Nurse-Sensitive Indicators and Patient Transition Safety in Outpatient Hemodialysis Units

Purpose:  Outpatient hemodialysis centers are the most common site of long-term hemodialysis therapy for persons with ESRD in the United States (U.S.). Although hemodialysis in an outpatient setting is a routine mode of treatment, it is a complex and potentially hazardous procedure⁷. Patient shift changes in outpatient hemodialysis units occur several times a day and are high-volume, error-prone patient transition periods that can threaten patient safety^8-10. These transition periods in hemodialysis units are associated with adverse events that have been independently linked with hospitalization and mortality in hemodialysis patients¹¹. Despite the patient safety challenges in outpatient hemodialysis units, little attention has been allocated to assessing the patient safety cultures of these health care settings. Consequently, there is little evidence on which to guide strategies to ensure patient safety during peak transition times. A concern expressed by nephrology nurse leaders, nurse managers, and staff nurses is the need for more attention on the impact of the contributions of nephrology nursing on quality of care, patient safety, and outcomes in settings where nephrology nurses provide care^{12, 13}. Thus, the impact of nurse-sensitive indicators (RN staffing, workload, hemodialysis practice environment support, adequacy of nursing care processes) on the safe transition of patients during these periods in outpatient hemodialysis units, merit attention. The purpose of this study was to 1) describe nurses’ ratings of patient transition safety during patient shift changes and 2) examine the impact of nurse sensitive indicators on patient transition safety in outpatient hemodialysis units.

Methods:  A secondary analysis of data collected in a sample of 422 registered nurses who worked in outpatient hemodialysis facilities in the United States was conducted. Multiple linear regression and ordinary least squares path analysis with bootstrap samples was conducted to examine direct and indirect effects of nurse-sensitive indicators on patient transition safety.

Results: High RN workloads, unsupportive dialysis practice environments, and missed nursing care were independent predictors of unsafe patient transitions. These variables explained 33% of variance in patient transition safety Additionally, missed nursing care is an important operant mechanism (i.e., mediator) in the relationships between nursing structures (RN staffing, RN workload, practice environment support) and patient transition safety in outpatient dialysis units.

Conclusion: The findings from this study can inform the design and evaluation of innovative care models that target modifiable nursing structures and care processes to improve the safe transition of patients during patient shift changes in outpatient hemodialysis settings.