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The scope of end-of-life communication is not well known among nephrology advanced practice nurses (APNs). Guided by the Theory of Planned Behavior, the study aimed to examine the independent effects of knowledge, attitude, and perceived behavioral control on the engagement of APNs in end-of-life communication and the mediating and moderating effects of attitude and perceived behavioral control on the relationships between knowledge and end-of-life communication. A theoretically derived 17-item survey measuring the concepts was administered to a convenience sample of 127 APNs. Descriptive statistics, Pearson's correlation, and multiple linear regression were employed. Attitudes and perceived behavioral control on end-of-life communication mediated and moderated the relationship between knowledge of end-of-life communication and engagement in end-of-life communication among nephrology APNs., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this nursing continuing professional development (NCPD) activity., (Copyright© by the American Nephrology Nurses Association.)

The End-Stage Renal Disease Treatment (ETC) Model, an aspect of the Advancing American Kidney Health Initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in 2019, is designed to shift the predominant in-center hemodialysis dialysis model in the United States to a home dialysis model. This shift represents a monumental change in the treatment of end stage kidney failure and is occurring amid a strained nursing workforce. The CMS Conditions for Coverage for dialysis facilities mandate registered nurse responsibility for the conduct of patients' home dialysis training, and the current nursing shortage presents challenges because the need for nephrology nurses will increase to meet the growing demand for home dialysis during the ETC implementation period. As the ETC Model is implemented in randomly selected dialysis facilities across the United States, nephrology nurses must have leading roles as full partners with CMS and other stakeholders for the mutual determination of short- and long-term solutions for meeting the growing home dialysis training demands., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this nursing continuing professional development (NCPD) activity., (Copyright© by the American Nephrology Nurses Association.)

Nephrology nurses face health and wellness challenges due to significant work-related stressors. This survey, conducted online between July 24 and August 17, 2020, assessed the psychological well-being of nephrology nurses in the United States during the COVID-19 pandemic (n = 393). Respondents reported feeling burned out from work (62%), symptoms of anxiety (47% with Generalized Anxiety Disorder-7 [GAD-7] scores ≥ 5), and major depressive episodes (16% with Patient Health Questionnaire-2 [PHQ-2] scores ≥ 3). Fifty-six percent (56%) of survey respondents reported caring for COVID-19 patients, and 62% were somewhat or very worried about COVID-19. Factors, including high workload, age, race, and the COVID-19 pandemic, may partially explain the high proportion of nephrology nurses who reported symptoms of burnout, anxiety, and depression., (Copyright© by the American Nephrology Nurses Association.)

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 registered nurse (RN) staffing, workload, nursing care left undone, and patient safety outcomes in hemodialysis settings. 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 nursing 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 workloads, as well as redesigning responsibilities so RNs can complete necessary care activities., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Patients living with end stage renal disease (ESRD) who are undergoing hemodialysis experience frequent hospitalizations associated with complications of care and exacerbations of illness. Efforts to reduce hospitalizations have had limited success. The purpose of this study was to explore why hospitalizations occur from the perspectives of patients undergoing hemodialysis treatment, their caregivers, and health care providers. Semi-structured interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. Findings are discussed under four main themes: Graft site/Catheter/Access issues, "My resistance is low," "I could not breathe,"" and "The perfect storm." Results highlight the complexity of care and vulnerability of patients with ESRD. Further interprofessional research is needed to improve transitional care and care delivery for patient populations receiving hemodialysis., Competing Interests: This study was supported through a pilot grant from the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Maya Clark-Cutaia was supported in part by a NIH-NINR K23 Mentored Patient-Oriented Research Career Development Award Recipient (NR015058-01). Olga Jarrín was supported in part by an AHRQ/PCOR K99/R00 award (HS022406)., (Copyright© by the American Nephrology Nurses Association.)

Nursing is the largest healthcare profession in the United States (U.S.). As principal frontline caregivers in the U.S. healthcare system, nurses have tremendous influence over a patient's healthcare experience. A growing body of evidence states that the nursing workforce has a direct impact on healthcare quality. A standardized approach to measuring nursing's contribution to patient care and safety using nursing-sensitive quality indicators assists in examining the extent to which nurses and nursing affect the quality and safety of health care. This article focuses on nursing-sensitive quality indicators and discusses healthcare quality indicators and nursing-sensitive indicators used in the U.S. A summary of the work of the American Nephrology Nurses' Association Task Force on Nephrology Nursing-Sensitive Quality Indicators (NNSQI) and an NNSQI exemplar are provided., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Competent nurse managers of outpatient hemodialysis (HD) units are invaluable in enhancing patient safety, creating a culture of safety, and preventing adverse events. Yet little is known regarding the characteristics of a professional work environment that supports their important managerial role. The purpose of this qualitative study was to identify those organizational characteristics that outpatient HD unit nurse managers describe as important to a supportive managerial work environment. A total of six major themes with descriptive categories and exemplars emerged from the analysis. Findings from this study can inform HD administrators in their efforts to create and sustain work environments that support the professional practice of outpatient HD unit nurse managers. Notably, findings can also provide guidelines for nurse managers considering employment opportunities in that they can be used to assess and compare the work environments of outpatient HD facilities and organizations., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Little is known regarding the specific managerial activities or best practices that nurse managers in outpatient hemodialysis settings use to achieve positive safety outcomes. The purpose of this study was to identify and describe specific managerial practices used by nurse managers in outpatient hemodialysis units to enhance patient safety and quality of care. A descriptive qualitative design was used. Seventeen nurse managers in outpatient hemodialysis units comprised the study sample. Telephone interviews were conducted, and qualitative content analysis was used to encode the data. Nurse managers identified patients, staff, the dialysis unit environment, and the dialysis organization as sources of safety risks. Nurse manager safety practices illuminated from the data were complex and multifaceted, and were aimed at reducing patient, staff environmental, and organization risks. The findings from this study offer a description and a better understanding of the practices in which nurse managers in outpatient hemodialysis units engage to keep patients safe in their units, and they underscore the critical role of nurse managers in creating and maintaining patient safety within outpatient hemodialysis settings.

Little attention has been given to the effects of registered nurse (RN) staffing and processes of nursing care on patient outcomes in hemodialysis units. This research examined the effects of patient-to-RN ratios and necessary tasks left undone by RNs on the likelihood of nurse-reported frequent occurrences of adverse patient events in chronic hemodialysis units. Study findings revealed that high patient-to-RN ratios and increased numbers of tasks left undone by RNs were associated with an increased likelihood of frequent occurrences of dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints in hemodialysis units. These findings indicate that federal, state, and dialysis organization policies must foster staffing structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses.

While the nephrology nursing shortage persists despite the continued growth of the population of individuals with Stage 5 chronic kidney disease, there is a paucity of empirical data regarding nephrology nurses' perceptions of their work environments. Moreover, there are no studies that have examined the relationship of work environment attributes to patient and nurse outcomes in dialysis settings. The purpose of this study was to examine the relationships between staff nurses' perceptions of dialysis work environments, nurses' intentions to leave their current jobs, nurse turnover, patient satisfaction, and patient hospitalization rates. A descriptive, correlational design was used. Nurse level and facility level data were obtained. The sample for nurse-level data consisted of 199 registered nurses in staff nurse roles in 56 dialysis facilities of a national dialysis company. The sample for facility-level analysis consisted of 46 dialysis facilities, and nurse-level data were aggregated for facility-level analysis. The Practice Environment Scale-Nursing Work Index (PES-NWI) was used to measure nurses' perceptions of the dialysis work environment. Nurses' intention to leave their jobs and facility-level turnover rates were the nurse outcomes examined in this study. Facility-level patient satisfaction and hospitalization rates were the patient outcomes examined. Correlation coefficients were computed to measure the relationships between study variables, and independent t-tests were performed to examine subgroup differences in work environment perceptions. Overall, nurses rated the work environment somewhat favorably. Nurses who expressed intention to leave their jobs rated the work environment more negatively compared to nurses who intended to stay. Significant correlations were found between nurses' perceptions of the dialysis work environment, nurses' intention to leave their jobs, nurse turnover rates, and patient hospitalizations. Study findings suggest that nurses' perceptions of the dialysis work environment are important for nurse and patient outcomes in dialysis settings. Further research is needed to explore the predictive ability of the work environment for nurse and patient outcomes in hemodialysis units.

While one suggested cause of the current nursing shortage is nurses' negative perceptions of the work environment, little is known of nephrology nurses' perceptions of the dialysis work environment. The purpose of this study was to assess the extent to which staff nurses who work in freestanding hemodialysis facilities rate the presence of organizational characteristics common to magnet hospitals in their current job. Study findings indicate that staff nurses in hemodialysis units identify several notable features of magnet hospitals in their work settings. However, a majority of nurses disagreed that many attributes of magnet hospitals are present in hemodialysis work environments. This study provides a preliminary description of some of the factors that affect nurses' perceptions of the work environment in freestanding dialysis facilities. Further work is needed in this area.

While one suggested cause of the current nursing shortage is nurses' negative perceptions of the work environment, little is known of nephrology nurses' perceptions of the dialysis work environment. The purpose of this study was to assess the extent to which staff nurses who work in freestanding hemodialysis facilities rate the presence of organizational characteristics common to magnet hospitals in their current job. Study findings indicate that staff nurses in hemodialysis units identify several notable features of magnet hospitals in their work settings. However, a majority of nurses disagreed that many attributes of magnet hospitals are present in hemodialysis work environments. This study provides a preliminary description of some of the factors that affect nurses' perceptions of the work environment in freestanding dialysis facilities. Further work is needed in this area.

Dialysis patients experience numerous symptoms, some serious in terms of medical outcomes and all serious in terms of potential reductions in functioning and well-being. This cross-sectional study used self-reports of hemodialysis patients to catalogue symptoms; hypothesizing that frequently experienced symptoms, regardless of acuity, negatively affect functioning and well-being. Data were collected from 307 randomly selected hemodialysis patients from 14 dialysis facilities. Twenty-two of the 47 symptoms queried had mean experience scores of > or = 1 on a scale of 0-4, that is, were experienced by patients at least "a little of the time." Seventeen of these 22 symptoms were significantly correlated (< or = .01) with the SF-36 Physical Component Summary (PCS) scale, Mental Component Summary (MCS) scale, or both. All but four of these 17 symptoms (dry mouth, itchy skin, lack of appetite, and restless legs) clustered around fatigue/sleep, sexual concerns, or mobility. Linear multiple regression showed age, diabetes, the fatigue/sleep and mobility clusters, and itchy skin to be negatively associated with the PCS (p < or = .01). The fatigue/sleep cluster was also negatively associated with the MCS. Because previous research has shown the PCS and MCS to be associated with morbidity and mortality, management of common, non-acute symptoms may have long-term benefits for hemodialysis patients.