I wrote an article for NN&I, published in the July 2013 issue, entitled, “Five challenges impacting nephrology nursing,” They included legislation and regulation, advances in technology, evidence-based practice, crossing borders, and nurse sensitive outcomes. Since that article was published, additional changes have taken place in nursing in general and nephrology nursing specifically. NN&I has asked me to detail the progress on the challenges discussed in that article.

1. Legislation and regulation/nurse licensure compact

The Nurse Licensure Compacts (NLC) allow a nurse to have one license (in his or her state of residency) and to practice in other states (both physically and electronically), subject to each state’s practice law and regulation. The NLC includes registered nurses (RNs) and licensed practical or vocational nurses (LPN/LVNs). Advanced practice registered nurses (APRNs) are not included in the NLC. A separate APRN Compact is being implemented in 2015. As of 2013, 24 states have enacted Nurse Compact Acts and an additional 6 states have pending legislation.

Dialysis facilities have developed a disaster response process through the Kidney Community Emergency Response Coalition (KCER) to ensure that patients requiring dialysis will continue to receive treatment in times of disasters. Unfortunately, staffing for dialysis is often delayed in non-Compact states due to the inability of nephrology nurses to work across state lines. In addition, health care delivery is changing and services provided to patients through telehealth and case management is for the most part provided by nurses physically located in one state and patients located in another. The provision of nursing care services is changing and legislation and regulation must change with it.

2. Advanced degrees in nursing

The National Institutes of Health released a European study in 2012 that supports nurse’s critical role in improving patient outcomes. A better-educated nurse workforce was associated with fewer deaths. For every 10% increase in nurses with bachelor's degrees, there was an associated drop in the likelihood of death by 7%. The findings complement studies in the United States linking improved hospital nurse staffing and higher education levels with decreased mortality. These types of analyses support the recommendation of the Institute of Medicine that 80% of nurses in the U.S. have a bachelor's degree by 2020.1

In addition, the IOM’s report on the Future of Nursing, released in 2011, encourages nurse residency programs for new graduates. We all know the turnover rate for new graduate nurses is  high; investments in nurse residency programs have proven results for retention and for increasing the competency of new nurses.

3. Nurse sensitive outcomes/patient outcomes

The American Nephrology Nurses Association has endorsed the concept of nephrology nursing- sensitive quality indicators as measures that reflect the structure, processes, and outcomes of care influenced by registered nurses. Structure is indicated by the nursing practice environment, RN skill mix, RN-to-patient ratios and the education/certification of RNs. Process indicators measure aspects of nursing care such as assessment, diagnosis, planning, intervention, and evaluation, including the surveillance and supervision of staff. Outcome indicators include patient outcomes, clinician outcomes, or provider outcomes sensitive to the quality or quantity of nursing care. Care coordination improves patient outcomes. Because poorly coordinated care leads to unnecessary suffering for patients, as well as avoidable readmissions and emergency department visits, increased medical errors, and higher costs, coordination of care is increasingly recognized as critical for improvement of patient outcomes and the success of health care systems. Individuals with chronic conditions and multiple co-morbidities often find it difficult to navigate the complex and fragmented health care system. As the patient with kidney disease transitions from one care setting to another, poor outcomes resulting from incomplete or inaccurate transfer of information, poor communication, and a lack of follow-up care become more likely. The sharing of information across settings and between providers through health information technology (HIT) could reduce the unnecessary and costly duplication of patient services.

4. Patient engagement

Patient engagement is the involvement in their own care by individuals (and others they designate to engage on their own behalf), with the goal that they make competent, well-informed decisions about their health and health care and take action to support those decisions.2

While an engaged patient is probably more likely to adhere to recommended care, including self-care, we need to put patients at the center of care, and let them “take power.” Nurses need to continue to focus on improving access to care and reducing health care disparities. There must be acknowledgement and appreciation for cultural, racial/ethnic diversity. Health literacy and language needs to be understood, supported, and taken into account when developing patient education programs.

5. Patient safety

The Joint Commission and the Agency for Healthcare Research and Quality have very clear definitions of the term culture of safety. Culture of safety refers to a shared responsibility among all workers to pay attention to safety and appropriately respond when issues occur.3 In the dialysis environment these include staff training and turnover, economics, reporting process, oversight and regulation, water treatment, dialyzer reuse, medication errors, patient compliance, patient education, vascular access, infection, infrastructure in dialysis units, and the increased age and comorbidities of the ESRD population.

The “culture” in the dialysis unit can influence patient safety. A “blaming” culture of individuals involved in adverse events or near misses discourages reporting. Units should be using these events to identify systemic problems.


The health care system is in the midst of great change and nephrology nurses continually face challenges in their work environments. Nephrology nurses are well poised to meet these challenges by virtue of their numbers, scientific knowledge, and adaptive capacity, and providers would benefit from taking advantage of the contributions nurses can make.


1. Institute of Medicine (2011). The future of nursing: Leading change, advancing health. Washington, D.C.: The National Academies Press. Retrieved from http://www.thefutureofnursing.org/IOM-Report

2. Robert Wood Johnson Foundation (2008). Transforming care at the bedside toolkit. Retrieved from http://www.rwjf.org/qualityequality/product.jsp?id=30057

3. The Joint Commission. Advancing effective communication, cultural competence, and patient and family-centered care: a roadmap for hospitals. Available at: www.jointcommission.org/Advancing_Effective_Communication/. Retrieved Feb. 14, 2014.

4. U.S. Department of Health and Human Services, National Institutes of Health, NIH News, National Institute of Nursing Research (NINR) www.ninr.nih.gov/. Feb. 26, 2014. NINR News, 301-496-0235.