8/7/2020 Acknowledgments Dr. Bronwyn Hayes Dr. Rosabeth Moss Kanter Dr. Milisa Manojlovich Dr. Heather “Spence” Laschinger Dr. Meg Larson Dr. Colleen Bessetti-Barrett Dr. Jill Rodgers Dr. James Vroom Dr. Gwyndolan Swain Dr. Susan Luck Dr. Jane Blystone Dr. James Vroom Dr. Stephen Driggers Dr. Nur Onvural Dr. Michael Seda Dr. David Hollar Dr. Mary Sylvia-Reardon Dr. Pearl Cunningham Dr. Emiliah Kambarami-Sithole Phase One Dialysis Expert Nurses Phase Two Random Participants Tana and Madeleine Cadena-Vuignier Jason Barefoot Nancy Nixon-Ensign My Father, Sister, entire family, and friends Hank, Veda, and Birdie RETENTION, STRUCTURAL EMPOWERMENT, AND DIALYSIS NURSING: INTEGRATING KANTER’S THEORY AND THE REFINED NURSE WORKLIFE MODEL RICHARD C. SCEPURA, DNP (candidate), MBA/MHA, RN, NEA-BC, CDN Abstract During this two-phase project, factors that dialysis nurses experience contributing to stress, retention, and the ​intentions of staying w ​ ere examined. The theoretical frameworks of Kanter’s Theory of Structural Empowerment (KTSE) and The Refined Nurse Worklife Model (NWLM) were utilized in the creation of a learning module regarding structural empowerment. In phase one this was reviewed by an expert dialysis nurse focus group from seven different states with experience in dialysis from seven to forty years. During phase one, the expert panel gave high-frequency domain input including access to support, resources, and the need for strong leadership. The module was adjusted based on this input. In phase two this was launched in dialysis user groups. These nurses were asked to give quantitative and qualitative feedback. Phase two participants reported retention and stress factors including the ​need for information, on-call, education for pandemic procedures and policies, access to supplies, compensation, patient issues, ratios, racial and cultural differences, bullying, respect, favoritism, mental health support, and achievement of a sense of personal accomplishment. ​As a response to this information project management reflection tools for nurses and nurse leaders were formulated based on KTSE and NWLM. The learning module and tools were designed to facilitate changes that improve the work-life of dialysis nurses and the intention to stay in their specialty. Future studies should look at the outcomes of the implementation of the learning module and the use of the tools in improving the expertise of dialysis care for patients by better retention and empowerment of dialysis nurses. Table of Contents Chapter 1 Introduction Background of the Problem Statement of the Problem Research Question(s) Definition of Terms Need for the Study Significance of the Problem Assumptions Limitations (in prospectus) Summary of the Problem 1. Chapter 2 Review of Related Literature Related Research Conceptual Framework Summary of the Review of Literature 2. Chapter 3 3. Methodology Introduction Design of the study/type of research Sample/recruitment/protection, inclusion/exclusion criteria with data Site from which the sample is selected Measuring instruments – reliability/validity Procedures for data collection Plans for treatment of the data A “mock-up” of any tables for figures should be included Time schedule for conducting the study Information regarding any grants Summary of Methodology 4. Results and Discussion Introduction Results Discussion of Results Limitations Summary 5. Summary, Conclusions, and Recommendations Summary of the Findings Limitations Implications for Nursing Recommendations for Further Research Summary References Appendix A: Consent to Participate Appendix B: Learning Module Appendix C: Dialysis Structural Empowerment Tool Appendix D: Potential Mock-Up of Quantitative Summing Appendix E: Divided Response Tables Appendix F: Flyer Appendix G: Reflection Tools Appendix H: Phase One Frequency Tables Appendix I: Table A Phase One: Focus Group Data ​ ist of Tables L Table 1: ​KTSE Elements Key 2:​ ​NWLM Elements Key 3:​ ​KTSE/NWLM Frequency Table 4: ​Dialysis Structural Empowerment Tool (condensed) 5:​ ​Dialysis Structural Empowerment Tool Results Page 41 42 43 45-47 48-49 Chapter 1 Introduction If one searches the internet for a dialysis nurse position, one will see many opportunities listed. The dialysis nurse is a registered nurse that specializes in nephrology nursing. Their responsibilities include caring for patients with impaired kidney function receiving hemodialysis or peritoneal dialysis. Rosenstock (2015), also noted that alarming warnings regarding burnout, strain, dialysis nurses feeling undervalued, overworked, and compensation concerns lead to perceived greener pastures elsewhere. Additionally, Rosenstock (2015) noted that there will be no improvement in the dialysis nursing landscape in the foreseeable future. To understand the current state of dialysis nurse retention factors which is critical in today's nursing shortage, this researcher performed a keyword search for "dialysis retention" and these terms appeared consistently: shortages, burnout, intention to leave, stress, job satisfaction, high turnover rates, and nurse-to-patient ratios. Understanding the rewards and stresses that dialysis nurses face may be relevant to retain nurses. For instance, intense relationships with the chronic dialysis patient and family produce stress and may also elicit recurring grief. A dialysis nurse manager's crucial task may be to implement stress management efforts to improve job satisfaction and workforce retention (Hayes, Bonner, & Douglas, 2015). Dialysis nurses have oversight of and perform life-sustaining treatments, and this is incredibly valuable for patients and organizations. A 2016 survey administered by Avantas, an American Mobile Nurses (AMN) Healthcare company, found that nearly 70 percent of nurse managers reported high levels of concern regarding the effects of nurse scheduling and staffing problems on the patient experience and patient satisfaction. Another 2016 survey by Nursing Solutions Incorporated (NSI) (2016), found 81.8 percent of hospital leaders said nurse retention is a key strategic imperative for organizational success. However, only 51.5 percent reported having a formal retention plan in place (Zimmerman, 2016). Therefore, the researcher will be creating a nurse retention learning module including information that reflects Kanter's Theory of Structural Empowerment as well as the Refined Nurse Worklife Model as one strategy to improve dialysis nurse retention. A select focus group of expert dialysis nurses providing peer review and a social media field study will be conducted following the development of the module, and evaluation by participants. Background of the Problem Retention concerns with dialysis staffing are not merely happening in the United States according to a study conducted by ​Karkar, Dammang, and Bouhaha (2015), who examined issues related to dialysis nurse stress; the r​esearchers are also identifying these issues internationally. According to the US Bureau of Labor Statistics (2018), 1.1 million additional nurses are needed to avoid an expanding shortage. Employment opportunities for nurses are projected to grow at a faster rate (15%) than all other occupations from 2016 through 2026 (Haddad & Tony-Butler, 2018). Exploring reasons why this is occurring in the dialysis industry is of interest to the researcher and retention very well may be one reason. Kanter's Theory of Structural Empowerment and The Refined Nurse Worklife Model can be applied to dialysis nurse retention conceptually. To examine an area of retention in nursing, the researcher will apply Kanter's Theory of Structural Empowerment which has been identified to have a strong effect on healthcare organizations. ​The theory can be measured regarding employee empowerment, morale, and job satisfaction. According to Kanter's theory, with the right tools, support, and information, employee skill sets improve. Additionally, with structural empowerment, employees increasingly make better decisions and accomplish more overall which benefits the organization greatly. Retention rates of employees in healthcare settings improve when Kanter's empowerment principles are applied. Kanter's principles have been implemented since the 1970s and used in large teaching magnet facilities and remain relevant today (Kanter’s Theory, n.d.). Statement of the Problem Turnover in nursing seems to be leveling off, but only after years of steadily climbing in rates (Haddad, 2019). According to Colosi (2016), the current national average for turnover rates is 8.8% to 37%, depending on geographic location and nursing specialty. ​While other disciplines' research on nurse retention can be applied to the dialysis nurse specialty, it is undetermined if other disciplines' retention studies are reflective of the dialysis nurse specialty factors absolutely, with certainty. The purpose of this research project is to determine which factors are influencing the retention of dialysis nurses. ​Additionally, it may be apparent to the dialysis nursing staff that there is an increasing problem with poor retention of dialysis nurses in the acute, chronic, and combination acute and chronic dialysis units. According to Wells (n.d.), it is important to note that when there is a constant turnover in any unit, (let alone a specialty unit like dialysis), this may not have the best quality outcomes. Furthermore, Antwi & Bowblis (2016) found that nurse turnover impacts quality of care and mortality in their study. Retention of dialysis nurses is a serious concern and has many implications for the quality of care for the end-stage renal disease population. Therefore, the purpose of this research is to determine which factors are influencing the​ ​retention of dialysis nurses and then create a learning module to raise awareness of typical dialysis-related stressors. By integrating Kanter’s Theory and the Revised Nurse Worklife framework within the proposed learning module, a possible solution to improving dialysis nurse retention may be offered. Research Question What factors influence the retention of dialysis nurses? Secondary question: Does the use of a learning module increase dialysis nurses’ “​intending to stay”​ ? Definition of Terms Dialysis- ​a medical procedure that removes “blood from an artery [and is] used to ​remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances by utilizing rates at which substances diffuse through a semipermeable membrane” (Merriam-Webster Medical Dictionary, 2019, para 1). Peritoneal Dialysis- ​a procedure performed in the peritoneal cavity in which the peritoneum acts as the semipermeable membrane ​(Merriam-Webster Medical Dictionary, 2019, para 1). Six Conditions for Empowerment: ● Formal Power- ​that which accompanies high visibility jobs and requires a primary focus on independent decision making ● Informal Power- ​comes from building relationships and alliances with peers and colleagues ● Opportunity for advancement ● Access to support ● Access to resources ● Access to information ​(Kanter’s Theory, n.d.). Need for the Study Retaining nurses within the healthcare system is a challenge for hospital administrators, therefore, understanding factors important to nursing retention is essential (Bugajski et. al., 2017). In acute environments and because dialysis has largely been outsourced in many healthcare organizations, often the dialysis department doesn't get included in various informational organizational surveys. Instead, dialysis-specific surveys are administered and maintained separately. For example, in the 2016 survey by Nursing Solutions Incorporated noticeably the "RN Turnover by Specialty" chart does not identify dialysis as a specialty, and no data for the dialysis specialty is included. This study may help fill the gap in knowledge with dialysis nurse retention factors. The high cost of nurse turnover can have a huge impact on an organization’s profit margin (Antwi & Bowblis, 2016). Rosenstock (2015) stated, “​If you work in dialysis, it's hard to deny there is a dearth of nurses across the board"​ (p.1). Besides, this "across the board" observation can be applied to dialysis nurse retention specific studies currently available (Hayes, Bonner & Douglas, 2015). The proposed study will create value by including and identifying current state dialysis nurse retention factors. By identifying these factors, this may allow leadership within the organization to identify potential solutions, thereby not only decreasing turnover rates but also increasing the quality and safety of patient care. Significance of the Problem It is evident through a simple job engine search for “dialysis nurse” that there are numerous vacancies nationally. For instance, a search on “Indeed” (an internet employment search engine) for a dialysis nurse yielded 9,069 jobs nationally (Dialysis nurse jobs, July 2019). The US Department of Labor Bureau of Labor Statistics website (BLS) (2018) noted that the general field of nursing will grow quickly by 2020, with a 26% increase in nursing jobs. Major increases in demand for dialysis nurses are happening for several reasons: ▪ Kidney disease is a common concern in the US. Approximately 10% of the U.S. population is affected, according to the CDC (BLS, 2018) ▪ Hypertension and diabetes are common and are a major cause of kidney ailments. The U.S. population is growing older, so most likely there will be a greater need for dialysis nurses (BLS, 2018). ▪ Kidney transplants are more successful today. However, dialysis is still the most frequent treatment modality for kidney disease (BLS, 2018). Assumptions ● Individuals will answer the questions honestly when using the learning module evaluation survey. ● Participants will complete the survey in its entirety. ● Participants will understand the questions being asked. Limitations ● Small sample and effect sizes in the pilot study. ● The potential for false positive or false negative results of the post-module evaluation survey. ● Although there are several benefits to the use of social media for the distribution of the post-module evaluation survey, the information exchanged needs to be monitored for quality and reliability, and the users’ confidentiality and privacy need to be maintained. Summary of the Problem Dialysis nurse retention is a real concern deserving investigation. Several subjects arise from an internet or periodical keyword search of "dialysis nurse retention." Most common terms such as nurse shortages, nurse to patient ratios, stress, high turnover rates, burnout, overworked, and satisfaction appear with retention search term findings. Cinahl, Cochrane Library, and MEDLINE search engines were utilized and some authors displaying the search terms include Buck (2017), Drennan, Halter, Gale & Harris (2016), Haddad (2019), Hayes, Bonner, & Douglas (2015), Karkar, Dammang & Bouhaha (2015). The dialysis landscape has changed over the past two decades and there is no foreseeable change in sight (Rosenstock, 2015). Recently, an executive order was signed by the current administration ​directing the Department of Health and Human Services to develop policies addressing three goals: reducing the number of patients developing kidney failure, reducing how many Americans get dialysis treatment at dialysis centers and making more kidneys available for dialysis treatment at dialysis centers and making more kidneys available for transplant (​Simmons-Duffin & Wroth, 2019). Another recent finding by a Duke University study discusses large dialysis chain for-profit organizations and how patient outcomes have declined. Coincidentally, highly skilled nurses were replaced with dialysis technicians in order to reduce labor costs, and patient loads (per employee) were increased by 11.7% and the number of patients being treated at each dialysis station grew by 4.5% (Duke University & Gaucher, 2019). Recently in California, Governor Newsom signed a bill (AB-290) which limits dialysis company profits (the State of California, 2019). With so much change on the horizon regarding dialysis care, particularly in the home setting, plenty of dialysis nurses will be needed to accommodate the increases and shifts due to any new policies the Department of Health and Human Services may develop to meet the proposed goals. With shortages and retention concerns as they are, retention and hiring plans should be in place, or at least being actively developed by the various dialysis facilities in response to the administration's latest kidney disease executive orders. Engaging with dialysis nurses to meet the demands is a great way for the successful implementation of new policies mandated from the executive level. Chapter 2 Review of Related Literature A literature review of information on the retention of dialysis nurses will be conducted. However, due to the paucity of information specific to dialysis nursing the research will examine several other clinical settings, i.e., medical-surgical nursing, and critical care nursing. Application of other specialties’ retention concerns may pose helpful in spearheading further research on the topic, retention of nurses in the dialysis setting. During a review of the literature, common variables were identified related to retention of nurses, i.e., stress and burnout, value congruence, intention to leave, professional autonomy and magnet recognition programs, job satisfaction, team collaboration, quality of care, and manager leadership competencies. Each of these areas will be discussed in further detail in this chapter. Stress and Burnout In a study by Karkar, Dammang, and Bouhaha (2018), the researchers examined stress and burnout on retention using a questionnaire derived from Sister Callista Roy's Adaptation Model. The researchers distributed questionnaires to 93 nurses which assigned numeric values to a stress scale with various stressor descriptors. Results of the study indicated that 79% of nurses experience mild level of stress, 16% moderate level of stress, and 5% with no reported stress in the workplace; additional results of the study related to burnout indicated that 42% of the dialysis nurses reported a moderate level of burnout, 32% reported a high level of burnout, and 26% reported a low level of burnout. Karkar et al., (2018), stated the results of their study have implications for nursing and hospital administration as well as educators. Implications that may include further assessment of the structural and managerial aspects of dialysis nursing, properly addressing the dialysis nurses' stress and burnout to prevent major crises, and providing continuous support and effective guidelines to enable the nursing staff. The results of the study by Karkar et al., (2018) were conducted in one outpatient dialysis unit and may be used as a basis for further studies in other dialysis settings. Karkar et al., (2018) reiterated that excessive and sustained exposure to stress may lead nurses to exit (intention to leave) the profession and consequently may contribute to the shortage of nurses. Karkar et. al., (2018) also describe types of stress which are specific to dialysis including: ● dialysis nurses encounter complex dialysis techniques ● sophisticated modern dialysis machinery ● strict infection (and disinfection) control policies and procedures ● increased work demands due to the growing volume of dialysis patients in need of treatments ● continuous shortage of dialysis professionals ● chronic relationships with patients and their families ● intense activities during initiation and termination of the dialysis treatment ● urgent interventions when life-threatening complications arise ● sudden confrontation with patients that may become verbally or physically abusive Karkar et al., (2018) quoted Hayes & Bonnet’s (2010) study indicating an inverse relationship between nurse stress and job satisfaction. Value Congruence and Intention to Leave In a 2013 study conducted by Dotson, Dinesh, Dave, Cazier, and McLeod the researchers examined the environment in which nurses choose to work, rural or urban. According to Dotson et al., (2013), the nursing shortage is even more severe and more demanding in rural areas. The purpose of the study was to identify and describe rural nurses and their satisfaction levels and identify the most important factors. There were 976 female and 33 male participants that were either Associates, Bachelor, or Master prepared responding to an unnamed survey instrument developed from a review of the literature and focus group findings. The results yielded four statistical cluster group categories titled: ambivalent, leave the job but keep profession, leave job and profession, and keep job and profession. According to Dotson et al., (2013) 52 % of the nurses surveyed wanted to keep their current job and stay in the nursing profession, 30% wanted to leave their current job and stay in the nursing profession, 13% had ambivalence toward job and profession, and 5% wanted to leave the current job and leave the profession. Important factors for keeping their rural job were identified as job satisfaction, value congruence, and ability to fulfill altruistic needs. Low pay and stress were the key factors for rural nurses leaving their jobs and/or profession. The researchers also stated that if nurses perceive that management values are in alignment with their own, there is an increased likelihood of retaining nurses. "Value congruence" was a key term in the study by Dotson et al. (2013) which was identified as a potential strategy for management to align their values with the nurse values to increase retention of nurses. It is important to note that Dotson et al. mentioned that this may be a focus for further study, the role of value congruence in the healthcare environment. The researchers noted that the nurses were happiest when they experienced the greatest levels of value congruence in the organizations studied. The researchers identified value congruence, stress, and economics as key variables for the retention of nurses in rural areas. The researchers also proposed that nurse retention may be impacted by increased professional autonomy which, if enabled by a network of support, would allow nurses to fulfill their altruistic needs while at the same time reducing stress. According to the researchers, organizations should organize policies and procedures with increased buy-in and input of nurses, in addition to evidence-based practice. Another study conducted by Van den Heede, et al. (2011), examined the impact of nursing practice environments, nurse staffing, and nurse education on nurse reported “intention to leave” the hospital environment. An analysis was performed on data gathered from a survey using 56 hospital nurses who worked in the acute environment on medical-surgical floors. A portion of the data was gathered from specific focus group interviews with six chief nurse officers in high performing and low performing hospitals; performance was defined as turnover rates. Van Heede et al. (2011), noted that high performing hospitals had lower staff turnover. In the study by Van Heede et al., (2011), a common theme noted that 29.5% of nurses surveyed have an “intention to leave” the hospital. This statistic resembles the findings of the study conducted in 2013 by Dotson, et al. (2013); the results of Dotson et al (2013) research identified 30% of nurses “wanting to leave their current job and stay in the profession." Additionally, the Van den Heede et al. (2011) research cited that high performing hospitals with higher retention rates were notably characterized by a flat organization structure with a participative management style, structured education programs, and career opportunities for nurses. The study concluded that improving nursing work environments is a key strategy to retain nurses and this is done through the Magnet Recognition which fosters nurse autonomy in decision making, participation in hospital governance, and participative unit management in a hospital setting. In a study conducted by Sawatzky, Enns, and Legare (2015), the researchers examined the key predictors of retention in nurses working in critical care units. Utilizing the conceptual framework for Predicting Nurse Retention, the researchers determined that 24% of their respondents have an intention to leave the critical care setting within the next year. The researchers also noted that intention to leave was influenced by organizational factors directly, while intermediary factors of job satisfaction, engagement, compassion satisfaction, and burnout were convincing predictors of intention to leave. The study delivers insight for nurse leaders to develop strategies to improve retention efforts of critical care nurses, as well as in other areas. Although Sawatzky et al., identified that their findings may not support applicability in other units within the hospital setting. With further literature review searching another category related to retention of nurses involves the role magnet environments and leadership have on the retention of nurses and will be discussed further in the next section. Magnet Environments, Leadership Capability & Retention Hairr, Salisbury, Johannsson, and Redfern-Vance (2014) examined the relationships between nurse staffing, job satisfaction, and nurse retention in acute care hospital environments. The research identified important variables which included: magnet hospitals have lower patient morbidity and mortality rates, have optimal outcomes for patients, and greater nurse satisfaction and lower turnover rates. The results of the study included descriptive statistics of the nurse to patient ratios which derived a weak positive relationship and an implication that there is a relationship between workload and job satisfaction. Additionally, Hairr et al., (2014) examined whether or not there was a correlation between job satisfaction with nurse retention. Data results indicated an inverse relationship between job satisfaction and nurse retention which indicates as job dissatisfaction increases, the more likely a nurse will think about leaving their nursing position. Another study by Twigg & McCullough (2014) reviewed the literature looking for strategies that support nurse retention. In their review, strategies to create a positive practice environment that contributes to the retention of nurses included: RN participation in hospital affairs, nursing foundations for quality care, nurse manager ability, leadership and support of nurses, staffing and resource adequacy, and collaborative nurse-physician relationships which are indicative of a magnet environment. Aiken et al., (2011) is an important study that looked at nurse staffing ratios concerning retention. The researchers noted that the nursing practice environment directly impacts nurse retention and the quality of patient care. Supporting the study conducted by Aiken et al., Kutney-Lee et al., (2015) compared non-magnet hospitals to magnet hospitals, and their results provided evidence that magnet recognition, in general, is an intervention that may result in improved nursing and better patient outcomes. Using the opposite approach of intent to stay (versus intent to leave), Buck (2017) discussed appreciative inquiry (AI) as a means for building a sense of community as an organizational development tool. In the 2017 study conducted by Buck, the researcher examined whether or not the use of AI could provide a framework for improving the sense of community, and if a heightened sense of community would lead to improved intent to stay working in the hospital. The participants completed the Sense of Community Index 2 tool which examines the perception of the sense of community of participants. Twenty-two nurses participated in a pre and post evaluation survey as part of the study. The results of the post-summit demonstrated an increase in the likelihood of leaving with two participants attributed to career growth. For those RN's reporting unlikely in the pre-summit survey, there was a two participant change indicating an intention to stay increasing. Therefore, AI may be a useful framework for increasing the community and promoting the intention to stay. AI evaluates current workplace circumstances, indicates what is positive, and builds upon the positive-present for a desirable future. The use of Buck's (2017) concept of "intention to stay" rather than a focus on "intention to leave" may pose useful within the learning module that will integrate Kanter's Theory of Structural Empowerment for the proposed project. A review of the literature revealed a two-part study by Baptist Health in regards to nurse retention. Lengerich et al (2017) led part one and Bugajski et al. (2017) was the principal for part two. Lengerich et.al. (2017) discusses in part one a 2015 survey conducted by American Mobile Nursing (AMN) Healthcare. The AMN survey data was collected from 8828 RN's. The AMN survey revealed that 30% of nurses feel like leaving their position (intent to leave), 50% believed that their jobs are adversely affecting their health, and 52% agreed that the quality of nursing care has declined since they started their career. Lengerich et. al. (2017) administered the part one Baptist Health Nurse Retention Questionnaire (BHNRQ) to 279 bedside nurses at 391-bed magnet hospitals. Results were divided into three subscales: 1) nursing practice, 2) management, and 3) staffing. Nurse retention factors were identified and the following factors were ranked as “very important” to “not important.” ● flexible scheduling ● competent management ● management that supports staff ● recognition of staff for good work ● the manager is engaged in the unit ● clinically competent colleagues ● sufficient nursing staff ● sufficient ancillary/support staff ● positive relationships with physicians ● nurses and physicians function as a team ● support for autonomy to practice effectively ● quality care is provided The statistical data is made transparent in part two of the Baptist Study, by Bugajski et. al. (2017) where the results suggested that regardless of generation, nursing degree, unit, or years of nursing experience, nurses share similar concerns associated with retention. The researchers suggested that managers need basic competencies regarding patient care, excellence in leadership qualities, engagement with clinical nurses, and presence in the unit. These nurse manager characteristics are necessary if staff nurses are to remain in their positions. The Part Two Baptist study also notes that through management, staffing, scheduling, and support enable nurses to remain in their positions. This researcher believes it is interesting to note that it is unknown if the dialysis RN were included within the medical-surgical area highlighted in the results of part two, and it was difficult to determine if the dialysis nurses were included as participants within the specialty units category. Therefore, this researcher proposes that there is a gap and the proposed study will help fill the gap in the literature, discussed in the next section of this chapter. Gaps with Inpatient, Home-Setting, and Outpatient Dialysis Nurse Retention In 2015, Hayes examined several international renal nurse stress, burnout, and retention studies. However, many of these studies were greater than five years old, and not conducted in the U.S.A. Several of the studies this researcher has identified in this literature review are greater than five years old, therefore, the proposed study may provide more recent and important information related to retention of dialysis nurses. Nonetheless, relevant information from the research conducted by Hayes is valuable in identifying what is not known about the problem of dialysis nurse retention. This researcher believes it is important to note that several factors in the study on stress and burnout (Hayes, 2015) correlated with several previously conducted studies (Bugaiski et. al. (2017), Hairr et. al. (2014), Karkar et. al. (2018), & Lengerich et. al. (2017). These factors included: ● years of work as a nurse ● weekly work hours ● number of night hour duties (on-call expectation) ● number of patients cared for each day ● stress related to the risk of contamination from patient ● death of a patient ● increased responsibilities ● low involvement in decision making ● limited resources ● busyness as the main stressor ● continuous high level of stress throughout the workday ● perceived unrealistic expectations of the patient in the outpatient setting ● lack of advancement Additionally, the researcher noted that older staff and staff with a greater length of service in dialysis appeared to have higher levels of burnout, distress, and job dissatisfaction, and lower education levels increasing stress levels. The information presented by Hayes (2015) also suggested that hemodialysis nurse managers ought to undertake regular staff satisfaction surveys as part of on-going quality improvement. Additionally, Hayes identified a lack of current knowledge and research into job satisfaction, stress, and burnout for hemodialysis nurses (which directly relate to retention) and that further research and solutions are necessary. Therefore, this researcher proposes developing a learning module integrating Kanter's Theory of Structural Empowerment within the context of dialysis nurse retention. This module may be offered as a new-hire orientation strategy for reducing the turnover of dialysis nurses. By equipping nurses with the principles of structural empowerment, retention concerns may be reduced. The learning module for the researcher's DNP project will be pilot tested for clarification purposes and then implemented in a field study and completed by participants. Theoretical Framework Kanter's Theory of Structural Empowerment as a conceptual framework is most relevant in the growing problem of dialysis nurse retention. The various stress, burnout, and retention factors in Hayes's (2015) thesis align with Kanter's Theory and the Six Conditions of Empowerment. Opportunities for advancement, availability of support and information, availability of resources, informal and formal power, and manager leadership qualities have been mentioned in the literature reviewed. Nurse educators have used Kanter’s theory as a framework in research involving innovative behavior and correlations with structural empowerment (Hebenstreight, 2012). In 2008, Larkin, Cierpial, Stack, Morrison, and Griffin applied Kanter's Theory within nursing to collaborative governance and as a central framework for magnet implementation and achievement within hospitals by researchers Armstrong and Laschinger in 2006. Additionally, the theory has also been utilized by physical therapy (Miller, Goddard & Laschinger, 2001), and university psychologists (Obragambidez-Ramos & Borrego-Ales, 2014) as a framework for understanding empowered employees. One hallmark concept in Kanter's Theory is having an opportunity for advancement; some inpatient and outpatient settings offer clinical advancement programs for dialysis nurses. For instance, one for-profit dialysis global dialysis giant offers the Career Advancement Program (CAP) for dialysis nurses. Despite offering CAP, in a recent Duke University study by Gaucher (2019), outcomes of for-profit dialysis outpatient centers have been declining as well as the number of qualified dialysis nurses performing the treatments that have been replaced by dialysis technicians increasingly over the past decade. In addition to using Kanter’s theory, the researcher will incorporate another framework into the learning module, which is the refined Nursing Worklife Model by Laschinger, and Manoljlovich (2007). The refined Nursing Worklife Model demonstrates the role of empowerment in creating positive practice conditions that contribute to job satisfaction. Using the refined Nursing Worklife Model, there are seven domains addressed in the learning module: 1) empowerment, 2) nursing job satisfaction, 3) strong leadership, 4) adequate staffing and resources, 5) collegial RN/MD relations, 6) participation in hospital affairs and 7) Nursing model of care. Each element will be discussed in the learning module. By doing so, the researcher's dialysis nurse work-life theory may be perceived as a positive tactic to improve dialysis nurse retention and address burnout. Summary of the Review of Related Literature In summary, this chapter contained a review of the literature relevant to the retention of dialysis nurses. Specific gaps of knowledge in the literature were identified related to the retention and satisfaction of dialysis nurses in the work environment. Because of the lack of research specific to the dialysis setting regarding retention of dialysis nurses, other clinical settings' literature is drawn upon for analysis and synthesis of the topic. Common variables were identified related to retention of nurses including stress and burnout, value congruence, rural nurse shortages, intention to leave or stay, professional autonomy and magnet recognition programs, job satisfaction, team collaboration, quality of care, and manager leadership competencies. Each of these areas was discussed in this chapter. Kanter’s Theory of Structural Empowerment will act as the key guiding framework as well as The Refined Nurse Worklife Model for the development of the learning module, which is the proposed project. Each of the points in the theory: an opportunity for advancement, access to information, access to support, access to resources, formal power, and informal power can be examined by the researcher and integrated within a learning module that could be pilot-tested for clarity and then implemented in the proposed project. The researcher proposes that perhaps the development of this module may provide an instrument that may be used as a new-hire orientation tool resulting in the reduction of dialysis nurse turnover. During the search of the literature, it was noted that there was a lack of knowledge concerning burnout and empowerment among HD RNs. Thus, more research is needed with HD RNs working within different healthcare systems and settings (university hospitals, affiliated hospitals, and satellite HD facilities) to better prevent the occurrence of burnout and promote the well-being of these RNs (Dore, Duffet-Leger, McKenna, & Breau, 2017). As noted by Weaver, Hessels, Paliwal, and Wurmser (2019), effective collaboration and communication are vital for creating work environments conducive to excellence in patient quality and safety. By creating the structural empowerment learning module, educating staff dialysis nurses about stress, burnout, Kanter's Theory of Structural Empowerment, and The Refined Nurse Worklife Model in specific dialysis-related context, a strategy for increasing dialysis nurse retention may be implemented for the researcher's DNP project. Chapter 3 Methodology The purpose of this chapter is to describe the methods for carrying out the proposed project. Regarding dialysis nurse retention, the researcher plans to use Kanter's Theory of Structural Empowerment and The Refined Nursing Worklife Model as a framework that will be the primary driver for the creation of the dialysis-specific retention learning module. Upon approval from the Institutional Review Board (IRB), a small focus group of consenting experienced dialysis nurses will be conducted for clarification purposes/peer review for the proposed learning module as well as purposeful program evaluation. Evaluation of the module will be helpful in order to improve or make changes prior to launching the proposed project through social media in various online dialysis nursing user groups. Purpose of the project Retaining nurses within the healthcare system is a challenge for hospital administrators, therefore, understanding factors important to nursing retention is essential (Bugajski et. al., 2017). In acute environments and because dialysis has largely been outsourced in many healthcare organizations, often the dialysis department doesn't get included in various informational organizational surveys. Instead, dialysis-specific surveys are administered and maintained separately. For example, in the 2016 survey by Nursing Solutions Incorporated noticeably the "RN Turnover by Specialty" chart does not identify dialysis as a specialty, and no data for the dialysis specialty is included. The implementation of a learning module may help with dialysis nurse retention factors. Research Question What factors influence the retention of dialysis nurses? Secondary research question Does the use of a learning module increase the retention of dialysis nurses? Research Design After obtaining IRB approval, the learning module that was created integrating Kanter’s Theory of Structural Empowerment and The Refined Nurse Worklife Model will be implemented via various online dialysis nursing user groups via Google Slides. As individuals access the learning module, at the beginning of the survey questions will be asked to gather descriptive statistics regarding factors that influence the retention of dialysis nurses, e.g., educational level, years of experience, area of dialysis: acute or chronic. These statistics may provide data for supportive use of the learning module and provide insight as to the retention of dialysis nurses. Setting A focus group of expert dialysis nurses that work in either chronic or acute dialysis units will be engaged for the first phase of the project which will be conducted virtually (due to the pandemic). The expert nurses have a history of working in small or large academic teaching hospitals, rural or urban areas throughout the United States, with adult or pediatric experience, and with hemodialysis or peritoneal dialysis experience for the proposed focus group study to consist of a two-week review period. Upon implementing any changes from the focus group feedback, the proposed learning module will be presented via social media dialysis nurse user groups, social media platforms such as Facebook dialysis nurse user groups, LinkedIn dialysis user groups, and the AllNurses.Com website dialysis user groups. All dialysis nurse settings will be engaged, for instance, chronic (outpatient environments), acute (inpatient environments), and home care dialysis nurses. Sample The random sample will consist of male or female dialysis nurses (Ph.D., DNP, MSN, BSN, Diploma, or Associate prepared RN or LPN) that perform acute or chronic dialysis therapy in a hospital or home setting. The process for selection was determined with the rationale of capturing both acute and chronic dialysis nurses that are knowledgeable in dialysis care. The sample for the Phase One focus group was determined to be a small group of no more than fourteen experienced dialysis nurses having three or more years of professional experience in dialysis. The allotted time frame for the proposed Phase Two Social Media field project will be thirty days. During those 30 days, the researcher anticipates collecting data from as many as 400 participants. However, researchers will allow an additional two weeks to obtain an adequate sample. Ethical Considerations Prior to undertaking the proposed project, the researcher has completed the CITI training to ensure the rights of the participants have not been violated. By using Google Slides to deliver the learning module, the dialysis nurses will be protected from violation of human rights by withholding their names attached to any feedback obtained in the focus group interviews and the implementation of the project itself. For the proposed project, which will be performed in dialysis nurse user groups via social media, no names will be collected associated with the learning module or post evaluation collected in Google Forms, thereby maintaining the anonymity of any participants. Upon completion of the proposed project, all data will be downloaded from Google Forms on a flash drive and secured in a locked office at the home of the researcher. All data will be kept for five years and then destroyed. Participation in the proposed project is strictly voluntary, and there will be no repercussions for not completing the module. Additionally, there will not be any financial rewards for completing the module. The researcher considers it important that all ethical considerations related to privacy, anonymity, and protection of data will be adhered to. Informed consent will be obtained by the participants upon opening the learning module within Google Forms. Instrumentation The research tools include 1). Learning module. 2). Post learning module evaluation feedback tool (Scepura Dialysis Structural Empowerment Tool). While the learning module was developed mostly based on Kanter’s Theory and The Refined Nursing Worklife Model, the module will first be pilot tested using a small group of experienced dialysis nurse participants to determine the reliability and validity of the instrument. A participant agreement (see Appendix A) will also be needed and a post-evaluation (Dialysis Structural Empowerment Tool) link to Google Forms will be voluntarily filled out by the participants to obtain the descriptive statistics related to the effectiveness of the learning module and other factors related to the content of the learning module. The specific learning module is included in this document within Appendix B. The specific post-learning module questionnaire (Scepura Dialysis Structural Empowerment Tool) is also included in Appendix C and represented in Table 4. Data Collection The first step in the process will be for the researcher to obtain IRB approval for doing the project. The next step will be to deliver the learning module to a select focus group. Evaluation feedback will be collected for clarification of information contained within the learning module. Additional information obtained from the focus group will be used for refinement and improvement of the learning module. The focus group participants will be given two weeks to review the learning module and supply evaluation feedback. Once the feedback is collected by the researcher one to two additional weeks will be needed to implement the improvements prior to the social media field project launch. Clarifying interviews with participants to review KTSE and NWLM elements of concern will occur and the focus group participants will validate through teaching back to the researcher the KTSE and NWLM domains that will be coded for frequency measurement and verified with the participants. Over a thirty-day period, the proposed project will be disbursed via dialysis nurse user groups on various social media platforms such as Facebook and LinkedIn, or AllNurses.com dialysis user groups. The evaluation data will be automatically collected via Google Forms. An additional two weeks will be added if a small sample is present. Data Analysis Data from the field test will be collected via Google Forms. Google Forms offers a number of data analysis templates. A simple frequency chart may be examined for any comparisons. Data will be displayed in table, figure, or scatterplot format to illustrate feedback from participants. The data will be analyzed either in a simple frequency or table chart analysis. The variables of interest related to the learning module participant evaluation responses and the demographics of the participant population, such as RN level of education, years of dialysis experience, and age groups of participants. Any comparisons will take the demographic questions and relate them to the learning module content questions. Determining whether the learning module would be valuable as a potential onboarding dialysis nursing tool is something important to analyze also, thus a specific question related to this is included in the post-learning module questionnaire. There will also be an opportunity for the dialysis nurses to contribute to the free text within the questionnaire for any other stress factors or retention factors that may be absent from the content of the learning module. Determining descriptive statistics in regard to questions related to the elements of Kanter's Theory of Structural Empowerment or The Refined Nurse Worklife Model within the various dialysis workplaces would also be helpful to evaluate. Therefore, questions related to for-profit, or not-for-profit environments are included as well as whether the workplace of the dialysis nurse is an outpatient freestanding clinic, outpatient hospital clinic, or a blended outpatient and inpatient hospital setting. Understanding whether inpatient or outpatient dialysis nurses have more or less exposure to structural empowerment elements is helpful in demonstrating any deficits that would be described later in the discussion and perhaps the conclusion sections of the project. A mock-up of just one potential example of collected descriptive statistics is included in Appendix D for review to illustrate how several other questions may be evaluated and depicted for the DNP project. Time Schedule Once the learning module is created it will be disbursed to the focus group participants with a two-week time period for review and evaluation. The researcher will then use the next two weeks to implement corrections to enhance the learning module. Once this achieved, a thirty-day launch and collection time period for the learning module via social media will transpire. An additional two week period will be offered if more participants are needed. Summary of Methodology Kanter's Structural Empowerment Theory and The Refined Nurse Worklife Model offer a framework for the goal of improving dialysis nurse retention and burnout concerns. By creating a learning module with dialysis-specific content that illustrates the concepts and domains of the frameworks proposed, a strategy for addressing retention may be achieved. Collecting feedback from the proposed focus group will assist with fine-tuning the learning module and deliver valuable exercise in the proposed field test. Retention rates of dialysis nurses in various settings are a challenge. By teaching dialysis nurses about structural empowerment and the other concepts and domains of the suggested frameworks a tactic to ameliorate turnover can be actualized. CHAPTER 4. Results and Discussion The purpose of this chapter is to discuss the results of Phases One and Two of the research conducted regarding retention, burnout, and stress factors and the dialysis nurse in the various settings in which they work. Phase One entailed enlisting ten expert dialysis nurses that reviewed a learning module that the researcher compiled. Once the nurses reviewed the learning module, they provided feedback as to what to improve and what to scale back. The feedback was not only applied to the learning module but also the Dialysis Structural Empowerment tool that the researcher developed for post-module evaluation. The tool was developed specifically from Kanter's Theory of Structural Empowerment and The Refined Nurse Worklife Model with additional questions regarding frustration, burnout, and power. After the feedback was collected, the principal investigator and co-investigator added questions to clarify some concerns regarding the indication of powerlessness. The findings will be broken down by the phases, in order. Phase One Results Originally the study was to be conducted within two major magnet hospitals in the New England area. After the co-investigator had sent out request letters to the hospitals, a major pandemic hit the entire globe and suddenly seemed an inopportune time to research "retention and burnout" in the dialysis setting "for obvious reasons" one of the managers wrote back to the co-investigator, and the other manager at the other hospital telephoned with a similar sentiment. Because of the time-sensitive nature of the DNP Project, the research project was slightly altered, and instead, a focus group of expert dialysis nurses from across the United States was engaged to complete the task of providing feedback on reviewing the learning module and perfecting it. Also, they were asked to consider the tool and ensure that the questions reflect Kanter's Theory of Structural Empowerment and The Refined Nurse Worklife Model elements. They did so over two weeks. Fourteen experts were invited to participate and ten volunteered within the prescribed time frame. The focus group provided written feedback, as well as a telephone interview. All written feedback was typed into an excel spreadsheet and separated by order in which nurses responded. As the nurses responded they were ascribed a number in chronological order, for example, RN #1, RN#2, RN#3, etc. Next, the gender of the RN was identified and recorded by the RN #. Following this demographic, the state in which the RN last practiced as an RN was documented for this study. Of the ten nurses interviewed, they came from different regions of the USA. There were a total of seven different states where the nurses practiced: 2 in TX, 1 in PA, 1 in CA, 2 in WA, 2 in MA, 1 in NV, and 1 in NC. Next, the researcher identified the most recent role that the expert dialysis RN was the last practicing in which included acute, chronic, blended acute/chronic hospital-based units, adult population, pediatric population, peritoneal dialysis RN, for-profit or not-for-profit organizations, and rural or urban settings noted. The number of years of nursing (in general) was noted ranging from the lowest 17 years and the highest 48 years of participants. Next, the number of specific years of working within the dialysis RN specialty was recorded. The lowest was 7 years and the highest at 40 years. Each of the expert dialysis nurses was asked if they were or ever had been burned out and notes taken and added to Table A (Appendix I) in the ​Defense DNP Project PowerPoint s​ lide show indicating such. From the written information that the expert dialysis nurses provided and reviewing the learning module with the nurses, specifically Kanter's Theory of Structural Empowerment and The Refined Nurse Worklife Model each nurse described in "teach-back" format the specific theory elements the concerns that they originally raised, toward any deficits of elements in the workplace. In other words, their feedback was translated into the codes that were ascribed to each of the domains of KTSE and NWLM. Concretely, in Kanter's Theory of Structural Empowerment, Opportunity for Advancement was given the letter code A, Informal Power given the letter code B, Formal Power C, Access to Resources D, Access to Information E, and Access to Support F. For The Refined Nurse Worklife Model Elements, Empowerment was given small letter a, Nursing Model of care given small letter b, Participation in Organizational Affairs given small letter c, Collegial RN/MD Relations d, Adequate Staffing, and Resources e, Strong Leadership f, and Nursing Job Satisfaction g. By simply creating a frequency chart (Appendix H) and then creating ticks and summing each concern code of each theory element, the highest frequency and lowest frequency concern codes of KTSE/NWLM elements were determined and are exhibited in Table B below. KTSE/NWLM concern codes before tabulation: Simple keys below identify a Table 1: KTSE Elements Key KTSE Elements Key Concern Code Opportunity for Advancement A Informal Power B Formal Power C Access to Resources D Access to Information E Access to Support F Table 2: NWLM Elements Key NWLM Elements Key Concern Code Empowerment a Nursing Model of Care b Participation in Organizational Affairs c Collegial RN/MD Relations d Adequate Staffing and Resources e Strong Leadership f Nursing Job Satisfaction g Once the interview and teach-back from expert nurses were performed of KTSE/NWLM elements and their responses, the following descriptive objective data was extracted, tabulated, and summed: Table 3: KTSE/NWLM Frequency Table KTSE/NWLM Element Code Frequency Table RN# A 1 2 1 B C 1 1 1 1 1 1 1 3 4 E 1 5 1 6 1 1 1 1 8 1 1 1 1 a b 1 c d 1 1 e f g 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 F 1 1 7 Sum D 1 1 1 1 1 9 1 1 1 1 1 1 10 1 1 1 1 1 1 9 6 9 3 3 4 5 1 4 2 8 8 4 As mentioned previously, fourteen participants were engaged initially but only ten were able to participate. One nurse participant from Hawaii was struck with Covid-19 and was unable to continue with the study. Since then, the nurse has fortunately recovered. The other three nurses were unable to continue participating in the study because at each of their facilities the demand for dialysis nursing was too great and these nurses were working many hours of over-time because colleagues of theirs had been exposed and symptomatic and their units were sharply short-staffed. Two of the nurses were in the greater New York City area, and one in the Research Triangle Park, NC area. After the process of teach-back occurred with KTSE/NWLM, the researcher continued interviews with the expert dialysis nurses and conversations involved specific improvements to be made to the learning module and the tool developed by the co-investigator. While some expert nurses answered the tool questions specifically, others provided more in-depth and lengthy subjective feedback, which will be included in the defense PowerPoint presentation of the DNP project. One expert dialysis RN raised an important and valuable question concerning the title of the presentation regarding "​Intending to Stay”​ and how that relates to the study. The participant felt that this piece needed further clarification on how KTSE/NWLM would improve intentions of staying and improvements to the learning module slides with clarifying language were added. It was explained that when elements of the theories are deficient in the workplace that nurses may remain in flux and lesser states of structural empowerment and perhaps frustrated in their working environments, which may or may not lead to an intention to leave (or decrease ​intentions of staying​). It was Dr. Buck who wrote in ​Retention Remedy​ (2017), that we build a sense of community through appreciative inquiry and improve ​intentions of staying​ that inspired the researcher with the title. Dr. Buck chose the positive stance of looking at staying rather than leaving in her study, and this researcher wanted to do the same, especially with retention concerns as they are in the dialysis industry (Rosenstock, 2015). Phase Two Results A copy of a simple flyer (see Appendix F) was placed on LinkedIn, Facebook, and AllNurses.com dialysis user groups. The flyer contained a live link where the dialysis nurse participant could navigate to the learning module to partake in program evaluation. At the end of the learning module, a link to the Dialysis Structural Empowerment tool that the co-investigator designed was also linked to a Google Forms survey that was secure. Below is a copy of the questionnaire (which is the same data as in Appendix C, but only in a more comprehensive chart view) and the possible choices that were asked. Most questions were yes/no, some with multi-choice for the quantitative aspect, and four questions had free text boxes to obtain qualitative feedback. The results follow in the second table below (except for four free text box questions # 4, 9, 10, and 16 which are only present in Appendix C) qualitative data. Table 4: Dialysis Structural Empowerment Tool (condensed) Question Possible Choices Less than a year, 1-2, 2-5, 5-10, >10 1 How long do I intend to stay in my dialysis RN job? years 2 There is adequate access to informal or formal power in my dialysis workplace. Yes/No 3 There are enough dialysis nurses present at work each day. Yes/No 4 What other dialysis nurse retention factors are missing from this presentation? Free Text Box This module may help with retention if presented during the onboarding of new nurse 5 hires. Yes/No 6 There are enough opportunities in my organization for advancement to retain my service. Yes/No The organization I work for supports my education with mentorship, tuition 7 reimbursement, and supports my advancement. Yes/No 8 Our team collaborates well with each other. Yes/No 9 I have enough access to resources. If not, what sort of resources would you like more of? Free Text Box Are there other dialysis stress factors missing from this presentation? If so, what are 10 they? Free Text Box 11 I am paid fairly for my work compared to other nurses in other specialties. Yes/No 12 My work-life balance is stable with my dialysis RN position. Yes/No 1-3, 3-5, 7-10,10 or 13 I practice self-care activities on how many times per week. > 14 I feel burned out. Yes/No 15 Have you ever left a dialysis organization because you felt burned out? Yes/No 16 How can this learning module be improved? Free Text Box 17 I feel frustrated with my work situation. Yes/No 18 Do you feel powerless about your work situation? Yes/No 18-24, 25-35, 36-45, 19 My age is: 46-55, 56 and > Ph.D., DNP, Diploma, Associate, 20 What is the highest degree you have completed? Bachelor, Master 21 What is your gender? Male/Female 1-3, 3-5, 7-10, 22 How many years have you worked as a nurse in a dialysis setting? 10-20, 20 or > Strongly Agree, Agree, Somewhat Agree, Neither Agree nor Disagree, Somewhat Disagree, Disagree, 23 I learned something from this learning module. Strongly Disagree 1. Outpatient, freestanding clinic, 2. Outpatient, hospital-based clinic 3. A blended unit where there is a mix of inpatient and outpatients in a hospital setting 24 I work in this type of dialysis setting: 4.Inpatient setting For-Profit/Not for 25 My organization is: Profit USA, Canada, UK, 26 What country do I live in? Other 27 Has the recent pandemic influenced your responses to the questions? Yes/No These are the results: Table 5: Dialysis Structural Empowerment Tool Results Q# Results n size 1 38.2% 10 or > , 28.5% 5-10 yrs, 17.6% 2-5 yrs, 5.9% 1-2 yrs, 11.8% less than a year 34 2 58.8% Yes, 41.2% No 34 3 55.9% No, 44.1% Yes 34 4 27 Free Text Box Responses 27 5 88.2% Yes, 11.8% No 34 6 58.8% Yes, 41.2% No 34 7 73.5% Yes, 26.5% No 34 8 76.5%, 23.5% No 34 9 22 Free Text Box Responses 22 10 26 Free Text Box Responses 26 11 67.6% Yes, 32.4% No 34 12 52.9% Yes, 47.1% No 34 13 52.9% 1-3, 35.3% 3-5, 5.9% 7-10, 5.9% 7-10 34 14 52.9% No, 47.1% Yes 34 15 55.9% No, 44.1% Yes 34 16 19 Free Text Box Responses 19 17 55.9% No, 44.1% Yes 34 18 64.7% No, 35.3% Yes 34 19 0%= 18-24, 30.3%= 56 and >, 27.3%=46-55, 24.2%= 25-35m 18.2%=36-35 33 20 51.5%= Bachelor, 27.3% = Associate, 12.1%= Diploma, 9.1%=Master, 0%=DNP, 0%=PhD 33 21 87.9%= Female, 12.1%= Male 33 22 32.4%= 20 or >, 29.4%= 10-20, 14.7%= 1-3, 11.8%= 5-10, 11.8%=3-5 34 50%= Agree, 23.5%= Strongly Agree, 14.7%= Neither Agree or Disagree, 8.8%= Somewhat 23 Agree, 2.9%= Disagree, 0%= Strongly Disagree 34 32.4%= Outpatient freestanding clinic, 32.4%= Blended Unit inpatient and outpatients in 24 hospital setting, 23.5%= Inpatient setting, 11.8%= Outpatient, hospital-based clinic 34 25 64.7% For Profit, 35.3% Not for Profit 34 26 85.3% USA, 0%= Canada, 0%= UK, 14.7%= Other 34 27 55.9%= No and 44.1% Yes 34 Discussion of Results Appendix C is a copy of the Google Forms results that depict several pie charts. Four of the questions (#4, #9, #10, and #16) on the Dialysis Structural Empowerment Tool are free text boxes that are out of chronological order, but immediately follow the series of pie charts in Appendix C. Review: Research Questions What factors influence the retention of dialysis nurses? Secondary question: Does the use of a learning module increase dialysis nurses’ “​intending to stay”​ ? Question One: How long do I intend to stay in my dialysis job? (34 responses) Thirteen respondents equaled 38.2% of the category representing 10 years or greater. Nine respondents equaled 26.5% of the category representing 5-10 years. Six respondents equaled 17.6% of the 2-5 year category, four respondents equaled 11.8% of the less than a year category, and two respondents equaled 5.9% of the 1-2 year category. Some interesting points include that the three largest sections of the pie represent two years and greater intention of staying. If you combine the top two slices of the pie chart, this equates to 64.7% (nearly 2/3 of RN respondents) indicating their intentions of staying are five years and greater. However, while examining the two lesser sections or percentages of the pie, they equate to 11.8% and 5.9% which summed equals 17.7% of RN participants intending to leave in two years or less. If this were a larger study sample, this might seem like a high turnover rate over two years, conceptually. Having worked in dialysis management, losing 11.8% of an RN workforce within one year or less is a concern. True, some dialysis nurses may be retiring, relocating, or advancing, career transitioning, or several other reasons they may not intend to stay. The retention factors in the learning module relate to this question as well. For instance, all the factors listed in the learning module are part of the 11.8% that a manager will not be retained within one year or less. Nonetheless, 38.2% of respondents reported intending to stay ten years or greater. This indicates either satisfaction or a need to stay in the position. Question Two: There is adequate access to formal and informal power in the dialysis workplace. Yes or No. (34 respondents) The results were 58.8% of the respondents (or 20) answered yes, while 41.2% (or 14) respondents answered no. So, when reflecting on the research questions per se, and retention or intention to stay, one cannot make a definitive claim that this question answers the research questions. However, concerning Kanter's Theory of Structural Empowerment one might look at this percentage and round it to the nearest tenth to 59% Yes and 41% No. This indicates only a slight majority by 9% of the affirmative responders. This would indicate that a slight majority perceives there are appropriate channels to access power in their workplace. This question is interesting in that further analysis by adding more questions about the type of power they specifically perceive not having access to would have been helpful, whether informal or formal. This question reflected Kanter's Theory of Structural Empowerment by affirming the need for access to power (either formal or informal) and the perceived access to it in the dialysis setting by the 34 responders. Question Three: There are enough dialysis nurses present at work each day. Yes or No. (34 respondents). The results of this question were 55.9% (19 RNs) answering no, while 44.1% (15 RNs) answered yes. The majority of respondents perceive there are not enough dialysis nurses present at work each day in this small-scale study. This question directly relates to the Refined Nurse Worklife Model (NWLM), as one of the domains Manojlovich and Laschinger describes, "Adequate Staffing and Resources." Again, if rounding to the nearest tenth, this would be 56% no, 44% yes- indicating a 12% difference in perceptions of whether there are enough nurses present. The majority being 12% more nurses believing no, not enough nurses present. If there are not enough nurses present at work, this creates an extra volume of workload, putting more stress upon the nurse. When there is more stress in the workplace this may lead to burnout, and in turn, render fewer effective nurses and less safe patient care and quality. This question should capture the attention of peers and perhaps review nurse to patient ratios in dialysis settings and be sensitive to any work overload that creates stress and may lead to burnout that also co-mingles with the retention factors that are listed in the learning module and the literature review of Chapter One. Ensuring adequate staffing and resources are available is a key domain that requires assessment in any organization, let alone a dialysis unit, and this question directly relates to The Refined NWLM. Question Four: What other dialysis nurse retention factors are missing from this presentation? (27 responses). The free text box data was collected (view the free text box data at end of Appendix C) and put into a chart where the researcher color-coded and grouped the information according to a similar tone and subject. Through this means, new and old key retention factors were easily identified by the researcher in the feedback prose. Four of the responses were shaded a light green representing no significant additional information was obtained, for instance, those comments included, "I feel the presentation covered retention factors well. I do not have anything to add", "I feel our needs are met", "none", or N/A. The next category in the table was shaded a light blue relating to management or leadership concerns, reflecting the KTSE domain of "Access to Formal Power" and the Refined NWLM domain, "Strong Leadership." Some of the feedback included: "Management and nursing departments need to encourage a higher level of professional growth", "concern over dialysis merging, outsourcing, and monopoly-like entities impacting nursing quality, time spent with a patient, the reduction of the workforce including educators and difficulty retaining managers, the recognition that nursing quality of care impacts patient satisfaction, and professional job satisfaction", "leadership coaches, encourages, and shows appreciation for and provides power to staff" and finally, "lack of patient interaction, lack of time, and a minimally qualified less seasoned manager." The next free text box category was highlighted light orange and that represented relationships, and the need to improve them within the workplace. This question directly relates to KTSE domain of "access to support" and The Refined NWLM domains, "collegial RN/MD relations" only no mention of the MD occurred throughout the study which indicated a collegial RN/MD relationship versus a hierarchical construct concerned with oppression and causing teammate disharmony (CDC, 2020). The following free text box category was shaded lavender and that related to feedback about needing access to a better work-life balance, the spiritual aspect of why this nurse is a nurse, stating that "this is where God wants me", and another RN stating the presentation was well done, that quality of life outside of dialysis plays a huge role in life and work-life balance is very important. The nurse wrote, "pursuing hobbies, having passions outside of work, developing 'thick skin' and rolling with changes and participating on committees to fix important issues, and to develop coping skills and practice mindfulness." The dark orange part of the feedback table represented "access to support" from KTSE. One RN mentioned how appreciative she was that during the pandemic her company provided childcare. Another RN reported that she wanted more support for RNs that do other tasks in addition to providing treatments. Multiple RNs had concerns about the on-call "lability" and "lack of consideration" another RN mentioned concern over the patient to staff ratios in this category.The dark green represented fair compensation, and one nurse went as far as to mention the desire for "profit-sharing, retention bonuses" in the advent of for-profit dialysis business models. Finally, in lime green shading these were the new retention factors that hadn't been mentioned in the learning module that directly relate to the first research question above. These new factors involved "encouragement by management to help nurses" advance within the organization, the nature of urban vs. rural dialysis work setting, and the socioeconomic status of the dialysis work setting as new factors not mentioned in the learning module after Phase One of the study. While advancement is related to the KTSE domain and NWLM empowerment domain, the new factor of receiving help and encouragement by management for nurses to advance within the organization seemed worth mentioning and evaluating. This question was purely qualitative and had no quantitative results, other than the frequency of feedback reoccurring by more than one respondent. Question Five: This module may help with retention if presented during the onboarding of new nurse hires. (34 respondents) This question was added to the tool to see if the participants found the information helpful and gain insight into whether it may be worthwhile expanding the learning module in the future into an entire program and provide support to dialysis nurses seeking empowerment. The feedback was very helpful because after Phase One dialysis nurse experts reviewed and gave input, it was improved. Having the Phase Two anonymous responders provide feedback with this question was also helpful to determine whether enough nurses might find the information beneficial for onboarding or perhaps a separate program about structural empowerment. Thirty participants answered in the affirmative while four participants in the opposing (88.2% vs. 11.8%). When evaluating the opposing and reflecting on some of the free-text comments received, it may be pure speculation that perhaps some comments may have been scribed from an anonymous management participant who reviewed the learning module on one of the websites where the flyer was posted. In Phase One of the study, a Director and Charge RN had made comments about "audience" per se, not knowing whether the material in the learning module was suitable for staff dialysis RN's or not, or whether they would be interested in the material. Nonetheless, with the ever-changing world, technology and information at the fingertips of anyone, and the business of dialysis infused into patient care it is important for Kanter's Theory of Structural Empowerment and The Refined Nurse Worklife Model to not be siloed and made available to staff dialysis nurses particularly now in the time of the pandemic when the small study Phase One finding is relevant, particularly access to resources. These Phase Two findings were positive, that 88.2% valued the information and felt it might be worthwhile in onboarding or repeated periodically and that the questionnaire results shared, made transparent (and updated when repeated) throughout a dialysis nurse tenure, much like Hayes recommends performing regularly occurring nurse satisfaction surveys. Question Six: There are enough opportunities in my organization for advancement to retain my services. Yes or No. (34 responses) Question Six refers to Kanter's Theory of Structural Empowerment Opportunity for Advancement Domain, as well as the Empowerment Domain of The Refined Nurse Worklife Model. Twenty respondents answered in the affirmative or 58.8%, and fourteen respondents or 41.2% answered in the opposing. By glancing at the percentages and knowing that advancement is a real opportunity and well-published in literature as a concern, it remains a concern with this sort of statistic, of 41.2% (in this small study) of respondents with a perception that there are not enough opportunities to advance within their current organization. (However, the learning module points out differently, that there are some opportunities to advance with several different roles within either the for-profit or not-for-profit dialysis settings.) If rounding, 59% say there is. It is seemingly noticeable that there may be opposing forces with certain questions. Question Seven: The organization I work for supports my education with mentorship, tuition reimbursement, and supports my advancement. (34 responses) This question directly refers to Kanter's Theory of Structural Empowerment and the domain of "Access to Support" as well as The Refined Nurse Worklife Model domain of Adequate Resources, all of which have a modest impact with retention, stress, and burnout. Twenty-five participants answered yes at a statistic of 73.5% while 26.5% or 9 participants said no. This was a clarifying question to look at the perception of mentorship, tuition reimbursement, but also had a component of "advancement" within the question. It was very positive to note that 73% of the respondents perceive their dialysis organization supports their education with tuition reimbursement (yet several responses in Phase Two request more education, more information), but when the additional advancement component was added it did not have an impact in keeping the score similar to the previous question, therefore, one could rationalize that the participant dialysis organizations do fair with educating their staff, and supporting reimbursement. Although, 27% (rounded) more than a quarter of the pie chart do not perceive this, so there may be some room for improving that perception. But again, without a larger n size, it may be difficult to know for certain. Question Eight: Our team collaborates well with each other. Yes or No. (34 responses) Question Eight refers to The Refined Nurse Worklife Model, RN/MD relations domainbut with this domain, we must also go further and look at peer relationships, and subordinate/teammate relationships which seem to be a bit more compelling in the dialysis work setting compared to the RN/MD relationship, at least in this small study qualitative findings. This is strictly objectively noted by the feedback provided by participants in both Phase One and Phase Two, particularly the free-text comments. For instance, there was no specific mention of RN/MD relationship concerns per se, instead, peer to peer or teammate bullying concerns were the recurring theme with this domain. As you see, 26 respondents or 76.5% reported that their team collaborates well with each other, while 23.5% or 8 participants said no. Question Nine: I have enough access to resources. If not, what sort of resources would you like more of? (22 responses) This question was the second free text box question and feedback may be reviewed in Appendix C. The total n size of the overall questionnaire was 34 participants. Only 22 responded to this question. Four participants answered, "yes", "yes", "I have enough resources'', and "N/A". Therefore, there were only 18 of the 34 participants that made comments. This means that 16 participants agreed with the perception that they have enough access to resources. Another chart was created, and similar feedback was color-coded looking for recurring themes, and any new factors. Olive green represented the four satisfied responders. Light green shading represented educational related concerns or deficits. The desire for more education was the greatest repeated feedback provided. This correlates to many of KTSE elements, but "Access to information" seems to be the dominant domain, and for The Refined NWLM, the "Empowerment" domain stands out, as well as, "Nursing model of care." Some of the responders specifically mention American Nephrology Nursing Association and how "here used to be reimbursement", or that there is reimbursement for content, and this is supportive to the nurse and that they desired a "more engaged" educational department that would bring opportunities for educational learning to them. Some were particularly interested in the most current pandemic policies and procedures related to coronavirus and care of the patient for the best quality and safety of all. One nurse requested more education about homelessness and mental illness as she noticed a rise in the population at least in her unit. Another nurse requested more information about CMS requirements claiming that CMS isn't the best presenter of their information. An RN wanted an opportunity to cross-train and work in both inpatient and outpatient settings in her organization. The number one resource that nurses want more of, is education (Access to Information KTSE). This researcher noticed out of the ten comments requesting more education, only three made mention of reimbursement and to be paid for the educational time. The pink shading was a request for more social worker presence and nutrition services and evaluating their ratios. Finally, in red, two comments indicated the need for more supply/PPE resources. Question Ten: Are there other stress factors missing from the presentation? (26 responses) This question was the third free text box opportunity for the participants (see the end of Appendix C). Of the 26 responses received, six of them were "no, no idea, none at this time, very well thought out actually, and broad coverage of all factors." This feedback more or less was neutral and complimentary. So, 20 actual other items were color-coded and grouped according to common themes. Gray was used for the six just mentioned. Light beige shading was used for comments that pertain to rules. For instance, increasing CMS regulations were mentioned by two participants, new pandemic protocols, having to stay in patient rooms with n95/PPE long periods with no recognition from the administration were also mentioned as stress factors. In the chart, light blue was related to stressful scheduling concerns. For instance, one nurse reported that she had to plan paid time off a year in advance, saying that it was unrealistic to do so, yet it was required in her unit. For this nurse, "not being able to attend a first grandchild's birth or your child's wedding is stressful," due to having to work. Another nurse who works in the chronic setting stated that some nurses perceive that they are under stress but there may be many changes to the workday, yet everyone leaves on time, and the feeling that the day will never end is false. With this question, the researcher began to notice a pattern of division between perceptions. One other respondent stated the pace of the day was stressful, and another stated that the staff start times cause childcare issues. Another respondent said that miscommunication between specialties is stressful as well as scheduling patients for dialysis with those other teams. The light green shading indicated other stressful factors such as racial tension at work, cultural differences at work, misunderstandings, and micromanaging. last stress factors mentioned in the grid are shaded in bright orange color in the chart representing miscellaneous items not easily categorized, such as retention of clinical management and RNs, favoritism, new nurses "on the floor present a handicap" and "management doesn't encourage staff development." The Question Eleven: I am paid fairly for my work compared to nurses in other specialties. (34 responses) Question 11 refers to Adequate Resources, reflecting The Refined Nurse Worklife Model and Kanter's Access to Resources Domains. This question asked the participants whether they were paid fairly compared to other specialties and 67.6 % stated yes, or 26 participants and 32.4% or 11 participants said no. The majority of nurses (slightly more than 2/3) in this study do perceive they are being compensated fairly, yet nearly 1/3 do not. Perhaps, there is a bit of an opportunity to improve everyone's (in this small-scale study) perceptions, with fair compensation. Question Twelve: Work-life Balance is stable with my dialysis RN position. (34 responses) Question Twelve was added to the tool because of Phase One expert dialysis nurses’ comments and feedback regarding work-life balance and how disruptive the acute dialysis on-call demand can be in certain dialysis settings. Also, chronic dialysis nurses in Phase Two comments about childcare and the early hours of the workday were reported as disruptive to work-life balance. Eighteen respondents at 52.9% denied work-life imbalance, while 47.1 % affirmed imbalance (or 16 participants), nearly an even split in a divided response. This split could be related to the type of setting, for instance, acute vs. chronic as well. As one participant mentioned the chronic dialysis nurses typically start on time and leave on time, whereas acute dialysis RNs may be prone to irregular shift hours including long hours and on-call expectations. Perhaps the chronic dialysis nurses may perceive their work-life is better without the on-call demand, and therefore more stable. This compares similarly and relates as a major retention factor mentioned in the learning module and was cited. Question Thirteen: I practice self-care activities how many times per week. (34 responses). This question was added because of comments from a Phase One dialysis expert nurse who had concerns that she felt that organizations she had worked for were not doing enough to encourage nurses to take better care of themselves and their health. She had mentioned the physical, emotional, and spiritual domains of the whole person in her meaning of self-care. If you search the internet there are various definitions of self-care. But for this question, the researcher wanted to get a sense of just how much self-care was happening and at what frequency. More discussion of self-care is always needed and the World Health Organization offers some good examples of how you can define and practice self-care by doing simple things like practicing good hygiene, like brushing your teeth or getting a haircut, taking a walk, or exercising outside somewhere in nature, practicing mindfulness, doing yoga, or going to the gym and eating nutritious food. There are many activities that you can do to promote self-care and wellbeing. I think this is an area of opportunity for nurses to better connect with a deeper understanding of and perhaps self-care is an area of the learning module that could be expanded to define more thorough definitions and examples so that a more informed response might be received. For instance, when nurses responded 1-3, were they thinking of going to the gym 1-3 times per week? The results were 52.9% of the respondents have time for just 1-3 self-care activities per week, which amounted to 18 respondents out of 34, and 12 respondents said 3-5 or 35.3% (together with the two largest sections of a pie chart equals 88.2%) remarkably, which are the lowest amount of self-care activities that were offered in the scale choices. Only 2 nurses responded that they practice 10 or greater self-care activities per week. Question Fourteen: I feel burned out. (34 responses) Question 14 Refers to Burnout and 18 respondents out of 34, or 52.9% responded no, while 16 respondents or 47.1% responded yes. In this study, it appears burnout is below what has been reported recently in a large-scale study. For instance, in ​AMN’s 2020 Healthcare Trends,​ further evidence of rising burnout is shown in their data. A study known as the Physicians’ Foundation/Merritt Hawkins Study ​concluded that about 55 percent of healthcare workers described their morale towards their jobs to be negative due to the conditions. The study revealed that physician burnout has increased by 2 percent since 2018, while a nursing study revealed that a rising 63 percent of nurses reported burnout along with 44 percent often wanting to quit as a result. Question Fifteen: Have you ever left a dialysis organization because you felt burned out? (34 responses) Question 15 refers to having experienced burnout in the past, and 19 respondents denied leaving a dialysis organization due to burnout in the past, and 15 respondents said yes. So, 55.9% said no vs. 44.1% that said yes. Question Sixteen: How can this learning module be improved? (19 responses) This question was the final free text box (See the end of Appendix C), and in the same method the comments were grouped, and color-coded for similar feedback. The gray shaded item was "no suggestions at this time." The light orange color referred to the quantity of information provided. For example, five respondents wanted more explanations, wanted more information on how to gain power. One nurse wanted to know how to bring about changes even after being informed about structural empowerment in the learning module. Another nurse stated it was "well put together" (meaning the learning module) but felt it was "too wordy" and having just started in dialysis in January of 2020 there was enough to learn then and it was overwhelming enough. There were also comments about child-care issues and how when a team member is out sick it causes the RN to have to pick up more direct patient care and picking up the workload of the sick call team member and that takes time away from other RN duties that they usually are doing more of when there isn't a sick call. The light green shaded comments were all very complementary to the learning module that the researcher developed and the ten expert dialysis nurses ranging in dialysis experience from 7-40 years gave feedback for program evaluation. Some of the comments were, "seems reasonable for the content, provide a learning module with onboarding and then repeat periodically while in the workplace, life-changing, it was a well- constructed module, looks good, and excellent presentation and well-received, no changes at this time." The dark orange was leadership-related, and the comments were "send it to all administrators, and the climate is difficult. We are in crisis mode if there was more preparedness before the pandemic, we would have been prepared." Lastly, the two lavender shaded comments were simply statements not related to any specific improvement of the learning module, one comment was that patient satisfaction is a nurse satisfaction booster, and identifying the stress factors at work can prevent burnout at work. Question Seventeen: I feel frustrated with my work situation. (34 responses) A question about frustration in the tool was added to examine frequency because Lewandowski (2003) wrote that "sources of workplace frustration leading to burnout may originate within the organization, though individual characteristics can contribute to one's ability to cope with high-stress work environments. ​Role conflict and ambiguity, value conflicts, feelings of isolation, and working with high-stress clients or in high-stress fields of practice are some of the key organizational factors identified in the literature as contributing to burnout." With this in mind, one nurse in response to this question stated that caring for patients with chronic illness may be frustrating if quality outcomes may not increase or improve, one may have a sense of reduced personal accomplishment." Therefore, knowing this is the case, the researcher wanted to acknowledge that sort of frustration and to compare this question to the other burnout frequency questions, as frustration is one of the symptoms of risk of burnout and experiencing fatigue. The results indicate a divided perception among participants. Nineteen respondents denied feeling frustrated, or 55.9%, while 15 respondents or 44.1% said yes. Question Eighteen: Do you feel powerless about your work situation? (34 responses) This question was added due to some feedback received in the Phase One part of the study, and the principal investigator suggested it's important for presence. The question of powerlessness is a serious concept for nursing. Manojlovich (2007) gives a compelling explanation of powerlessness and states that powerless nurses are ineffective and may cause poor outcomes in safety and quality for patients due to depersonalization and burnout. The CDC has a 2020 (cited in references beginning with Oppressed) reviewed slide show about oppressed group behavior, referring to nursing which also mentions peer to peer conflicts, peer to subordinate conflicts in part due to "frustration" from feelings of powerlessness in hierarchical systems within healthcare. While aligning the two perspectives of Manojlovich and the CDC, it became evident that a more modern understanding of the definition of powerlessness is needed (at least for this researcher). Considering the advent of the pandemic, nurses' perceptions of short staffing in Phase Two Question 3 of this small study, and at the expense of being labeled ineffective, when nurses are in real survival mode (Dunham, 2020). With the rising numbers of burnout newer tactics and approaches are needed to tackle a rather complex situation and bolster the resilience health care workers already have (Milanowski, 2017). Therefore, a more inclusive approach to powerlessness by eliminating blame words, such as "ineffective" is something as clinicians we ought to do to offer support to those growing numbers of clinicians that have very real feelings collectively evidenced in high percentages that are growing with each passing day of the coronavirus pandemic, and even before the pandemic presented noted in the National Academies of Medicines' Taking Action Against Clinician Burnout (2019), and the AMN Leadership Solutions 2020 Healthcare Trends by AMN Healthcare reports (2020).Without agreeing or disagreeing, and in the spirit of continuous improvement this question is a challenging one to consider. With this in mind- related to the question, 64.7% of the respondents or 22 stated no, and 35.3% or 12 stated yes, in this small study. While researching powerlessness, the Marr (2020) website offers interesting explanations of powerlessness worthy of review and consideration. In their explanation, they remark that submitting to what is, is a step of strength. Question Nineteen: My age is: (33 responses) Question 19 is a demographic question related to the age of participants. There were no age 18-24-year-old RN participants, The breakdown is almost in quarters of a visual pie chart, with the two highest sections of participants aged 56 and greater and 46-55 years of age. Together, both slices equal more than half of the pie at 57.6% or a total of 10 and 9 nurses in each group. There were 8 nurses in the 25-35-year range, and 6 nurses in the 36-45-year range. Is there a need to begin mentoring and sponsoring nursing programs for nursing candidates at an earlier age, perhaps nurses volunteering, reaching out to high schools, and making regular visits discussing the profession and improving the marketing for a younger target audience? Perhaps mentorship programs that join high school-age volunteers or younger workers to become interested in healthcare as a career at a younger age and giving them the opportunity in some way to become interested earlier on. Improving the social media and marketing portraying nurses even more positively might help and using that social media and marketing where younger generations might be online or with their smartphones What new attraction strategies can be tried to capture the hearts, minds, and nurture the calling of those in an earlier age group to choose nursing as their profession? As one looks at the numbers and percentages of the age of nurses, at least in this small study it is obvious that the more seasoned you are, there are more nurse participants (refer to the pie chart for a visual). Question Twenty: What is the highest degree you have completed? (33 responses) Question 20 had no Ph.D. or DNP participants. The largest slice of the pie chart is the Baccalaureate prepared nurse participant with 51.5% of the pie chart representing 17 RNs. The next largest slice is the Associate prepared RNs with 27.3% of the pie, or 9 nurses. The following were 12.1% Diploma nurses representing 4 RNs, and 3 Master prepared RNs at 9.1%. Question Twenty-One: What is your gender? Male or Female (33 responses) Question 21 refers to the gender of the RN participants. We had 29 females and 4 males. For this small sample study, one in every 7.25 females, is male. This demonstrates the presence of more male percentage participation than typically noted, as the U.S. Bureau of Labor Statistics states 12% of registered nurses are male (Egan, 2019). Question Twenty-Two: How many years have you worked as a nurse in a dialysis setting? (34 responses) Question 22 asked the RN participants how many years they have been working in a dialysis setting. Eleven nurses answered 20 or greater at 32.4% (this indicated longevity within the specialty of the highest slice of the pie chart participants). Ten nurses answered 10-20 years or 29.4% (also notably lengthy investment of time and commitment to the specialty and population). However, the next group in blue, 5 nurses was 14.7% at 1-3 years, indicating less experience in a higher percentage group over the 3-5- or 5-10-year ranges which were both 11.8% at 4 nurses in each slice of the pie chart. With the 3-5- and 5-10-year ranges having less percentage of years in dialysis setting, this, if it was a larger study sample may indicate a gap in the workforce for some time. Question Twenty-Three: I learned something from this learning module. (34 responses) Question 23 was entered as a validation question. The navy-blue slice is 23.5% representing Strongly Agree, and 50% is half of the pie chart, together they are 17 and 8 participants for a total of 25 RN's. Combined they are at 73.5%. The next category is "Somewhat Agree" at 8.8% representing 3 RN's. RN's Neither Agreeing nor Disagreeing equaled 5 RN's at 14.7%, and we had 1 RN at 2.9% that disagreed. No one strongly disagreed. Question Twenty-Four: I work in this type of dialysis setting. (34 responses) Question 24 asked the respondents what type of dialysis setting they worked in. There was a tie reported- an equal frequency percentage of 32.4%. One representing blended unit settings where there is a mix of inpatients and outpatients in a hospital setting, and the other representing an outpatient setting. These two groups are the largest slices of the pie chart. Together, both equaled 22 nurses. Next, the inpatient setting was the second-largest slice at 23.5% or a total of 8 nurses. The smallest slice was in red, representing hospital-based outpatient units at a percentage of 11.8% representing 4 dialysis nurses. Question Twenty-Five: My organization is Not-for-Profit or For-Profit (34 responses) For question 25, it was asked whether the participant dialysis RN worked in a for-profit or not-for-profit environment. Twenty-two or 64.7% of the nurses said, "For-Profit," while twelve nurses or 35.3% said "Not-for-Profit." The for-profit dialysis industry has greater representation in this small study sample. Question Twenty-Six: What country do I live in? (34 responses) For question 26, the flyer (Appendix F) with the link to the learning module was placed on Facebook and LinkedIn and Allnurses.com user groups related to dialysis. Therefore, the chance of dialysis RN participants from other countries was a possibility. We had listed out Canada, the UK, and Other as possibilities. At the time, embedding a scroll down comprehensive country code list was a challenge, therefore only the four choices were offered, and to perfect the tool, in the future, this feature would need to be added to evaluate the other countries that dialysis nurses may participate from. Twenty-nine participants were from the USA or 85.3%, none from the UK or Canada, and five participants or 14.7% were identified as the "Other" country category. Question Twenty-Seven: Has the recent pandemic influenced your responses to the questions? (34 responses) Question 27 was added on to the Dialysis Structural Empowerment Tool because during this DNP project after Chapters 1-3 were constructed, the Covid-19 pandemic hit. The formal request letters had gone out to two teaching hospitals in New England for expert dialysis RN participation in the review of the learning module at the time the study about retention and burnout were to occur just before news of the pandemic. Nonetheless, the project needed to keep moving forward and so this project is a reflection of a snapshot in time. We added this question to see how the participants would respond considering the many factors already mentioned in the defense PowerPoint presentation such as access to resources, access to support, strong leadership, and so on. As you can see in the table above (or Appendix C) 19 or 55.9% stated "No" that the pandemic did not influence their responses in the questionnaire after they reviewed the learning module, while 44.1 % (or 15 participants) said "Yes", the pandemic did influence their responses to the questions. As we review the divided responses, Question 3 stands out as something of a bit of a concern because the majority of nurses perceive that there are not enough dialysis nurses present at work each day in this study. Question 27 is also an interesting response because the majority responded that the pandemic did not affect their responses to the questions. There were six questions from the tool with responses nearly divided. They are represented and can be viewed in Appendix E. Limitations of Phase One and Phase Two The limitations of this study were related to the timing of the study, the passive nature of Phase Two social media sourcing aspect of the study, and the low participant response of the study in the 45 days. Originally, the plan was to conduct the Phase One part of the study with two major teaching academic medical center dialysis units in the New England region. Because of the global pandemic of coronavirus, it was determined that it was not exactly an appropriate opportunity to study "retention and burnout" at that time per the management. Several other expert professional dialysis registered nurses volunteered to participate. Fourteen were invited. While it was a limitation that the original plan for Phase One was not conducted and it caused a delay, the alternative plan moved forward in an amenable suitable manner and the learning module was reviewed by voluntary expert dialysis nurses that ranged in experience from seven to forty years of dialysis specific nursing- giving quite valuable feedback and efficacy to the Phase One aspect of the project. The Phase Two aspect of the study was limited in that it was quite passive. A simple flyer with a link was created and placed in a handful of specific user groups on Facebook, LinkedIn, and AllNurses.com, and a whole social media campaign was not conducted to recruit participants, rather, it was merely left on its own to attract and entice dialysis nurses to participate all with no repetition of repostings. Finally, the lower participant participation is most likely due to the passive nature of the social media posting procedure and the chosen path of not creating daily repostings of the flyer containing the link to the learning module. Summary In this chapter, we discussed two Phases of this study. Phase One consisted of enlisting ten expert dialysis nurses with seven to forty years of dialysis specific experience in all the various modalities and settings to review a learning module about structural empowerment as well as retention and stress factors and provide their input for program evaluation. Their verbal and written feedback was collected and stored in an excel spreadsheet where later, through an interview the researcher discussed KTSE and the refined NWLM elements of concern which are synonymous with domains of each theory. Both theories were utilized as a guide for the framework of two phases of the study. In the teach-back method, the expert dialysis nurses concurred that the feedback they supplied correlated with the element concern codes that were ascribed to each KTSE and Refined NWLM element of concern. The findings resulted in high frequencies of elements of concern regarding Access to Support, Access to Resources, Access to Information from the KTSE domain list. In reviewing The Refined NWLM list, Adequate Staffing and Resources, and Strong Leadership were the next highest frequency occurrences confirmed during teach back. Qualitative data was also collected and utilized for the slide show presentation only, but the highlights of the further investigation were that several bullets indicated retention factors and stress factors that largely were identified in the learning module, except the spiritual realm and the need for encouragement of self-care from the organizations to the RNs on the frontline. As far as burnout and stress, it was found that of the expert nurses, 3 RN's were currently burned out, 3 RN's reported burnout in the past, 3 RN's reported feeling currently stressed, 1 RN reported prior dialysis-related PTSD event, and 2 out of 10 deny ever experiencing burnout symptoms. With the support and feedback of the expert nurses, the learning module was improved and Phase Two of the study was launched on LinkedIn, Facebook, and AllNurses.com dialysis user group social media sites in a simple flyer with approximately five locations within a week. The 45-day period commenced, and data was collected via Google Slides, and the n size of the study was 34 for most of the questions. The question about age, one participant didn't answer. The findings of Phase Two were generated from yes or no style questions, multiple-choice questions, or four free text boxes (with no limitation of character amount style questions) which are placed in Appendix C. Chapter 5 Summary, Conclusions, and Recommendations Summary of Findings Chapter One was the introduction of the problem statement and research questions for the study involving retention, stress, and burnout of the dialysis nurse with also concern regarding the nurses' intentions of staying. Because Rosenstock (2015) had described no foreseeable future in the dialysis landscape which has changed over the past two decades the researchers were interested in learning more about the current state of dialysis retention, stress, and burnout in the industry and the factors of each. Kanter's Theory of Structural Empowerment (KTSE) and the Refined Nurse Worklife Model (NWLM) were also discussed as the framework for building the study. Chapter two contained a review of the literature relevant to the retention of dialysis nurses. Specific gaps of knowledge in the literature were identified related to the retention and satisfaction of dialysis nurses in the work environment. Because of the lack of research specific to the dialysis setting regarding retention of dialysis nurses, other clinical settings' literature is drawn upon for analysis and synthesis of the topic. Common variables were identified related to retention of nurses including stress and burnout, value congruence, rural nurse shortages, intention to leave or stay, professional autonomy and magnet recognition programs, job satisfaction, team collaboration, quality of care, and manager leadership competencies. Kanter's Theory of Structural Empowerment was discussed as the key framework as well as The Refined Nurse Worklife Model for the development of a learning module, which was the proposed project. The domains in the theory include the opportunity for advancement, access to information, access to support, access to resources, formal power, and informal power which were proposed to be examined within a dialysis scenario context by the researcher and integrated within a learning module that could be pilot-tested for clarity and then implemented in the proposed project. The researcher proposed that the development of this module may provide an instrument that may be used as a new-hire orientation tool or program resulting in the reduction of dialysis nurse turnover. It was noted that there was a lack of knowledge concerning burnout and empowerment among HD RNs. Thus, more research is needed with HD RNs working within different healthcare systems and settings (university hospitals, affiliated hospitals, and satellite HD facilities) to better prevent the occurrence of burnout and promote the well-being of these RNs (Dore, Duffet-Leger, McKenna, & Breau, 2017). As noted by Weaver, Hessels, Paliwal, and Wurmser (2019), effective collaboration and communication are vital for creating work environments conducive to excellence in patient quality and safety. By creating the structural empowerment learning module, educating staff dialysis nurses about stress, burnout, and Kanter's Theory in a specific dialysis-related learning module, a strategy for increasing dialysis nurse retention may be implemented for the researcher's DNP project was discussed. Chapter Three discussed Kanter's Structural Empowerment Theory and the refined Nurse Worklife Model offering a framework for the goal of improving dialysis nurse retention and burnout concerns. The creation of a learning module with dialysis-specific case scenarios that illustrate the concepts and domains of the frameworks proposed a strategy for addressing retention and was also discussed. Discussion of collecting feedback from the proposed focus group was discussed regarding how it would assist with fine-tuning of the learning module and deliver a valuable exercise in the proposed field test. It was stated that retention rates of dialysis nurses in various settings are a challenge. By teaching dialysis nurses about structural empowerment and the other concepts and domains of the suggested frameworks a tactic to ameliorate turnover could be actualized. Chapter Four discussed the two Phases of the study that were executed. Phase One consisted of enlisting ten expert dialysis nurses with several years of dialysis specific experience in all the various modalities and settings to review a learning module and provide feedback and guidance for evaluation. The verbal and written feedback was collected and stored in an excel spreadsheet where later, through an interview the researcher discussed KTSE and refined NWLM elements of concern which are synonymous with domains of each theory. Both theories were utilized as a guide for the framework of both phases of the study. In the teach-back method, the expert dialysis nurses concurred that the feedback they supplied correlated with the element concern codes that were ascribed to each KTSE and refined NWLM element of concern. This translated into a segment of descriptive quantitative analysis. The findings resulted in high frequencies of elements of concern from Access to Support, Access to Resources, Access to Information from the KTSE list of domains. From the refined NWLM list of domains, Adequate Staffing, and Resources, and Strong Leadership were the next highest frequency occurrences during teach back. Qualitative data was also collected and utilized for the slide show presentation only, but the highlights of the further investigation were that several bullets indicated retention factors and stress factors that largely were identified in the learning module, except the spiritual realm and the need for encouragement of self-care from the organizations to the RNs on the frontline, as well as recognition. Other factors such as urban vs. rural setting, socioeconomic geographic location of a dialysis setting, and collaborative relationships with peers and teammates were also discussed regarding Phase Two findings. As far as burnout and stress, it was found that of the expert nurses in Phase One, 3 RN's were currently burned out, 3 RN's reported burnout in the past, 3 RN's reported feeling currently stressed, 1 RN reported prior dialysis-related PTSD event, and 2 out of 10 denied ever experiencing burnout symptoms. With the support and feedback of the expert nurses, the learning module was improved and Phase Two of the study was launched on LinkedIn, Facebook, and AllNurses.com dialysis user group social media sites in a simple flyer with approximately five locations each on separate days. The 45-day period commenced, and data was collected via Google Slides, and the n size of the study was 34 for most of the questions. There were a total of 27 questions asked of the participants and they are detailed in the chapter. The question about age, one participant didn't answer, however the age and demographics of the participants are interesting in the study as well and inferences one may deduce, despite being a small sample. The findings of Phase Two were generated from yes or no style questions, multiple-choice questions, or four free text boxes with no limitation of character amount style questions which are placed in Appendix C. Implications for Nursing Some key findings in the small-scale Phase Two study were that there is a high percentage of nurses that “intend to stay” in dialysis for 5 years and greater equaling 64.7%.​ ​The majority of nurses perceive there aren’t enough nurses at work each day, and the majority of nurses did not agree that the pandemic influenced their answers in the study.​ ​It is unknown if the participants in Phase Two are certified nurses who have typically engaged nurses and may skew results positively in a global study. Needing access to educational information, on-call demand, up to date education for pandemic procedures and policies, access to supplies, fair compensation, patient transportation issues, demanding ratios, addressing racial tension in the workplace, cultural differences, teammate bullying, feeling respected, favoritism, access to mental health support when needed, and the need to achieve a better sense of personal accomplishment are feedback received causing stress and burnout, among other cited factors in the learning module which all impact retention. One nurse with dialysis and critical care background commented in Phase On that "the retention factors are the same for all nursing areas." Solutions were provided also in the DNP PowerPoint project, specific management tools (Appendix G) that were created from the framework of KTSE and NWLM theories. A self-rating system of each domain or element of concern with the ability to free text are two of the tools suggested capabilities, with a frequency for distribution at management’s discretion and preference to improve retention efforts and help build trust, transparency, collaboration, and quality of care within an organization. Another tool developed (present in the slide show presentation of the DNP project) is a self-reflection journaling tool that could be distributed to an entire workforce where the user may address each self-care domain including physical needs, psychological needs, spiritual needs, emotional needs, and learning needs. An additional tool was developed for self-reflection regarding repairing relationships which were a recurring theme about needing improved collaboration in the workplace and for recognition of near equal divisions of perceptions to be noticed. ​ ​Self-Reflection develops emotional intelligence (EI)(Stanley, 2017). Increasing EI improves empowerment (Udod, Hammond-Collins, & Jenkins (2020)​.​ Self-reflection is an underutilized tool that develops emotional intelligence, and therefore strengthens a workforce. Having proactive organizational demonstrations of encouragement of self-care with the use of the suggested KTSE and NWLM tools that could be developed with IT and quality departments may decrease burnout, improve intentions to stay, build trust, reduce turnover rates and engage management more with staff. There was some discussion of powerlessness that came up, the need for a more modern definition in the advent of the pandemic being experienced, the inspection of blame-like terminology that points toward the staff member rather than a joint responsibility between an organization and employee to prevent. Also, discussion of "what is" in hierarchical systems, terminology, and the effects of inaction toward correcting the use of terminology, such as the word "order" in healthcare specifically keeping a patriarchy hierarchy at least symbolically intact along with the notion of nursing as an oppressed group. The key findings from Phase Two of the study include needing access to educational information, on-call demand, up to date education for pandemic procedures and policies, access to supplies, fair compensation, patient transportation issues, demanding ratios, addressing racial tension in the workplace, cultural differences, teammate bullying, feeling respected, favoritism, access to mental health support when needed, and the need to achieve a better sense of personal accomplishment is feedback received causing stress and burnout, among other cited factors in the learning module which all impact retention. Recommendations for Further Research The study could be used as a stepping point for further research about retention factors, burnout, and stress in the workplace not just with the dialysis industry but in any nursing area. One never knows when there will be a global pandemic. There never is a perfect time where predicting studying retention, burnout, stress, or intentions of staying might not be impacted by a disaster or global event that may persuade opinion in a survey. If the research was to be repeated, there would have been much more involvement with a statistician, the use of a valid and reliable tool such as Spreitzer's (2010), a much longer data-gathering period, and the study would include a question about whether the dialysis RN was certified or not, the goal being a balanced sample of both certified and uncertified dialysis nurses in a global context with comparisons and contrasts. A much more rigorous social media campaign to collect data would also be recommended with a digital marketing expert. Also, a more thorough consideration of powerlessness, the difficulty of grasping its meaning in the face of a global pandemic to aligning oneself with "what is" and effectiveness, would be another area to spend more time in self-reflection and study with. The Scepura Dialysis Structural Empowerment Tool was revised from the highest frequency occurrences of particular elements of concern related to KTSE and NWLM for this study, from the feedback of the dialysis nurse expert focus group. Adapting the tool is a possibility where the focus on lower frequency elements of concern could potentially be integrated within the tool for evaluation as well. For instance, the question, "Does your organization have a specific nursing model of care?" (This would represent The Refined Nurse Worklife Model domain) Another question added might be, "are you a certified nurse or not certified?" This would be recommended to ensure that what study you are reviewing has well-represented participation from both types of dialysis nurses. References Aiken H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work ​Medical environments. ​49​(12), Care, 1047-1053. DOI:10.1097/mlr.0b013e3182330b6e AMN Leadership Solutions. 2020 Healthcare Trends. AMN Healthcare. 2020.https://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Campaigns/10-he althcare-trends-white-paper-2020.pdf. Accessed April 14, 2020. A New Dimension of Health Care: Systematic Review of the Uses, Benefits, and Limitations of Social Media for Health Communication. (n.d.). Retrieved July 20, 2019, from https://www.jmir.org/2013/4/e85/ ANNA. (2019, April 23). Nephrology Nursing Shortage and Solutions Invitational Summit. Retrieved July 19, 2019, from https://www.annanurse.org/about-anna/committees-and-spns/nephrology-nursing-shortag e-and-solutions Antwi, Y., & Bowblis, J. (2016). The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession. Retrieved August 12, 2019, from https://research.upjohn.org/up_workingpapers/249/ Armstrong, K. J., & Laschinger, H. (2006, April-June). Structural Empowerment, Magnet Hospital Characteristics, and Patient Safety Culture. Retrieved September 17, 2019, from:https://pdfs.semanticscholar.org/4e7f/26ef40468a73a63acd4cc07a323dcaf7b56a.pdf Bernstein, N. (2014, February 12). Hospitals' Dialysis Plan Is Under New Scrutiny. Retrieved July 19, 2019, from https://www.nytimes.com/2014/02/13/nyregion/new-york-hospitals-set-to-move-dialysiscare-to-private-chain-despite-track-record.html Buck, J. (2017). Retention remedy. ​Nursing Management (Springhouse),48(​ 4), 9-12. DOI:10.1097/01.numa.0000514065.22949.2a Bugajski, A., Lengerich, A., Marchese, M., Yackzan, S., Davies, C., & Brockopp, D. (2017, June 01). The Importance of Factors Related to Nurse Retention: Using the Baptist Health Nurse Retention Questionnaire, Part 2. Retrieved August 13, 2019, from https://insights.ovid.com/crossref?an=00005110-201706000-00004 Colosi, M. (2016). Registered Nurses: Occupational Outlook Handbook: (n.d.). Retrieved July 19, 2019, from https://www.bls.gov/ooh/Healthcare/Registered-nurses.htm#tab-1http://www.nsinursings olutions.com/files/assets/library/retention-institute/nationalhealthcarernretentionreport20 18.pdf Crownweb. In The Know: How Dialysis Facilities Report Patient Data. (n.d.). Retrieved July 19, 2019, from http://mycrownweb.org/in-the-know-how-dialysis-facilities-report-patient-data/ Deaver, K. CNNT REVIEW: The Future of Dialysis for Technicians and Nurses. (2017, July 18). Retrieved July 19, 2019, from https://www.kidney.org/newsletter/cnnt-review-future-dialysis-technicians-and-nurses DeVault, G. (2018, December 23). Market Research 101: Develop the Research Plan. Retrieved July 20, 2019, from https://www.thebalancesmb.com/market-research-101-sampling-plan-and-frame-2296679 Dialysis. (n.d.). Retrieved August 12, 2019, from https://www.merriam-webster.com/dictionary/dialysis#medicalDictionary Dialysis+nurse jobs. (n.d.). Retrieved July 20, 2019, from https://www.indeed.com/jobs?q=dialysis%2Bnurse&l= Doré, C., Duffett-Leger, L., Mckenna, M., & Breau, M. (2017). Perspectives on burnout and empowerment among hemodialysis nurses and the current burnout intervention trends: A literature review. ​CANNT Journal​, ​27​(4), 16–31. Retrieved from http://search.ebscohost.com.proxy-clarion.klnpa.org/login.aspx?direct=true&db=ccm&A N=128883796&site=eds-live&scope=site Dotson, M. J., Dave, D. S., Cazier, J. A., & Mcleod, M. D. (2013). Nurse retention in rural United states A CLUSTER analytic approach. ​International Journal of Healthcare Management,​ ​6​(3), 184-191. DOI:10.1179/2047971913y.0000000037 Drennan, V., Halter, M., Gale, J., & Harris, R. (2016, November). Retaining nurses in metropolitan areas: Insights from senior nurse and human resource managers. Retrieved July 19, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/27291829 Duke University, & Gaucher, R. (2019, October 23). As large chains grow to dominate dialysis, patient outcomes decline. Retrieved November 09, 2019, from https://www.eurekalert.org/pub_releases/2019-10/du-alc102319.php Dunham, J. (2020, June 04). 'One of the most dangerous jobs in the World': COVID-19 kills more than 600 nurses. Retrieved July 27, 2020, from https://www.ctvnews.ca/health/coronavirus/one-of-the-most-dangerous-jobs-in-the-world -covid-19-kills-more-than-600-nurses-1.4969041 Egan, B. (2019, May 6). The male nurse: Benefits and percentages of men in nursing. Retrieved July 26, 2020, from https://www.snhu.edu/about-us/newsroom/2019/05/male-nurse Gardner, J., & Walton, J. (2011). Striving to be heard and recognized: nurse solutions for improvement in the outpatient hemodialysis work environment. Nephrology Nursing Journal. Vol. 38, No. 3 Gaucher, R. (2019, October 23). As large chains grow to dominate dialysis, patient outcomes decline (D. University, Ed.). Retrieved October 25, 2019, from https://www.eurekalert.org/pub_releases/2019-10/du-alc102319.php Haddad, L. (2019, January 19). Nursing Shortage. Retrieved July 19, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK493175/ Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014, May/June). Nurse Staffing and the Relationship to Job Satisfaction and Retention. Retrieved August 20, 2019. Hayes, B. (2015). Job Satisfaction, Stress, and Burnout in Hemodialysis Nurses. Retrieved August 20, 2015, from https://eprints.qut.edu.au/84620/8/Bronwyn_Hayes_Thesis.pdf Hayes, B., Bonner, A., & Douglas, C. (2015, November 10). Haemodialysis work environment contributors to job satisfaction and stress: A sequential mixed-methods study. Retrieved August 14, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640200/ Hebenstreitt, J. J. Nurse Educator Perceptions of Structural Empowerment and Innovative Behavior. Nursing Education Perspectives (National League for Nursing), [s. l.], v. 33, n. 5, p. 297–301, 2012. Hemodialysis. (2017, February 14). Retrieved July 19, 2019, from https://www.kidney.org/atoz/content/hemodialysis Hiltzik, M. Column: Dialysis firms' profits are obscene. What will happen if California tries to cap them? (2018, July 20). Retrieved July 19, 2019, from https://www.latimes.com/business/hiltzik/la-fi-hiltzik-dialysis-20180720-story.html Identifying Assumptions and Limitations For Your Dissertation. (n.d.). Retrieved July 20, 2019, from https://www.academicinfocenter.com/identifying-assumptions-and-limitations-for-your-d issertation.html Kanter's Theory. (n.d.). Retrieved August 12, 2019, from https://structuralempowerment.weebly.com/kanters-theory.html Karkar, A., Dammang, M., Bouhaha, B. Stress and burnout among hemodialysis nurses: A single-center, prospective survey study. ​Saudi J Kidney Dis Transpl​ [serial online] 2015 [cited 2018 Sep 25];26:12-8. Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with magnet hospital recognition. ​Medical Care,​ ​53​(6), 550-557. DOI:10.1097/mlr.0000000000000355 Lahti, M., Haapaniemi-Kahala, H., & Salminen, L. (2017). Use of Social Media By Nurse Educator Students: An Exploratory Survey. ​The Open Nursing Journal,11​(1), 26-33. DOI:10.2174/1874434601711010026 Larkin, M., Cierpial, C., Stack, J., Morrison, V., Griffith, C., (March 31, 2008) "Empowerment Theory in Action: The Wisdom of Collaborative Governance" ​OJIN: The Online Journal of Issues in Nursing​. Vol. 13 No. 2. Lengerich, A., Bugajski, A., Marchese, M., Hall, B., Yackzan, S., Davies, C., & Brockopp, D. (2017). The Baptist Health Nurse Retention Questionnaire. ​JONA: The Journal of Nursing Administration,47​(5), 289-293. DOI:10.1097/nna.0000000000000480 Lewandowski, C. (2003) Organizational factors contributing to worker frustration: the precursor to burnout. Journal of Sociology and Social Welfare, December 2003. Healio.com, (2017). What dialysis nurses are saying about nursing ratios. Retrieved July 20, 2019, from https://www.healio.com/nephrology/practice-management/news/online/%7Ba6b9fddc-de 0f-4b80-83f5-e8ce0f3b95a5%7D/what-dialysis-nurses-are-saying-about-nursing-ratios Hunter W. (2010, July 14). Pep: Poise, Efficiency, Peace: William C. Hunter: Free Download, borrow, and streaming. Retrieved July 24, 2020, from https://archive.org/details/pep_1007_librivox Manojlovich, M., & Laschinger, H. (2006, March 22). The Nursing Worklife Model: Extending and Refining a New Theory. Journal of Nursing Management, 2007, 15, 256-263 Retrieved November 09, 2019, from https://deepblue.lib.umich.edu/bitstream/handle/2027.42/75205/j.1365-2834.2007.00670. x.pdf?sequence=1 McMillan, D., & Chavis, D. (1986). Sense of Community: a definition and theory. Journal of Community Psychology. 14:6-23. Messana, A. (2003, September). Common concerns among hospital-based dialysis providers. Retrieved July 19, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/14533515 Miller, P., Goddard, P., & Laschinger, H. (2001). Evaluating Physical Therapists’ Perception of Empowerment Using Kanter’s Theory of Structural Power in Organizations. Physical Therapy, [s. l.], v. 81, n. 12, p. 1880–1888, 2001 Milanowski, A. (2017, October 20). Why resilience training isn't the antidote for burnout. Retrieved July 27, 2020, from https://consultqd.clevelandclinic.org/why-resilience-training-isnt-the-antidote-for-burnout Moorhead, S., Hazlett, D., Harrison, L., Carroll, J., Irwin, A., & Hoving, C. (2013, April 23). A new dimension of health care: Systematic review of the uses, benefits, and limitations of social media for health communication. Retrieved August 14, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636326/ National Academy of Sciences. (2020, January 31). Systems approaches to improve patient care by supporting clinician well-being. Retrieved July 27, 2020, from https://nam.edu/systems-approaches-to-improve-patient-care-by-supporting-clinician-wel l-being/ NSW Health, WOW Project tool 2011. (2011). Benner’s stages of clinical competence. Retrieved July 19, 2019, https://www.health.nsw.gov.au/nursing/projects/Documents/novice-expert-benner.pdf Obragambidez-Ramos, A. & Borrego-Ales, Y. (2014).Empowering Employees: Structural Empowerment as Antecedent of Job Satisfaction in University Settings. Psychological Thought, [s. l.], n. 1, p. 28. Retaliation is a real issue in nursing. (2015, November 04). Retrieved July 19, 2019, from https://mnnurses.org/retaliation-is-a-real-issue-in-nursing/ Rosenstock, F. October 18, 2. (n.d.). The dilemma of dialysis nurse retention. Retrieved July 19, 2019, from https://www.healio.com/nephrology/practice-management/news/online/%7Bea3e0cbf-3b ba-4064-be1b-a2b6bdbaa92f%7D/the-dilemma-of-dialysis-nurse-retention Sawatzky, J., Enns, C., & Legare, C. (2015, June 03). Identifying the key predictors for retention in critical care nurses - Sawatzky - 2015 - Journal of Advanced Nursing - Wiley Online Library. Retrieved July 19, 2019, from https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12701 Shinkman, R. The Big Business of Dialysis Care. (2019, April 17). Retrieved July 19, 2019, from https://catalyst.nejm.org/the-big-business-of-dialysis-care/ Simmons-Duffin, S., & Wroth, C. (2019, July 10). Trump Administration Announces Plans To Shake Up The Kidney Care Industry. Retrieved July 20, 2019, from https://www.npr.org/sections/health-shots/2019/07/10/740276389/trump-administration-a nnounces-plans-to-shake-up-the-kidney-care-industry Spreitzer G. (2010, May). Psychological empowerment instrument. Retrieved July 25, 2020, from https://www.statisticssolutions.com/psychological-empowerment-instrument/. Annotation re: O’Brien, Janice L. May 2010. Structural Empowerment, Psychological Empowerment, and Burnout in Registered Staff nurses Working in Outpatient Dialysis Centers. (The State University of New Jersey). Stanley. (2017). Reflection and emotional intelligence. Retrieved July 25, 2020, from https://onlinelibrary.wiley.com/doi/10.1002/9781119253785.ch15 The state of California. (2019, October 13). Governor Newsom Takes final action of 2019 Legislative Season. Retrieved October 25, 2019, from https://www.gov.ca.gov/2019/10/13/governor-newsom-takes-final-action-of-2019-legisla tive-season/ The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession. (n.d.). Retrieved July 20, 2019, from https://www.mitpressjournals.org/doi/abs/10.1162/ajhe_a_00096?journalCode=ajhe The Importance of Factors Related to Nurse Retention: Using the Baptist Health Nurse Retention Questionnaire, Part 2. (n.d.). Retrieved July 20, 2019, from https://www.nursingcenter.com/journalarticle?Article_ID=4153701&Journal_ID= Twigg, D., McCullough, K. International Journal of Nursing Studies, 2014; 51(1): 85-92. 8p. (Journal Article - research, systematic review, tables/charts) ISSN: 0020-7489 PMID: 238096444024&Issue_ID=4153681 Udod S., Hammond-Collins K., & Jenkins M. (2020, May 10). Dynamics of emotional intelligence and Empowerment: The perspectives of middle managers - Sonia a. Udod, Karon, Hammond-Collins, Megan, Jenkins, 2020. Retrieved July 25, 2020, from https://journals.sagepub.com/doi/full/10.1177/2158244020919508 U.S. Bureau of Labor Statistics (BLS). (n.d.). Retrieved July 19, 2019, from https://www.bls.gov/ Wargo, W. G. (n.d.). Identifying Assumptions and Limitations For Your Dissertation. Retrieved August 14, 2019, from https://www.academicinfocenter.com/identifying-assumptions-and-limitations-for-your-d issertation.html Weaver, S. H., Hessels, A. J., Palawi, M., & Wurmser, T. A. (2019, March/April). ​Nursing Economics​.​ Administrative Supervisors and Nursing Unit-Based Managers: Collaboration and Job Satisfaction. Retrieved October 25, 2019, from https://www.nursingeconomics.net/necfiles/2019/MA19/67.pdf Wells, M. (n.d.). Healthcare Turnover Rates in 2018. Retrieved July 20, 2019, from https://business.dailypay.com/blog/employee-turnover-rates-in-the-healthcare-industry Van der Heede, K., Florquin, M., Bruyneel, L., Aiken, L., Diya, L., Lesaffre, E., & Sermeus, W. (2013). Effective strategies for nurse retention in acute hospitals: A mixed-method study. International Journal of Nursing Studies,50​(2), 185-194. DOI:10.1016/j.ijnurstu.2011.12.001 Zimmerman, B. (n.d.). How DaVita improved nurse retention and identified the top performers with customized hiring process: In the era of value-based care, optimizing the patient experience and patient safety are crucial to the success of a hospital. A critical component in meeting these challenges is hiring talented frontline providers poised to thrive. Retrieved July 19, 2019, from https://www.beckershospitalreview.com/human-capital-and-risk/how-davita-improved-nu rse-retention-and-identified-top-performers-with-customized-hiring-process.html Appendix A EDINBORO UNIVERSITY OF PENNSYLVANIA Edinboro, Pennsylvania CONSENT TO PARTICIPATE IN A RESEARCH STUDY Title of Study: Retention, Structural Empowerment, and Dialysis Nursing: Integrating Kanter’s Theory and the Refined Nurse Work-Life Model Principal Investigator: Dr. Meg Larson Co-investigator(s): Richard Scepura Introduction This section makes it clear that a study is to be conducted and the individual is being “asked” to participate. It can also indicate why the individual was chosen. You are being asked by Richard Scepura to be in a research study. You should understand that this study involves research. This consent describes your role as a participant in the study. Purpose of The Study Retention of dialysis nurses is a concern and not merely happening in the USA. It is undetermined if other disciplines’ research on nurse retention can be applied to the dialysis nurse specialty, with certainty. The study will help improve the body of knowledge specific to dialysis nurse retention. The expected participation duration is brief, no more than an hour and any follow-up will be scheduled with the particular focus group participant. For the field study participants, the learning module should take no more than thirty minutes. What Will Happen During the Study? There are two phases of the study. The first phase is a focus group of dialysis nurse experts providing feedback verbal or written on the proposed learning module related to retention concerns. The second phase will be a social media field test of the improved learning module to gather descriptive statistics via Google Slides questionnaire. What Are the Possible Risks or Discomforts? There are no risks. What Are the Possible Benefits of Being in This Study? The benefit is to enhance specific knowledge about dialysis nurse retention factors that can be utilized to improve management of the retention concerns. Are Other Treatments Available? There is no other treatment. How Will the Data Collected Be Kept Confidential? You should know that your name will be kept as confidential as possible, within local, state and federal laws. Records that identify you and this signed consent form may be looked at by the Edinboro University Institutional Review Board (IRB). The results of this study may be shared in aggregate form at a meeting or in a journal, but your name or individual results/score(s) will not be revealed. Expert dialysis nurse participants in the focus group will be numbered chronologically. E.g. RN 1, RN 2, RN 3. The data will be kept within the co-investigator’s locked home office in a secure password protected digital environment. What Happens If I Have More Questions? Your questions about a research-related injury or the research study will be answered by at (814) -732-2900. If you have a question about your rights as a research participant that you need to discuss with someone, you can call the Edinboro University Institutional Review Board at (814) 732-2856 or at irb-chair@edinboro.edu. What Will Happen If You Decide Not To Be in the Study? Your participation is strictly voluntary. Also, you may decide to quit at any time without any penalty, retribution, or repercussion. SUBJECT’S STATEMENT I had a chance to ask questions about the study. These questions were answered to my satisfaction. I realize that being part of this study is my choice. I am at least 18 years of age. I have read the consent form. I was given a copy of this consent form for my own records. SUBJECT’S SIGNATURE DATE Appendix B: Learning Module Appendix C Retention, Structural Empowerment, and Dialysis Nursing Google Slides Questions/Dialysis Structural Empowerment Tool Free Text Box Questions Question 4 Question 9 Question 10 Question 16 Appendix D Potential Mock Up Example (One) Question One: ). I intend to stay in my job 1 year 2 years 5 years 10 years, greater than 10 (choose one) Demographics Age Group Total Response % Mean Median Mode ONE YEAR Demographics Age Group Total Response % Mean Median Mode TWO YEARS Demographics Age Group Total Response % Mean Median Mode FIVE YEARS Demographics Age Group Total Response % Mean Median Mode TEN YEARS Demographics Age Group Total Response % Mean Median N= 21-25 N= 26-35 N= 36-45 N= 46-55 N= 56- above N= 21-25 N= 26-35 N= 36-45 N= 46-55 N= 56- above N= 21-25 N= 26-35 N= 36-45 N= 46-55 N= 56- above N= 21-25 N= 26-35 N= 36-45 N= 46-55 N= 56- above N= 21-25 N= 26-35 N= 36-45 N= 46-55 N= 56- above Mode GREATER THAN TEN Data n total n 100 230 250 75 25 Number of Years Age Group 21-25 26-35 36-45 46-55 56- above 680 Depiction: Bar Graph 1 2 5 10 >10 60 100 75 10 2 20 75 25 30 4 5 28 30 10 12 6 20 35 15 6 9 7 85 10 1 Appendix E Appendix F Appendix G Appendix H Appendix I