What dialysis nurses are saying about nursing ratios

The debate in California over the value and importance of establishing minimum staffing levels in dialysis clinics isn’t about creating a numerical definition of quality care. While studies have shown that nursing burnout can occur from heavy patient workloads, no one knows if staff ratios work. Eight states have them now, and no research has been done to show whether patient care has improved.

It reminds me of when Thomas Scully, administrator of the Centers for Medicare & Medicaid Services from 2001-2003, changed the rules on how practitioners earn their monthly capitated payment. Scully pushed through regulations that required nephrologists––or nurse practitioners in their practice––to get paid only when a patient received a visit. Up to four visits were billable. CMS never looked at whether this approach improved patient care (previously, a nephrologist got paid monthly no matter how many visits they made).

Scully made the assumption that more visits was a better deal for the patient and for the taxpayers footing the bill for the ESRD Program. Did it improve care. It’s not really clear.

The Pro and the Con

In the California case, a union is behind the push for Senate bill 349, the Dialysis Patient Safety Act, to create staffing ratios (1:8 for nurses; 1:3 for patient care technicians; 1:75 for social workers). Both sides are making their case: dialysis providers say it would be too costly to hire more nurses, and say data shows that dialysis care in the Golden State is actually better than in others––even those with already established staffing ratios.

Those who are in favor say nursing staff are stretched thin in dialysis clinics, creating a high-risk environment for infectious disease, unnoticed needle dislodgements, and other potential disasters.

The California bill also calls for a mandatory 45-minute break between patient shifts, so staff members have time to disconnect patients properly and allow them to stabilize before leaving the clinic.

It would be the first law in the United States to set such limits, the other seven states have set minimum staffing through administrative regulations.

On the dialysis floor

In response to a Medscape Nephrology article on the topic published on April 21, many nurses who had worked 10-20 years in the dialysis field said there was room for improvement.

“I was a dialysis nurse for 19 years. I fondly remember the clinic being hospital based, employing an all RN staff, and the nephrologist rounding every shift,” wrote Deborah Donovan. “We were all trained to do acute dialysis as well. After leaving dialysis for 8 years, I went back into nephrology and took a position with one of the two largest for-profit clinics. How times had changed! We were overworked, understaffed, underpaid, and the bottom line (profit) was always in our face…It was the worst job I have had in my 39 years as a nurse!”

“I was an acute dialysis RN for Fresenius for 17 years. No breaks, no lunch, some days were 18 hours long, with an expected return the next day at 7am,” wrote Charles Berry. “About 35% of the time I was dealing with critically ill patients…I was often on call for two or more days in a row, called out at 3 am after working a 12-hour shift with no breaks and no lunch. I was grossly underpaid. I saw RN’s come and go, some would last 4 or 5 weeks then quit, when that happened my work time would increase.”

“I left my job as a dialysis nurse, because the job was making me physically ill and it was killing my soul,” wrote Anne Strandberg. “I was not allowed to leave the building, during the long days, due to being the only nurse there…I got little sleep and very little respect from the techs working in my clinic. It was a "get 'em in, get 'em out…Rawhide!"

That image doesn’t bring up a pretty picture of patients being given excellent care by kidney professionals. Maybe it’s time to put aside ratios and star ratings, and listen to what patients and the care staff are saying. The ESRD Program was created in 1972 to help those with kidney failure avoid certain death. Forty-five years later, we should have higher goals for patient care.