Nurse Manager Leadership and Dialysis Patient Outcomes

Introduction: Nurse Leadership and Dialysis Care

This paper investigates how nurse manager leadership affects patients in terms of clinical outcomes, with a specific focus on dialysis patients. This role is critically important, particularly as it relates to medications administered during dialysis and to the monitoring of laboratory values.

The work of Karen Steib, entitled "Nephrology Nursing," describes the career paths of the nephrology nurse as potentially including direct care of patients with end-stage renal disease (ESRD) who receive dialysis or undergo renal transplants, as well as education of patients, communities, and health professionals about risk factors that can result in chronic kidney disease. Another career path is research into the effectiveness of treatment modalities and the impact of nursing practices on patient outcomes, or advocacy work with government agencies to develop health policies that improve care for kidney disease patients (Steib, 2008).

It is important to understand, as stated by Steib, that "nephrology nursing encompasses total patient care, because the kidneys affect every other major system in the body — cardiovascular, pulmonary, gastrointestinal, etc. Comorbidities, especially diabetes and high blood pressure, are usually causative factors in chronic kidney disease (CKD) and must be addressed concurrently. And because treatment for kidney disease is costly, patients also face numerous psychosocial and financial issues." (Steib, 2008)

For the nephrology nurse who has the capacity to deal with the "bigger picture," this may mean overseeing multiple dialysis centers and many hundreds of patients; for others, it may mean overseeing only one dialysis unit (Steib, 2008). Patients involved in dialysis sometimes must attend sessions lasting three to four hours at a time, multiple days per week, making treatment feel like a second job (Steib, 2008).

The work of Thomas-Hawkins, Denno, Currier, and Wick (2003), entitled "Staff Nurses' Perceptions of the Work Environment in Freestanding Hemodialysis Facilities," reports on a study of the hemodialysis work environment. The study found that while positive perceptions of the work environment were evident, "discontent with many aspects of the work setting also was apparent." Low levels of agreement with several characteristics that distinguish magnet hospital environments were noted. Among the specific findings: 34% of nurses agreed that the dialysis unit determined its own policies and procedures; 36% agreed that nursing contributions to patient care were publicly acknowledged; and 50% agreed that new and innovative ideas about patient care were supported (Thomas-Hawkins, Denno, Currier, & Wick, 2003).

Environmental Analysis of the Dialysis Unit

The study reports findings on the Practice Environment Scale of the Nursing Work Index (PES-NWI) subscales. The mean score for the Nurse Participation in Dialysis Provider Affairs subscale was 2.25, indicating that nurses in this sample did not perceive that their work environments supported a participatory role or valued status for nurses. The mean score for the Nurse Manager Ability, Leadership, and Support of Nurses subscale was 2.62, indicating that nurses agreed, somewhat, that the nurse manager had a critical role and supported nurses in their dialysis units (Thomas-Hawkins et al., 2003).

Specifically, 59% of nurses reported that their nurse manager was a good leader and manager, while 60% agreed that the nurse manager backed up the nursing staff in decision-making. However, only one half of the nurses agreed that they were given praise and recognition for a job well done (Thomas-Hawkins et al., 2003).

It is critical to note that the Staffing and Resource Adequacy subscale mean score of 2.28 indicates that respondents, overall, disagreed that there was adequate staff and support resources to provide quality patient care in their current jobs (Thomas-Hawkins et al., 2003). Additional statistics from the study included the following:

Thomas-Hawkins et al. (2003) note that magnet hospitals "were distinguished by organizational characteristics that promoted professional nursing practice." These attributes included: (1) decentralized decision-making by bedside caregivers; (2) inclusion of the chief nursing executive in top management decision-making; (3) strong, supportive, and visible nursing leadership; (4) unit self-governance; (5) participative management with open communication; (6) good nurse-physician relationships and collaboration; (7) low nurse turnover rates; (8) adequate staffing levels; (9) a richer nursing skill mix reflecting a high priority placed on quality nursing care; (10) flexible scheduling; (11) recognition for excellence in practice; and (12) opportunities for professional development and career advancement.

The study also found that two in ten nurses in dialysis units were planning to look for another position of employment in the near future. Nurses in the study came from the following types of organizations:

The study found that the potential for a long-term career in nephrology among nurses under the age of 30 was quite low, at only 5% (Thomas-Hawkins et al., 2003). As the "baby boomer" generation of nurses begins to retire, career opportunities for women continue to broaden, and the nursing faculty shortage worsens, dialysis providers will likely continue to face difficulty filling vacant nursing positions.

These authors argue that solutions addressing the shortage of nurses in hemodialysis settings must not only include strategies to increase the supply of new nurses entering nephrology, but must also include efforts to retain current nurses and to adapt the hemodialysis work environment to support an aging workforce. As they note, the traditional use of rewards for new employees — such as sign-on bonuses — penalizes those who remain loyal. To retain nurses, dialysis organizations will need to develop policies that foster, recognize, and reward retention and organizational loyalty.

Furthermore, while a richer nursing skill mix is characteristic of magnet hospital environments, the typical skill mix in hemodialysis units is 30% licensed personnel (including registered nurses and licensed practical nurses) to 70% unlicensed personnel. One identified challenge for executive and administrative staff in dialysis organizations is to identify effective models of care for hemodialysis units that enable nurses to provide quality patient care — for example, through the use of an advanced practice nurse as part of the dialysis team — and to gain a clear understanding of what is required to ensure successful implementation of these models (Thomas-Hawkins et al., 2003).

The study also noted that nurses were not asked directly about their reasons for leaving; however, data from other studies have indicated that job dissatisfaction and burnout may be important predictors of nurses' intentions to leave. For example, 43% of hospital nurses who reported high burnout and were dissatisfied with their jobs intended to leave their current position within the next 12 months, compared to only 11% who were not burned out and remained satisfied. Inasmuch as job satisfaction and low levels of emotional exhaustion are features of magnet hospital environments, dialysis organizations might consider a retention strategy that includes assessment of these important nurse outcomes and their relationship to hemodialysis nurse retention (Thomas-Hawkins et al., 2003). The study recommends that "factors contributing to job dissatisfaction and burnout in hemodialysis facilities could be explored and addressed, and the impact of these efforts on retention could be documented." (Thomas-Hawkins et al., 2003)

The following summarizes nurse responses to survey items organized by subscale from the Thomas-Hawkins et al. (2003) study:

Items on which nurses reported agreement included: nurse managers consulting with staff on daily problems and procedures; staff nurses having the opportunity to serve on committees; an administration that listens and responds to employee concerns; opportunities for advancement; senior management visibility and accessibility to staff (e.g., Vice President, Director of Quality Management); career development and clinical ladder opportunities; staff nurse involvement in the internal governance of the dialysis unit; and opportunity for staff nurses to participate in policy decisions.

Items on which nurses reported agreement included: high standards of nursing care expected by administration; working with clinically competent nurses; an active quality improvement program; patient assignments that foster continuity of care; written, up-to-date nursing care plans for all patients; nursing care based on a nursing rather than a medical model; a preceptor program for newly hired registered nurses; a clear philosophy of nursing pervading the patient care environment; the use of nursing diagnoses; and active professional development programs for nurses.

Organizational Characteristics That Promote Nursing Practice

Items on which nurses reported agreement included: supervisory staff supportive of nurses; the nurse manager backing up nursing staff in decision-making, even in conflicts with physicians; the nurse manager being a good manager and leader; and the receipt of praise and recognition for a job well done.

Items on which nurses reported agreement included: enough staff to get the work done; enough opportunities to discuss patient care problems with other nurses; adequate support services allowing time with patients; and enough registered nurses on staff to provide quality patient care (Thomas-Hawkins et al., 2003).

It is clear that staffing and resource adequacy is a significant problem in the dialysis units surveyed in this study, and the literature reviewed has demonstrated that this situation is characteristic of dialysis units throughout much of the United States — and that conditions are likely to worsen before they improve. Because of this reality, it is critically important that the nurse manager's leadership role be recognized as vital, and that support for nurses in their daily work be understood as a primary component of effective nursing leadership in dialysis units, if nurse turnover is to be reduced to the lowest possible level.

The nurse manager's role must proactively address burnout among dialysis unit nurses rather than waiting to respond after it occurs. Prevention is key. As the demands grow for quality and competent nursing staff, so too does the need grow for competency in nursing management and leadership roles. Because the dialysis unit nurse is closely involved in patient care — and because these patients are required to report for treatment several days a week for several hours at a time — the nurse's mental, physical, and emotional state quite clearly has a direct impact on the clinical outcomes of dialysis patients.

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