 33% of the variance in patient shift change safety.
On the other hand, the second adjusted model revealed the independent effects of patient-to-RN ratios, and RN workload on patient safety grade ratings were no longer sig- nificant when the effects of all predictors on this outcome were controlled for (see Table 3). However, the significant negative effect of nursing care left undone on patient safety grade ratings persisted in the adjusted model, indicating that for every one-unit increase in the number of tasks left undone, respondents’ safety grade ratings decreased by 6.4%. In this adjusted model, the three predictors accounted for 20% of the variance in patient safety grade ratings.
Four simple mediation models were examined to deter- mine any indirect effects of patient-to-RN ratios and RN workload on the two patient safety outcomes through their effects on the hypothesized mediator, nursing care left undone. In all mediation models, bias-corrected 95% con- fidence intervals, using 10,000 bootstrap samples, for the indirect effect of the two predictors on the safety outcomes through their effects on nursing care left undone were
High patient-to-RN ratios, high RN work- loads, and inadequate care processes were directly or indirectly associated with safety outcomes in hemodialysis facilities.
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2138
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
Figure 1 Distribution of Patient-to-RN Ratios (n = 104)
Figure 2 RN Workload Scores (n = 104)
Figure 3 Percent of RNs with Nursing Care Left Undone on Last Day Worked (n = 104)
P e
rc e
n t
o f
R N
s
50% 45% 40% 35% 30% 25% 20% 15% 10% 5%
0 < 4 5 to 9 10 to 12 > 12
Number of Patients per RN
P e rc
e n
t o
f R
N s
50% 45% 40% 35% 30% 25% 20% 15% 10% 5%
0 Lowest
through 8 9 to 10 11 to 12 13 and higher
Nurses’ Workload Score (ranged from 1 to 18)
P e
rc e n
t o
f R
N s
50% 45% 40% 35% 30% 25% 20% 15% 10% 5%
0 None 1 to 2 3 or More
Number of Nursing Care Activities Left Undone
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 139
examined. Results of mediation testing are presented in Table 4. The bias-corrected 95% confidence intervals for the indirect effect of patient-to-RN ratios and RN workload on patient shift safety were entirely below zero, indicating a significant, negative indirect effect of high patient-to-RN ratios and high workloads on this outcome through their negative effects on the number of nursing care activities left undone. Similarly, mediation analysis also revealed the bias-corrected 95% confidence intervals for the indirect effects of high patient-to-RN ratios and high RN workload on respondents’ patient safety grade ratings were also below zero, reflecting a significant, negative indirect effect of the predictors on patient safety grade ratings through their negative effects on nursing care left undone. Thus, a high number of care activities left undone was an operant mechanism, or pathway for negative effects of high patient- to-RN ratios and high RN workloads on the patient safety outcomes examined in this study.
Discussion Research in hospital settings has shown that safe patient
handoffs and transitions across inpatient units or during staff shift changes within patient units can facilitate positive patient outcomes and the reduction of adverse patient events (Mardon et al., 2010). Yet evidence demonstrates persistent problems in health care quality, such as adverse events and hospital readmissions, experienced by patients undergoing ineffective transitions across sites of care, such as primary care to specialty care or hospital to sub-acute care (TJC, 2012). Patient transitions during a patient shift change in hemodialysis units is a unique type of care tran- sition that occurs within a hemodialysis unit multiple times a day, and these patient turnover periods have a high potential for interruptions of care, miscommunication, and error. Findings from this study revealed only 34% of nurses rated patient shift change periods in hemodialysis units as
Table 3 Unadjusted and Adjusted Effects of RN-to-Patient Ratios, RN Workload,
and Nursing Care Left Undone on Patient Safety Outcomes
Patient Transition Safety Patient Safety Grade
Nursing Indicator
Unadjusted Model
β Coefficient
Adjusted Model
β Coefficient
Unadjusted Model
β Coefficient
Adjusted Model
β Coefficient
Patient-to-RN ratio -0.419*** R2 = 0.33 -0.245**
-0.332*** R2 = 0.20 -0.181NS
RN workload -0.441*** -0.271** -0.261** -0.084NS
Nursing care left undone -0.481*** -0.268** -0.429*** -.320**
Note: NS = non-significant. *p ≤ 0.05. **p ≤ 0.01. ***p ≤ 0.001.
Table 4 Mediating Effects of Nursing Care Left Undone on Relationships Between
Predictors and Patient Safety Outcomes
Patient Shift Change Safety Patient Safety Grade
Effect
95% Bias-Corrected Confidence Interval
Effect Size
95% Bias-Corrected Confidence Interval
Patient-to-RN ratio Indirect effect
-0.1768
-0.3155 to -0.0588
-0.1584
-0.2682 to -0.0658
RN workload Indirect effect
-0.1597
-0.2906 to -0.0511
-0.1846
-0.2998 to -0.0898
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2140
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
safe. Surprisingly, these findings do not differ from our pre- vious study in which only 39% of nurses in outpatient hemodialysis settings rated patient shift change periods as safe (Thomas-Hawkins & Flynn, 2015). Yet there was a striking difference in RNs’ perceptions of safety during the specific period of a patient shift change in their hemodial- ysis units compared to their overall perceptions of safety policies, procedures, and practices in their workplace, as reflected in their safety grade ratings. Specifically, in con- trast to the low percentage of RNs who reported safe patient transitions in their hemodialysis units, 72% of RNs graded overall patient safety in their hemodialysis units as very good or excellent, a finding consistent with our previ- ous work (Thomas-Hawkins & Flynn, 2015). These differ- ences in staff perceptions of certain aspects of patient safety in the workplace also exist in acute care hospital settings. Data from the AHRQ 2016 comparative database of 680 U.S. hospitals (Famolaro et al., 2016) reveal that while only 48% of hospital staff positively endorsed safe handoffs and transitions, 76% of staff graded overall safety in their work- place as excellent or very good. Thus, our findings under- score the multidimensional nature of safety culture in hemodialysis settings and the need for broad safety assess- ments and targeted interventions. In short, evidence indi- cates that some aspects of safety can be very good or excel- lent, while other aspects may require attention and improvement.
As RNs’ contributions to patient safety in clinical set- tings are increasingly quantified, it has become even more apparent that a sufficient supply of RNs in all areas of prac- tice, including hemodialysis units, is essential to ensuring quality and safe patient care. Nearly 25% of RNs in the sample reported they cared for 12 or more patients at one time on their last day worked. Moreover, 40% of partici- pants had a workload score of 13 or greater, indicating a high workload. RN workload in this study was conceptual- ized differently from RN staffing (e.g., number of patients per nurse). Workload represented the extent to which pres- sure and urgency dominate the work environment and is reflected in the ability of RNs to monitor changes in patient status and take a meal break (Cox et al., 2006). Therefore, RN workload can be high despite differences in the num- ber of patients assigned to a nurse. In fact, while patient-to- RN ratios and workload were related to each other in this study (see Table 5), the low magnitude of the correlation supports the premise that RN staffing and workload are distinct from one another in hemodialysis settings.
In this study, high patient-to-RN ratios and high work- loads were independent contributors to RNs’ ratings of unsafe patient shift change periods in hemodialysis units. Based on these findings, increases in RN staffing, as well as reductions in their workload, are likely key factors in improving safety during the demanding and busy patient shift change periods in hemodialysis units.
Consistent with the premises of the Nursing Organi – zations and Outcomes Model, inadequate nursing care processes, or nursing care left undone, was an important predictor of safety outcomes in this study. One out of three RN participants (34%) in the study reported leaving three or more nursing care tasks undone on their last day worked. The percentage of RNs who left each of the seven nursing care task items undone on their last day worked is listed in Table 6. Notably, the prevalence of necessary nurs- ing care left undone in this study is consistent with nurse reports in our previous work in outpatient hemodialysis units (Thomas-Hawkins et al., 2008). Before and after
Table 5 Correlations Among RN Predictor Variables
RN Workload
Nursing Care Left Undone
Patient-to-RN ratio 0.239* 0.410** Workload 0.418**
*p < 0.01. **p < 0.001.
Table 6 Percent of RNs Who Missed Essential Nursing Care Processes on Their Last Day Worked
Essential Nursing Care Process
Percentage of Sample Who Reported Nursing Care Left Undone on Last Day Worked
Adequate patient surveillance 23%
Teach/counsel patients and family 53%
Comfort/talk with patients 34%
Coordinate patient care 18%
Document nursing care in the medical record 20%
Adequate supervision of patient care technicians 33%
Adequate monitoring of dialysis treatments 23%
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 141
adjusting for the effects of high patient-to-RN ratios and high workloads, regression models revealed that a high number of care activities left undone was an independent predictor of RNs’ negative ratings of patient shift change safety and the single greatest contributor to nurses’ nega- tive safety grades in their units. RNs in hemodialysis units strive to provide quality care, and when they are so busy that they do not have time to complete important patient care activities, there is an increased likelihood that these RNs perceive a lower level of patient safety in their work- place. Additionally, the independent association of care left undone by nurses and patient safety outcomes in this study is consistent with a growing body of hospital-based research that links missed care with lower patient safety rat- ings. Our findings underscore the premise that care left undone, considered an error of omission (Kalisch, 2015), is just as important for patient safety as errors of commission in hemodialysis settings (Ball & Griffith, 2018).
An important finding in this study is the mediating role of tasks left undone in relationships between high patient- to-RN ratios, high RN workloads, and safety outcomes examined in this study. The mediation models revealed that while high patient-to-RN ratios and workloads had a direct and independent effect on patient shift change safe- ty, these nursing indicators also had an indirect effect on this safety outcome through their negative effects on nurs- es’ ability to complete key nursing care activities. Moreover, while high patient-to-RN ratios and workloads did not have a direct effect on nurses’ patient safety grade ratings, mediation analysis revealed they had an indirect effect on safety grade ratings through their negative effects on nurses’ ability to complete necessary nursing care. These findings indicate that nursing care activities left undone is an operant mechanism or pathway that explains, in part, how high patient-to-RN ratios and RN workloads affect safety outcomes in outpatient hemodialysis centers. Based on these findings, improving RN staffing and reduc- tions in nurses’ workloads should be a key initiative in hemodialysis facilities’ efforts to improve patient safety overall and during the patient shift change periods. Findings also indicate that improvements in patient safety in outpatient hemodialysis units require that hemodialysis organizations maximize the capacity for nursing care to be delivered by identifying the array of activities in which RNs in hemodialysis units engage, ascertaining activities that are best accomplished by an RN, and reassigning remaining tasks to more appropriate personnel, freeing RNs to concentrate on patient care.
Overall, our study findings support relationships pro- posed by the Nursing Organizations and Outcomes Model. High patient-to-RN ratios, high RN workloads, and inadequate care processes were directly or indirectly associated with safety outcomes in hemodialysis facilities. These findings have vital implications for administrators of hemodialysis organizations concerned about patient safety outcomes in their hemodialysis facilities.
Limitations This study has several limitations worth noting. The
study was limited to RNs who work in hemodialysis facili- ties in only two states, thus limiting our generalizability of findings to the U.S. population of nurses who work in out- patient hemodialysis facilities. Secondly, the response rate to the mailed survey was low, despite repeated mailings and reminders. Several potential participants noted on uncompleted returned surveys that their employer would not allow them to complete the survey. Inasmuch as staff RNs are reliable informants about their staffing levels, workloads, and adequacy of care processes because of their close proximity to patients and knowledge of their working conditions, a reluctance on the part of RNs who work in hemodialysis facilities to respond to the type of survey administered in this study may constrain future efforts by researchers to employ key methodological features designed to link nursing indicators in hemodialysis units, as reported by nurses, to quality outcomes in these settings. Other data collection methods may need to be considered for future studies.
Conclusion According to these findings, high patient-to-RN
staffing, high RN workloads, and nursing care left undone are key contributors to unsafe patient shift change periods and lower overall safety ratings in hemodialysis facilities. Findings from this study indicate that these patient safety outcomes can be enhanced by ensuring adequate RN staffing and reasonable workloads, as well as redesigning responsibilities so nurses have time to complete necessary and important care activities. By ensuring that RNs have the human resources and time that allow them to provide quality patient care, hemodialysis providers will enhance patient safety in their dialysis facilities.
References Agency for Healthcare Research and Quality (AHRQ). (2019).
Nursing and patient safety. Patient Safety Network. https://psnet.ahrq.gov/primers/primer/22/nursing-and- patient-safety.
Aiken, L.H., Clarke, S.P., & Sloane, D.M. (2002). Hospital staffing, organization, and quality of care: Cross-national findings. Nursing Outlook, 50(5), 187-194. https://doi.org/ 10.1067/mno.2002.126696
One out of three RN participants (34%) in the study reported leaving three or more nursing care tasks undone on their last day worked.
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2142
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
Aiken, L.H., Clarke, S.P., & Sloane, D.M., Lake, E.T., & Cheney.T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. The Journal of Nursing Administration, 38(5), 223-229. https://doi.org/10.1097/ 01.NNA.0000312773.42352.d7
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M., & Shamian, J. (2001). Nurses’ reports on hospital care in five countries. Health Affairs, 20(3), 43-53.
Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S., Rafferty, A.M., Ball, J., Scott, A., Kinnunen, J., Heinen, M., Sjetne, I.S., Moreno-Casbas, T., Kózka, M., Lindqvist, R., Diomidous, M., Bruyneel, L., Sermeus, W., Aiken, L.H., & Schwendimann, R. (2014). Prevalence, patterns and predic- tors of nursing care left undone in European hospitals: Results from the multicountry cross-sectional RN4CAST study. BMJ Quality and Safety, 23(2), 126-135. https://doi. org/10.1136/bmjqs-2013-002318
Ball, J.B., & Griffiths, P. (2018). Missed nursing care: A key meas- ure for patient safety. Perspectives on Patient Safety. https://psnet.ahrq.gov/perspective/missed-nursing-care- key-measure-patient-safety
Cohen, J. (1988). Statistical power analysis for behavioral sciences (2nd ed.). Lawrence Erlbaum Associates.
Cox, K.S., Teasley, S.L., Zeller, R.A., Lacey, S.R., Parsons, L., Carroll, C.A., & Ward-Smith, P. (2006). Know staff’s ‘intent to stay’. Nursing Management, 37(1), 13-15.
DiCuccio, M.H. (2015). The relationship between patient safety culture and patient outcomes: A systematic review. Journal of Patient Safety, 11(3), 135-142. https://doi.org/10.1097/PTS. 0000000000000058
Dillman, D.A., Smyth, J.D., & Christian, L.M. (2014). Internet, phone, mail, and mixed-mode surveys. The Tailored Design Method (4th ed.). Wiley, Inc.
Famolaro, T., Yount, N.D., Burns, W., Flashner, E., Liu, H., & Sorra, J. (2016). Hospital Survey on Patient Safety Culture 2016 user comparative database report. https://www.ahrq.gov/ sites/default/files/wysiwyg/professionals/quality-patient- safety/patientsafetyculture/hospital/2016/2016_hospital- sops_report_pt1.pdf
Flynn, L., Thomas-Hawkins, C., & Clarke, S.P. (2009). Organizational traits, care processes, and burnout among chronic hemodialysis nurses. Western Journal of Nursing Research, 31(5), 569-582. https://doi.org/10.1177/0193945 909331430
Garrick, R., Kliger, A., & Stefanchik, B. (2012). Patient and facility safety in hemodialysis: Opportunities and strategies to devel- op a culture of safety. Clinical Journal of the American Society of Nephrology, 7(4), 680-688. https://doi.org/10.2215/CJN.06 530711
Hayes, A.F. (2018). Introduction to mediation, moderation, and condi- tional process analysis. A regression-based approach (2nd ed.). The Guildford Press.
Holley, J.L. (2010). Dangerous dialysis. https://psnet.ahrq.gov/ webmm/case/224/dangerous-dialysis
The Joint Commission (TJC). (2012). Transitions of care: The need for a more effective approach to continuing patient care. https://www.jointcommission.org/assets/1/18/Hot_Topics_ Transitions_of_Care.pdf
Kalisch, B. (2015). Errors of omission. How missed nursing care imperils patients. American Nurses Association.
Kliger, A.S. (2015). Maintaining safety in the dialysis facility. Clinical Journal of the American Society of Nephrology, 10(4), 688- 695. https://doi.org/10.2215/CJN.08960914
Lee, S.H, Phan, P.H., Dorman, T., Weaver, S.J., & Pronovost, P. (2016). Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMCHealth Services Research, 16(254). https://doi.org/ 10.1186/s12913-016-1502-7
Liu, X., Zheng, J., Liu, K., Baggs, J.G., Liu, J., Wu, Y., & You L. (2018). Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safe- ty: A structural equation modeling analysis. International Journal of Nursing Studies, 86, 82-89. https://doi.org/ 10.1016/j.ijnurstu.2018.05.005
Mardon, R.E., Khanna, K., Sorra, J., Dyer, N., & Famolaro, T. (2010). Exploring relationships between hospital safety cul- ture and adverse events. Journal of Patient Safety, 6(4), 226- 232. https://doi.org/10.1097/PTS.0b013e3181fd1a00
Sorra, J.S., & Nieva, V.F. (2014). Hospital survey on patient safety cul- ture: User’s guide. https://www.ahrq.gov/sites/default/ files/wysiwyg/professionals/quality-patient-safety/patient safetyculture/hospital/userguide/hospcult.pdf
Thomas-Hawkins, C., & Flynn, L. (2015). Patient safety culture and nurse-reported adverse events in outpatient hemodialy- sis units. Research and Theory for Nursing Practice, 29(1), 53-65. https://doi.org/10.1891/1541-6577.29.1.53
Thomas-Hawkins, C., Flynn, L., & Clarke, S.P. (2008). Relationships between registered nurse staffing, processes of nursing care, and nurse-reported patient outcomes in chron- ic hemodialysis units. Nephrology Nursing Journal, 35(2), 123- 131.
Ulrich, B., & Kear, T. (2015). Patient safety culture in nephrology nurse practice settings: Results by primary work unit, orga- nizational work setting, and primary role. Nephrology Nursing Journal, 42(3), 221-236.
Ulrich, B.T., & Kear, T.M. (2018). The health and safety of nephrology nurses and the environments in which they work: Important for nurses, patients, and organizations. Nephrology Nursing Journal, 45(2), 117-139, 168.
United States Renal Data System (USRDS). (2019). USRDS 2019 annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institutes of Diabetesand Digestive and Kidney Diseases. https://www. usrds.org/2019/view/USRDS_2019_ES_final.pdf
Nephrology Nursing Journal March-April 2020 Vol. 47, No. 2 143
Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units
Name: ___________________________________________________________________
Address: _________________________________________________________________
City: _____________________________________________________________________
Telephone: _________________ Email: ________________________________________
ANNA Member: Yes No Member #___________________________
Payment: Check Enclosed American Express Visa MasterCard
Total Amount Submitted: ___________
Credit Card Number: ____________________________________ Exp. Date: ___________
Name as it Appears on the Card: ______________________________________________
Complete the Following (please print)
1. I verify I have completed this education activity. n Yes n No
__________________________________________________ SIGNATURE Strongly Strongly
Disagree (Circle one) Agree 2. The learning outcome could be achieved using the content provided. 1 2 3 4 5 3. The authors stimulated my desire to learn, and demonstrated knowledge 1 2 3 4 5
and expertise in the content areas. 4. I am more confident in my abilities since completing this 1 2 3 4 5
education activity. 5. The content was relevant to my practice. 1 2 3 4 5
6. Commitment to change practice (select one): a. I will make a change to my current practice as the result of this education activity. b. I am considering a change to my current practice. c. This education activity confirms my current practice. d. I am not yet convinced that any change in practice is warranted. e. I perceive there may be barriers to changing my current practice.
7. What do you plan to do differently in your practice as a result of completing this educational activity? ______________________________________________________________________________ ______________________________________________________________________________
8. What information from this education activity do you plan to share with a professional colleague? _________________________________________________________________________________ _________________________________________________________________________________
9. This education activity was free of bias, product promotion, and commercial interest influence. n Yes n No If no, please explain: _________________________________________________________________
* Commercial interest – any entity either producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. Exceptions are non-profits, government and non-healthcare related companies.
Nephrology Nursing Journal Editorial Board Statements of Disclosure
In accordance with ANCC governing rules Nephrology Nursing Journal Editorial Board state- ments of disclosure are published with each CNE offering. The statements of disclosure for this offer- ing are published below.
Paula Dutka, MSN, RN, CNN, disclosed that she is a coordinator of Clinical Trials for the following sponsors: Amgen, Rockwell Medical, Keryx Biopharmaceuticals, Akebia Therapeutics, and Dynavax Technologies.
All other members of the Editorial Board had no actu- al or potential conflict of interest in relation to this continuing nursing education activity.
This article was reviewed and formatted for contact hour credit by Beth Ulrich, EdD, RN, FACHE, FAONL, FAAN, Nephrology Nursing Journal Editor-in-Chief, and Sally Russell, MN, CMSRN, CNE, ANNA Education Director.
American Nephrology Nurses Association – Provider is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing education requirements for certification and recertification.
SUBMISSION INSTRUCTIONS
Online Submission Articles are free to ANNA members
Regular Article Price: $15 CNE Evaluation Price: $15
Online submissions of this CNE evaluation form are available at annanurse.org/library. CNE certificates will be available im mediately upon successful completion of the evaluation.
Mail/Fax Submission ANNA Member Price: $15
Regular Price: $25 • Send this page to the ANNA National Office; East
Holly Avenue/Box 56; Pitman, NJ 08071-0056, or fax this form to (856) 589-7463.
• Enclose a check or money order payable to ANNA. Fees listed in payment section.
• A certificate for the contact hours will be awarded by ANNA.
• Please allow 2-3 weeks for processing. • You may submit multiple answer forms in one mail-
ing; however, because of various processing proce- dures for each answer form, you may not receive all of your certificates returned in one mailing.Note: If you wish to keep the journal intact, you may photocopy the answer sheet or
access this activity at www.annanurse.org/journal
Evaluation Form (ALL questions must be answered to complete the learning activity. Longer answers to open-ended questions may be typed on a separate page.)
ANNJ2009
Learning Outcome After completing this learning activity, the learner will be able to describe the effects of registered nurse staffing, workload, and care left undone on patient shift change safety and overall safety ratings by nurses who work in dialysis units.
N e p h r o l o g y N u r s i N g J o u r N a l
EVALUATION FORM – 1.4 Contact Hours – Expires: April 30, 2022
Copyright of Nephrology Nursing Journal is the property of American Nephrology Nurses’ Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.