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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 researchers 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.
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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
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 researchers 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.
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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