AJKD Interviews Editor Timothy Yau (@Maximal_Change) talks to Dr. Laura Plantinga and Dr. Bernard Jaar on their recent publication looking at burnout and turnover in dialysis patient care technicians (PCTs) in the United States.

Dr. Laura Plantinga is an Associate Professor at Emory University in Atlanta, Georgia. She received a PhD in Epidemiology from Emory and a masters in biostatistics from Johns Hopkins University. She serves on the Editorial Board of AJKD and is a Senior Board Member for BMC Nephrology. Her research focuses on multidisciplinary, patient-centered approaches to improving the quality of care among underserved patients with chronic diseases, including patients with CKD, ESKD, and lupus.

Dr. Bernard Jaar is an Assistant Professor of Medicine at Johns Hopkins University. He holds a Master of Public Health degree from the Johns Hopkins Bloomberg School of Public Health and is a Fellow of the American College of Physicians, of the American Society of Nephrology and of the National Kidney Foundation. He is interested in outcomes research among patients with CKD and on dialysis.

AJKDBlog: First of all, thank you for highlighting such an important topic pertaining  to the nephrology healthcare.  So often when we hear “nephrology workforce crisis” everyone thinks of the fellowship training issue, and your paper emphasizes that there has been strain on the workforce for dialysis nurses and PCTs.  Can you tell us from a historical perspective what burnout and turnover among staff in dialysis units has looked like over the past decades?

This is a very important question. It takes the entire dialysis care team to make a program successful. Dialysis patient care technicians are front-line care providers in U.S. dialysis centers. The work they perform, as well as the challenges they face, are too often overlooked by the nephrology community. These issues have been underexplored and there are actually very little data about burnout or turnover in this setting over the years.

Our group recently reported that 23% of nephrologists (as well as 30% of fellows) were experiencing burnout in 2018-2019. Recent, COVID-era surveys by other groups have shown that >60% of dialysis nurses reported burnout and similar percentages intended to leave their jobs. Similar burnout rates are reported at 57% in the U.K. nephrology workforce. While burnout and turnover intention have not been explored in-depth among dialysis social workers and dietitians, factors that increase the risk of burnout are common: social workers averaged around 130 patients in 2017 (vs. National Kidney Foundation recommendations of a maximum of 75 patients per social worker), and 58% of surveyed dietitians were dissatisfied with the amount of work they were assigned; both reported that only ~25% of their time was spent on direct patient care or counseling, the work for which they were trained, which can lessen professional fulfillment and increase risk for burnout.

AJKDBlog: Many people only noticed this issue when COVID-19 put the strain on dialysis care.  Can you briefly tell us how the pandemic unmasked this pre-existing issue?

This is a very good point. The U.S. dialysis care system was already quite strained and the pandemic only made this more apparent by introducing additional barriers to providing patient care in the dialysis centers.  These included:

• Treating and providing guidance to patients who were frightened or isolated
• Providing care without adequate information or personal protective equipment
• Experiencing hostility and threats due to virus misinformation
• Increasing patient caseload and severity beyond system capacity (which was exacerbated by increased rates of turnover at the start of the pandemic).

However, it is important to note that our participants did not cite the pandemic as a major factor contributing to their experiences of professional fulfillment and burnout, suggesting that other pre-existing and often reversible factors may be more strongly associated with these reported experiences.

AJKDBlog: Please walk us through the survey design, some of the questions you asked, and how you obtained responses from dialysis PCTs.

Our survey incorporated items from the Stanford Professional Fulfillment Index, which measures professional fulfillment and two domains of burnout, work exhaustion and interpersonal disengagement. We also asked participants to rank contributors to their feelings of professional fulfillment and burnout and about turnover intention (“Do you think you will still be working as a dialysis technician in 3 years?” and “Do you think you will be working at the same facility?”).

In partnership with the National Association of Nephrology Technicians/Technologists (NANT), we provided the survey link to dialysis PCTs via direct emails to the NANT listserv; on QR codes on postcards distributed at the NANT and National Kidney Foundation annual meetings, and via links/QR codes posted in NANT’s newsletters and on closed social media pages. We chose this method of recruitment because we believed that it was very important to work directly with this group of front-line dialysis providers, rather than through their employers.

AJKDBlog: And can you give us a snapshot of the results you obtained from the quantitative data?  Did anything stand out in particular?

Unsurprisingly we found a high prevalence of burnout, with 58% of dialysis PCTs reporting burnout, while only 37% reported professional fulfillment. For burnout, issues pertaining to work exhaustion, rather than interpersonal disengagement (with patients or other staff), seemed to drive these percentages.

The strongest contributors to their feelings of fulfillment vs. burnout were salary, supervisor support, respect from other staff and patients, sense of purpose, number of hours worked, and level of autonomy in their work. We also found that nearly half (47%) reported turnover intention within 3 years, and interestingly this was even higher among younger dialysis PCTs (68% vs. 40% for those aged <35 vs. ≥50 years). Even among those who planned to continue working as PCTs, only 69% planned to be working at the same facility.

The big takeaway is that the healthcare system need to start paying more attention to these front-line dialysis providers. Our patients, and the nephrology community at large, depend on them to deliver safe, high-quality care to our patients with kidney failure.

AJKDBlog: As someone who reviews student feedback all year, oftentimes I find responses from the qualitative narrative data to be the most helpful in identifying strategies to improve the system.  Did any themes emerge from the free-text responses?

Yes, we agree that qualitative data can be a rich source of data for potential improvement strategies. Our qualitative data (from an open-ended question) highlighted three major themes.

First, participants emphasized low pay, with several participants noting that pay levels were similar to those in retail or fast food, which is shocking when you think about the highly specialized medical service they provide. Second, insufficient staffing and training emerged as a theme, which is unfortunately a problem throughout our health system these days. Finally, participants often voiced opposing feelings of fulfillment vs. burnout, with participants often stating they loved their patients but that the workload and stress were making it hard to continue working in the dialysis environment.

AJKDBlog: Lastly, what changes do you think are needed to mitigate this issue for the future of dialysis care in the US?

This is a loaded question! We likely need multifactorial, multilevel changes to mitigate these issues, which threaten the current and future quality and safety of dialysis care. Addressing low pay requires employers to invest in higher salary and/or other employment incentives such as promotion and educational opportunities. Improving staffing and training will likely require interventions at the level of the employer, healthcare system, and policymaker. For example, standardized training and certification processes and mandated patient-to-PCT ratios (which only exist in some states) should be considered. Improving supervisor support and respect from other staff will likely require interventions at the dialysis care team level and would require both psychosocial (e.g., education in interpersonal teamwork) and organizational components.

Now that we have identified these important issues with our PCTs, more research is needed to develop and implement interventions at these multiple levels. Additionally, it will be important to examine longitudinal associations of these issues with outcomes among both technicians and patients, which may provide a more persuasive evidence base for employers and policymakers to facilitate such interventions.

To view Plantinga et al, please visit AJKD.org.

Title: Professional Fulfillment, Burnout, and Turnover Intention Among US Dialysis Patient Care Technicians: A National Survey
Authors: Laura C. Plantinga, Fran Rickenbach, Megan Urbanski, Courtney Hoge, Clarica Douglas-Ajayi, Jennifer Craft Morgan, Alexis A. Bender, and Bernard G. Jaar
DOI: 10.1053/j.ajkd.2022.12.017