The California Dialysis Patient Safety Act (SB 349) aims to require a ratio of one registered nurse for every eight patients, reducing RN workload in hemodialysis treatment facilities by approximately four patients per nurse.

CU College of Nursing Professor Linda Flynn, PhD, RN, FAAN, and Charlotte Thomas-Hawkins, PhD, RN, an associate professor at Rutgers School of Nursing, Rutgers University, are longtime researchers of care processes, nurse staffing, and patient outcomes and safety in dialysis facilities.

Flynn says, “My program of research has always been in system-level factors. When you think about hemodialysis, basically the clinician is draining the blood out of the patient, cleaning it and pumping it back in, so the opportunity for things to go wrong are immense and it has happened. And we read these horror stories in the newspaper about patients exsanguinating and dying on the spot because no one noticed that something was dislodged, et cetera. So we decided to marry my systems expertise with her dialysis clinical care expertise and we’ve been partners ever since.”

Flynn and Thomas-Hawkins have spent the past ten years focusing their research on RN staffing in outpatient dialysis facilities, an issue which SB 349 is designed to address specifically. “We were concerned about these very issues,” Flynn says. “The main issues being RN to patient staffing as well as the time, what they call transition time, from the time one patient finishes their dialysis and the next patient sits in that chair and it hooked up. The [California SB 349] legislation is proposing a staffing ratio of eight patients per one RN and there’s very little research in this area except for what Charlotte and I have already done. And the main study that they cite is this one from 2008 where we found that the best staffing ratio was almost five patients to one RN. The worst was twelve or more to one RN, so eight is kind of right in the middle.”

Thomas-Hawkins and Flynn’s work has been cited in recent news articles concerning the California bill. A March 2017 article in Nephrology News & Issues¹ mentions the 2008 findings of Thomas-Hawkins, Flynn, and Sean P. Clarke, Professor and Associate Dean of Undergraduate Programs at the Connell School of Nursing, Boston College, in which the authors determined that nurses with higher patient workloads were more likely to leave important tasks undone, leading not only to increased instances of dialysis hypotension, but also to negative patient behaviors such as complaints and skipped dialysis treatments.² This article also mentions another problem Flynn et al. have studied: nursing burnout. The authors found in 2009 that “when nurses must leave important patient care activities undone because they did not have time to complete them, the likelihood of burnout significantly increases.”³

An April 2017 Medscape⁴ article noted the authors’ findings that lower levels of RN staffing negatively affect patient care processes. One main reason for this negative outcome, Flynn et al. concluded in their 2008 study, is lack of adequate transition time between patients.² This conclusion has remained relevant, as Flynn and Thomas-Hawkins acknowledge in their more recent 2015 study, noting that “handoff and transitions safety during patient shift change in dialysis centers was perceived negatively by a majority of nurses.”⁵ It is worthy of mention that in the same study, the majority of nurses reported an overall patient safety culture rating of good to excellent for their dialysis facility, further indicating the cruciality of sufficient patient transfer time.

Transition time, an important aspect of the patient care process in dialysis facilities, has been written into SB 349, which sets a requirement of 45 minutes for each patient transition. While the mandates of the bill seem to uphold the recommendations of Flynn et al.’s work, it is not without opposition. “There is that pushback and it’s a very strong corporate pushback,” says Flynn.

Corporations DaVita and Fresenius control the majority of the dialysis market in the United States, which Flynn notes as a major source of opposition for dialysis RN staffing bills: “Charlotte and I met with the Centers for Medicaid and Medicare Services [CMS] back in 2008 and we were able to get them to change the federal regulations that now require at least one RN to be present. But one of the barriers that CMS faced at that time and that the California state legislators faced is that 80% of all outpatient dialysis care in the United States is delivered by one of two corporations and they’re for-profit corporations. Not that profit is a bad thing, but they have a monopoly and so they can say if you pass this legislation we’ll just pull out of California.”

Flynn acknowledges that DaVita and Fresenius are unlikely to leave the California market, but their monopolistic presence still has the power to influence legislation.

As for SB 349, it has been approved by the Judiciary Committee for the California State Senate and advanced to the Senate Appropriations Committee for a hearing on May 15, 2017. That Committee motioned to place it on suspense file to be heard at a later date.

In June 2017, Flynn and Thomas-Hawkins will travel to California as presenters to the United Nurses Associations of California / Union of Healthcare Professions on this topic. “We have been given an hour and a half time slot, which is huge. But they’re very interested, not just obviously in our dialysis work but my other research that is looking at these issues in a variety of settings: Medicare, certified home health, nursing homes, hospitals, and those kinds of things. So there is a mounting body of research now that says that these things are important no matter where nurses work. The ratios might change depending on the acuity of patients, but the fact about nurse staffing, their work environment, and whether or not it’s supportive of nursing practice or whether it’s bureaucratic, makes a difference,” says Flynn.

Flynn and her research partner are engaged in a current study funded by the American Nephrology Nurses Association. “We’re actually going to be surveying nurses in two states that work in dialysis and aggregating their responses to the facility level and then linking that with real facility level patient outcomes as released by CMS and publically available data sets,” says Flynn. “This would be the first study that actually links these staffing issues and work environment issues and burnout to actual and federally reported patient outcomes. And while this probably won’t be ready in time to help California and their decision, there are several states that are wanting to follow California and introduce legislation.”

References

1. Neumann, Mark E. (8 March 2017). Dialysis providers, union take sides in California over staffing ratios. Nephrology News & Issues. Retrieved from http://www.nephrologynews.com/dialysis-providers-union-take-sides-in-california-over-staffing-ratios/
2. Thomas-Hawkins, C., Flynn, L., & Clarke, S. P. (2008). Relationships Between Registered Nurse Staffing, Processes of Nursing Care, and Nurse-Reported Patient Outcomes in Chronic Hemodialysis Units. Nephrology Nursing Journal : Journal of the American Nephrology Nurses’ Association, 35(2), 123–131.
3. Flynn, L., Thomas-Hawkins, C., & Clarke, S. P. (2009). Organizational Traits, Care Processes, and Burnout Among Chronic Hemodialysis Nurses. Western Journal of Nursing Research, 31(5), 569–582. http://doi.org/10.1177/0193945909331430
4. Harrison, L. (21 April 2017). California First to Address Dialysis Staffing Problems. Medscape. Retrieved from http://www.medscape.com/viewarticle/878870
5. Thomas-Hawkins, C., Flynn, L. (2015). Patient safety culture and nurse-reported adverse events in outpatient hemodialysis units. Research and Theory for Nursing Practice: An International Journal, 29(1), 53–65.