The dialysis nurse training gap: One size doesn’t fit all

The shortage of dialysis nurses in the industry has become exacerbated with the increase in demand for services. In addition, efforts in California to mandate a nurse-to-patient ratio for outpatient clinics will, if passed, add more pressure to dialysis companies to increase their roster of qualified nurses. So, competent nurses should be encouraged to work in dialysis and welcomed by companies. It is, therefore, disconcerting when a nurse is forced to leave due to an inconsistent training system which, if not corrected, will result in a diminishing pool of qualified candidates.

Case study #1: Nancy (not her real name) had been an LVN (licensed vocational nurse) since 1993. In 2008, after working for 15 years in long-term care, she returned to school to become a registered nurse. In May 2009, graduating magna cum laude, she received a BSN. Nancy received her nursing license in July 2009 and returned to long-term care.

In 2014, she got restless and a little burned out, so she wanted to try something new. A renal dietitian suggested dialysis.

In October 2014, she took a staff job at a well-known company’s dialysis clinic near her home. After a few days of online paperwork, Nancy was on the floor where she shadowed a patient care technician (PCT) and learned how to set up and break down a dialysis machine. Then she worked with a different nurse each day for a week.

Nancy’s main duties were handing out medications, giving vaccinations, and hanging antibiotics and IV parental nutrition for all patients. Sometimes she had a station with a fixed number of patients, but those occasions were rare. There was always a schedule for what she would be doing on what days.

Becoming a travel nurse

A little more than a year after her start, she left the employ of the company and decided to become a dialysis travel nurse. She landed a plum assignment at a premier dialysis company with a world-wide presence.

After completing paperwork similar to what she had done at her first company, there were no similarities.

First, Nancy took a water treatment class. Then she learned about line rinsing. While in training at this assignment, she spoke with new hires for this company and they explained they were in school for several months. This was surprising to Nancy. No one at her first company offered her this kind of comprehensive training.

After three weeks, Nancy was terminated from this assignment because she was unable to perform her duties at the level this company expected.

She felt she let down her agency and the company where she was on assignment. Soon after, she found out her former company did offer training classes, but she was never told.

In retrospect, Nancy says, “I was too new to know how much I didn’t know.”

After regaining her confidence, she returned to long-term care, closing the door on her dialysis nursing career.

If a new hire has no dialysis experience, there should be checks and balances to make sure there is training before allowing that new staff member on the floor to touch patients. This was an important message and lesson learned for a nurse in our second case study. We’ll call her Nellie.

Case study #2: When she became a dialysis nurse, Nellie worked for a dialysis company for several years. She met their standards and was rewarded for her good performance. When she decided to travel, she wanted to stay in the same state. Her agency found her a great assignment at another dialysis company, coincidentally the same company Nancy went to for her first assignment.

Her assignment was terminated shortly after she started because she didn’t know how to cannulate. It was not a requirement in that state for nurses to know how to cannulate; PCTs did the cannulation. However, the new company she went to as a traveler in the same state required nurses to cannulate. For this company, every nurse is required to know how to do every job in a dialysis clinic which, in this case, exceeded state requirements.

Consistency in training

This brings to light deviations in dialysis nurse training among dialysis company providers and variances in state requirements. Some companies require all new nurses, both travel and permanent, to take classes regardless of their experiences, to fully understand the processes of how things are done by the company. Some companies limit training if a nurse is experienced. A few companies expect a nurse to be up and running when they cross the threshold, providing only orientation to the facility or clinic.

What should a travel nurse with a compact license who travels to different states and different companies do? There is no standard training provided by a dialysis company to its nurses or other personnel. Add to this the requirements of a nurse’s home licensing state in contrast to another state’s requirements, and you have a formula for failure, especially for a travel nurse with a compact license. The Federal Register states in Section 494.140 (4) that a staff nurse “...who provides care and treatment to patients must be either a registered nurse or a practical nurse who meets the practice requirements in the State in which he or she is employed.” The Centers for Medicare & Medicaid Services follows the Federal Register’s policy.

This puts the responsibility of defining nursing requirements on each state—regulations that companies and nurses must abide by. So in one state, a nurse may not be required to cannulate while in another state it may be a requirement.

Like Nancy and Nellie, nurses are not usually aware of regulations in other states or differences among companies. Company training reflects what a company expects its nurses to do. One company wants its nurses to be hands-on and know every element of every job in comparison to another company that just wants its nurses to do no more than what is required by a state. Sometimes, this may be just writing orders and perform assessments. Then there are the companies in between who have various requirements for their nurses. If a nurse changes states within a company, similar issues could be encountered.

One possible reason this occurs can be linked with mergers and acquisitions. When one company buys another, it is difficult for a corporate office to keep up with what is happening in their newly acquired field locations. It may be due to their preoccupation with form rather than function. Sometimes, the acquired company’s personnel have not been indoctrinated with the new company’s policies and procedures. Sometimes, managers are focused on meeting their immediate needs instead of seeing the bigger picture.

Summary

While it may not be the responsibility of a company to train beyond what its nurses need to know to work for them, how would a new nurse get a clear overview of what skills may be missing? In our case studies, Nancy didn’t know training was available until after she left the company. Nellie remained in the same state and met state requirements, not having any idea that another company would train its nurses to exceed state requirements. Should the onus of knowing what skills are required and what training is available at a company fall on a nurse’s shoulders? Perhaps there should be a central clearinghouse of requirements by state and companies for nurses. The more information that is available the better likelihood a dialysis nurse can meet clinic expectations. - by Francyne N. Rosenstock

Sources

Federal Register, Vol.73, No. 73 | April 15, 2008 Part II | Department of Health and Human Services, Centers for Medicare & Medicaid Services, 42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule

CMS Advanced Copy - End Stage Renal Disease (ESRD) Program Interpretive Guidance

Version 1.1, October 3, 2008, V688 (4), Interim Final Version 1.1, Page 270