Introduction: Suboptimal dialysis care may be in part due to staff issues such as job dissatisfaction, burnout, work overload, high staff turnover, and inconsistent training. Here, we leveraged data collected in a recent national survey to provide an initial, comprehensive description of current work experiences of US dialysis care providers. Methods: We conducted a cross-sectional survey of 1,240 active US dialysis clinic staff members (physicians, advanced practice providers, nurse managers/clinic coordinators, nurses, social workers, dietitians, and patient care technicians), who were recruited via emails to society membership lists. Respondents were asked about a wide variety of work experiences, including job satisfaction, professional fulfillment, and burnout (Stanford Professional Fulfillment Index), work culture, experiences of hostility and violence, and self-reported medical errors. Responses were summarized overall and compared by clinic role. Results: Most of the survey respondents, representing all 50 US states, were aged 35–49 years (58.3%) or ≥50 years (23.5%), female (60.7%), and white (59.8%; 23.1% black, and 10.0% Asian); 82.1% had been in their current role for at least 1 year. Most US dialysis staff responding to our survey reported being generally satisfied with their jobs (mean rating of 7.9 on 0–10 scale), but only 54.4% met criteria for professional fulfillment, and 32.8% met criteria for burnout, driven by high scores in the work exhaustion domain. Related issues, including high workloads, lack of respect (including experiences of violence and hostility), lack of autonomy, and suboptimal patient environments (in terms of both safety and patient centeredness), were commonly reported among dialysis care providers, although their prevalence often differed by provider type. Conclusion: Our results suggest that the dialysis workforce may be at a critical point. Preventing further staff burnout, which could lead to even greater staffing shortages and worse working conditions among those who continue to provide dialysis care, is essential.

Many aspects of US end-stage renal disease care are guided by the Centers for Medicare & Medicaid Services, including the composition of the dialysis care team [1]. Typically, teams caring for these patients include physicians, nurse managers/clinic coordinators, registered nurses (RNs), social workers, dietitians, and patient care technicians (PCTs), although some clinics additionally employ advanced practice providers (APPs) and/or licensed vocational nurses/licensed practical nurses (LVNs/LPNs). Centers for Medicare & Medicaid Services also oversee the pay-for-performance End-Stage Renal Eisease Quality Incentive Program [2], which includes an increasing number of performance measures related to clinical care, care coordination, patient safety, and patient and family engagement that drive team care. These performance data determine facilities’ Medicare reimbursement and are available to the general public [3]. However, despite the built-in interdisciplinary care team and financial incentives, US dialysis clinics still struggle to deliver high-quality, person-centered care [4, 6].

One underexplored reason for poor dialysis clinic performance may be job quality and work environment issues including job dissatisfaction, work overload, burnout, high staff turnover, and inconsistent training [7, 9]. Low ratings on job quality and work environment could reflect multiple issues, including administrative burden of dialysis care [2]; compassion fatigue and burnout [9, 11]; inadequate staffing and high caseloads [12, 15]; low or non-competitive pay [7]; perceptions of being undervalued by other team members [7]; and harassment or abuse from other team members, including those in leadership positions, or from patients [16, 17]. The COVID-19 pandemic likely only exacerbated these issues [18]. A critical first step to addressing the national priorities of healthcare worker burnout and well-being [19, 20], which may improve dialysis care and patient outcomes, is to describe the unique work experiences of the entire dialysis care team. Here, we leveraged data collected in a recent national survey to assess needs for dementia care in the dialysis setting (Bender et al., manuscript in preparation) to provide a preliminary but comprehensive description of current work experiences of US dialysis care providers, overall and across disciplines.

Study Design

An anonymized cross-sectional REDCap [21] survey including items related to work experiences (online suppl. Item 1; for all online suppl. material, see https://doi.org/10.1159/000530553) was distributed by the National Kidney Foundation and the National Association of Nephrology Technicians/Technologists via emails to membership listservs. Current US dialysis care providers among the membership listservs of NKF (2,322 physicians, 1,753 APPs, 5,295 nurses, 2013 social workers, 5,006 dietitians, 1,172 PCTs, and 7,483 others) and NANT (342 PCTs) were targeted. There were 1,561 clicks on the survey link; of these, 1,291 completed the survey between September 26, 2022, and October 22, 2022 (82.7% overall completion rate). Of the 1,253 respondents with complete and unique surveys, 1,240 (99.0%) were actively working as physicians, APPs, nurse managers/clinic coordinators, RNs, LVNs/LPNs, social workers, dietitians, or PCTs and were included. The 13 excluded respondents reported administrative roles only. Participants provided informed consent and the Emory University Institutional Review Board approved the overall study (approval number STUDY00004571).

Variables

Job Satisfaction

Job satisfaction ratings were assessed via a single item (“On a scale of 1–10, with 1 being very dissatisfied and 10 being satisfied, how satisfied are you with your current position?”) (online suppl. Item).

Professional Fulfillment

Likert scale items (range, 0–4) from the validated Stanford Professional Fulfillment Index [22] were used to assess professional fulfillment or intrinsic rewards derived from work (online suppl. Item). A cut-point of ≥3.0 for the overall score (average of all six relevant item scores) was used to define “professional fulfillment” [22].

Burnout

Burnout, consisting of the work exhaustion and interpersonal disengagement domains, was also assessed via Stanford Professional Fulfillment Index [22] items (range, 0–4; online suppl. Item). A cut-point of ≥1.33 for the overall score (average of four work exhaustion and six interpersonal disengagement items) was used to define “burnout” [22].

Work Culture

Likert scale items modified from the Kansas Culture Change Instrument [23] were used to assess work culture (online suppl. Item). Responses were dichotomized as “always” versus “often/sometimes/never” for analysis.

Hostility and Violence

Modified Likert scale items from the Negative Acts Questionnaire – Revised [24] were used to assess experiences of hostility and violence in the workplace (online suppl. Item). Responses were dichotomized as “sometimes/often/almost all of the time” versus “rarely/never.”

Patient Safety

Recency of medical errors (medical errors that could have or did cause patient harm [22]) was assessed via Likert scale items (range, 0–4; online suppl. Item). Responses were dichotomized as “within the last year/in the last 3 months/in the last month/in the last week” versus “in my lifetime/never.” Two additional items (“Patient areas are kept clean here” and “All personnel take responsibility for answering patient alarms” [25]), dichotomized as “strongly agree” versus “agree/disagree/strongly disagree,” were used to assess work conditions related to patient safety.

Other Variables

Several additional Likert scale items related to job satisfaction and financial rewards, job satisfaction, autonomy and respect, and the patient centeredness of the care environment were included [25, 26]. Responses were dichotomized as “strongly agree” versus “agree/disagree/strongly disagree.” Finally, respondents were also asked about personal (age at survey, gender, race, and ethnicity) and work (types and US state/territory of facilities, time in current position, work hours, and patient caseload) characteristics (see online suppl. Item).

Statistical Analysis

Characteristics of respondents and their work experiences were summarized and tabulated. χ2, rank-sum, and equality-of-medians tests were used to compare outcome variables across categories, as appropriate. Complete case analysis was used. Statistical analyses were performed using Stata v. 17.0 (Stata Corporation, College Station, TX, USA).

Characteristics of Respondents

Most of the survey respondents, representing all 50 US states, were aged ≥35 years (58.3% aged 35–49 years and 23.5% aged ≥50 years) and female (60.7%; Table 1). LVNs/LPNs were younger than other team members (88.1% aged 35–49), and APPs (71.8%), social workers (76.5%), dietitians (92.1%), and PCTs (80.0%) were most likely to be female (online suppl. Table 1). Overall, 59.8% of participants reported white race, while 23.1% and 10.0% reported black and Asian race; 12.3% reported Hispanic ethnicity (Table 1). The majority of respondents had been in their current role for at least 1 year (34.1% for 1–5 years and 48.0% for ≥5 years). Most (62.7%) reported providing care in a freestanding outpatient dialysis clinic (with 20.0% reporting providing inpatient dialysis care), while slightly more than half (55.0%) reported providing care in a for-profit clinic (Table 1). Social workers, dietitians, and PCTs were most likely to report providing care in freestanding outpatient and in for-profit clinics (online suppl. Table 1). Overall, about half of respondents (51.9%) reported working ≥40 h per week, and the median number of patients seen per day was 15 (Table 1). APPs (62.5%), LVNs/LPNs (61.0%), dietitians (63.1%), and PCTs (78.3%) were most likely – and nurse managers/clinic coordinators (28.5%) were least likely – to report working ≥40 h per week (online suppl. Table 1). APPs, social workers, and dietitians reported the highest median number of patients seen per day (20, 40, and 40 patients, respectively; online suppl. Table 1).

Table 1.

Overall characteristics of US dialysis care providers responding to the survey

CharacteristicNOverall
Overall 1,240 – 
Demographics 
Age, n (%) 1,233  
 18–34 224 (18.2) 
 35–49 719 (58.3) 
 ≥50 290 (23.5) 
Gender,an (%) 1,222  
 Female 742 (60.7) 
 Male 480 (39.3) 
Race,bn (%) 1,196  
 Asian 120 (10.0) 
 Black 276 (23.1) 
 White 715 (59.8) 
 Other 69 (6.4) 
Ethnicity, n (%) 1,178  
 Hispanic 145 (12.3) 
 Not Hispanic 1,033 (87.7) 
Work characteristics 
Time in current role, n (%) 1,233  
 <1 year 159 (12.9) 
 1–5 years 482 (39.1) 
 >5 years 592 (48.0) 
Type of dialysis facility(ies),cn (%) 1,240  
 Freestanding outpatient 777 (62.7) 
 Outpatient, hospital based 482 (38.9) 
 Inpatient 248 (20.0) 
Dialysis organization, n (%) 1,190  
 For-profit 655 (55.0) 
 Not-for-profit 353 (29.7) 
 Government/VA 182 (15.3) 
Hours worked per week, n (%) 1,238  
 <30 157 (12.7) 
 30–39 438 (35.4) 
 ≥40 643 (51.9) 
No. of dialysis patients seen per day, median (IQR) 1,015 15 (6.40) 
US region, n (%) 1,213  
 Northeast 223 (18.4) 
 South 483 (39.8) 
 Midwest 248 (20.5) 
 West 259 (21.4) 
CharacteristicNOverall
Overall 1,240 – 
Demographics 
Age, n (%) 1,233  
 18–34 224 (18.2) 
 35–49 719 (58.3) 
 ≥50 290 (23.5) 
Gender,an (%) 1,222  
 Female 742 (60.7) 
 Male 480 (39.3) 
Race,bn (%) 1,196  
 Asian 120 (10.0) 
 Black 276 (23.1) 
 White 715 (59.8) 
 Other 69 (6.4) 
Ethnicity, n (%) 1,178  
 Hispanic 145 (12.3) 
 Not Hispanic 1,033 (87.7) 
Work characteristics 
Time in current role, n (%) 1,233  
 <1 year 159 (12.9) 
 1–5 years 482 (39.1) 
 >5 years 592 (48.0) 
Type of dialysis facility(ies),cn (%) 1,240  
 Freestanding outpatient 777 (62.7) 
 Outpatient, hospital based 482 (38.9) 
 Inpatient 248 (20.0) 
Dialysis organization, n (%) 1,190  
 For-profit 655 (55.0) 
 Not-for-profit 353 (29.7) 
 Government/VA 182 (15.3) 
Hours worked per week, n (%) 1,238  
 <30 157 (12.7) 
 30–39 438 (35.4) 
 ≥40 643 (51.9) 
No. of dialysis patients seen per day, median (IQR) 1,015 15 (6.40) 
US region, n (%) 1,213  
 Northeast 223 (18.4) 
 South 483 (39.8) 
 Midwest 248 (20.5) 
 West 259 (21.4) 

APP, advanced practice provider; RN, registered nurse; LVN/LPN, licensed vocational nurse/licensed practical nurse; PCT, patient care technician; VA, Veterans Affairs; IQR, interquartile range (25th, 75th percentiles).

aExcluding n = 1 non-binary individual to protect identity.

bTotal may be >100% because participants could pick multiple categories. Other includes American Indian/Alaskan Native, Hawaiian/Pacific Islander.

cTotal may be >100% because participants could pick multiple categories.

dFor physicians, median number of patients per week is presented.

Job Satisfaction, Professional Fulfillment, and Burnout

The overall mean job satisfaction rating on a scale of 0–10, with 10 being most satisfied, was 7.9 (Fig. 1a). The highest mean job satisfaction ratings were reported by LVNs/LPNs (8.9), nurse managers/clinic coordinators (8.2), and APPs (8.1; Fig. 1a). Mean (SD) job satisfaction ratings were higher among those who worked in US government (8.5 [1.3]) and not-for-profit clinics (8.2 [1.5]) than among those who worked in for-profit clinics (7.6 [2.0]; p < 0.001). Workers who reported patient caseloads at or above the median versus less than the median had lower satisfaction scores (7.4 [2.1] vs. 8.2 [1.6]; p < 0.001). Overall, about one-quarter to one-third strongly agreed that their job measured up to their expectations (33.7%); their job offered good pay (29.4%); their position had good job security (39.0%); chances for promotion were good (21.1%); and promotions were handled fairly (22.2%). In general, LVNs/LPNs were most likely to strongly agree with the statements, while social workers, dietitians, and PCTs were the least likely (online suppl. Table 2). For example, among PCTs, only 3.3% reported that the pay was good and that the chances for promotion were good (online suppl. Table 2), while 25.3% and 14.1% strongly disagreed with the statements.

Fig. 1.

Overall job satisfaction (a), professional fulfillment (b), and burnout (c) among US dialysis care providers, overall and by role. p < 0.001 for comparisons across role by ANOVA (a) and χ2 test (b, c). APP, advanced practice provider; RN, registered nurse; LVN/LPN, licensed vocational nurse/licensed practical nurse; PCT, patient care technician.

Fig. 1.

Overall job satisfaction (a), professional fulfillment (b), and burnout (c) among US dialysis care providers, overall and by role. p < 0.001 for comparisons across role by ANOVA (a) and χ2 test (b, c). APP, advanced practice provider; RN, registered nurse; LVN/LPN, licensed vocational nurse/licensed practical nurse; PCT, patient care technician.

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The overall median score for professional fulfillment was 3.0 on a scale of 0–4 (online suppl. Fig. 1A). Overall, 54.4% of respondents met the cutoff for professional fulfillment; this percentage ranged widely, from 38.8% (dietitians) to 90.7% (LVNs/LPNs; Fig. 1b). The median scores for work exhaustion and interpersonal disengagement (the two domains of burnout) were 1.3 and 0.6, respectively, on a scale of 0–4 (online suppl. Fig. 1B, C). About one-third (32.8%) met the cutoff for burnout (Fig. 1c). LVNs/LPNs were the least likely (5.9%) and physicians were the most likely (47.2%) to report burnout. Those working in US government clinics were more likely than those working in not-for-profit and for-profit clinics to report professional fulfillment (80.8% vs. 55.5% and 47.2%, respectively; p < 0.001) and were also least likely to meet the cutoff for burnout (22.0% vs. 35.7% and 34.1%; p < 0.001). The median work exhaustion scores were the same (1.3) across all three settings (p = 0.9), whereas median interpersonal disengagement scores were lower among those working in government versus not-for-profit and for-profit clinics (0.0 vs. 0.6 and 0.6; p < 0.001). Additionally, workers with higher versus lower patient caseloads were less likely to report professional fulfillment (36.7% vs. 62.2%; p < 0.001) and more likely to report burnout (42.4% vs. 30.1%; p < 0.001).

Work Culture

About half of respondents reported that they always worked with the same group of patients (50.7%) and that the staff always work together to cover shifts (51.8%; online suppl. Table 3). Fewer (36.9%) reported that staff were always cross-trained to perform tasks outside of their assigned job duties. While 54.1% of respondents overall reported that direct care workers always have input into patient care planning, this percentage varied from 35.2% for PCTs to 85.1% for LVNs/LPNs. Fewer than one-third (27.7%) reported that staff teams always create their own work schedule (online suppl. Table 3), while 18.2% reported that staff teams never create their own work schedule. The percentages ranged widely: 43.0% of nurse managers/clinic coordinators versus 21.4%, 6.3%, and 10.0% of social workers, dietitians, and PCTs, respectively (online suppl. Table 3). About half of respondents strongly agreed that their supervisor treats them as an equal member of the care team (51.3%); their supervisor listens carefully to their observations and opinions (45.8%); it is their own responsibility to decide how their job gets done (42.1%); and they have input into patient care planning (44.4%; online suppl. Table 2). LVNs/LPNs were most likely to strongly agree with these statements, while physicians and PCTs were the least likely. For example, 38.2% and 22.8% of physicians and PCTs strongly agreed that it is their responsibility to decide how the job gets done (with 15.7% and 24.3% disagreeing), and 33.7% and 26.1% strongly agreed that they had input into patient care planning (with 8.1% and 31.5% disagreeing; online suppl. Table 2). Those working in US government clinics were most likely to strongly agree that staff covered shifts (76.4%) and that direct care workers had input into care planning (68.9%), whereas those working in not-for-profit clinics were most likely to strongly agree that staff created their own work schedules (42.0%) and that staff were cross-trained (48.8%; p < 0.001 by dialysis organization type for all). Workers with higher versus lower patient caseloads were less likely to strongly agree that staff covered shifts (33.2% vs. 58.4%), direct care workers had input into care planning (44.2% vs. 55.4%), staff were cross-trained (16.7% vs. 40.6%), or staff created their own work schedules (9.5% vs. 27.7%; p < 0.001 for all).

About one-quarter of respondents overall reported being humiliated or ridiculed (25.9%) or being shouted at or the target of spontaneous anger (27.4%) at least sometimes in the workplace (Fig. 2). Fewer reported experiencing discrimination based on personal characteristics (17.8%) or receiving threats of or actual abuse or violence (16.4%) at least sometimes while at work. Nurse managers/clinic coordinators were the most likely to report being humiliated (38.8%) or receiving threats of or actual abuse or violence (27.4%), while physicians were most likely to report being shouted at or the target of spontaneous anger (36.4%) or experiencing discrimination (28.1%). PCTs also commonly reported being shouted at or the target of spontaneous anger at least sometimes (36.0%; Fig. 2). Workers in not-for-profit clinics (vs. workers in for-profit and US government clinics) were the most likely to report experiencing all of these events at least sometimes: 33.0% reported being humiliated (p = 0.002), 32.5% reported being shouted at (p = 0.001), 22.2% reported experiencing discrimination (p = 0.05), and 33.0% reported receiving threats of or actual abuse or violence (p < 0.001). Those with higher versus lower patient caseloads were less likely to report being humiliated (21.9% vs. 32.2%; p < 0.001), experiencing discrimination (17.0% vs. 22.1%; p = 0.04), or threats of or actual abuse or violence (14.3% vs. 21.6%; p = 0.002).

Fig. 2.

Experiences of hostility and violence (sometimes/often/almost all of the time, vs. rarely/never) among US dialysis care providers, overall and by role. p < 0.001 for all comparisons across role by χ2 test. APP, advanced practice provider; RN, registered nurse; LVN/LPN, licensed vocational nurse/licensed practical nurse; PCT, patient care technician.

Fig. 2.

Experiences of hostility and violence (sometimes/often/almost all of the time, vs. rarely/never) among US dialysis care providers, overall and by role. p < 0.001 for all comparisons across role by χ2 test. APP, advanced practice provider; RN, registered nurse; LVN/LPN, licensed vocational nurse/licensed practical nurse; PCT, patient care technician.

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Perceived Patient Safety and Patient Centeredness of Care

Overall, 8.7% of responding dialysis care providers reported making a major error that could have resulted in patient harm within the past year; 6.0% reported making an error that did result in patient harm (Table 2). Physicians were the most likely to report these errors (30.7% and 20.5%, respectively). LVNs/LPNs were the least likely to report making a major error that could have resulted in patient harm (1.7%) and PCTs were the least likely to report making an error that did result in patient harm (1.1%). Error reporting did not statistically significantly differ by dialysis organization type for either potentially (p = 0.3) or actually (p = 0.2) harmful errors. Those with higher versus lower patient caseloads were less likely to report potentially (8.0% vs. 11.4%) or actually (4.9% vs. 7.5%) harmful errors, but the differences were not statistically significant. Only 52.0% strongly agreed that patient areas were kept clean in their clinic (Table 2), while 4.9% disagreed or strongly disagreed with the statement. Similarly, 39.5% strongly agreed, while 15.0% disagreed or strongly disagreed that all personnel take responsibility for answering patient alarms; those working at government clinics, versus those working at not-for-profit and for-profit clinics, were the most likely to strongly agree that patient areas were kept clean (69.8% vs. 56.6% and 45.3%; p < 0.001) and all personnel took responsibility for answering alarms (55.5% vs. 45.0% and 33.0%; p < 0.001). Those with higher versus lower caseloads were less likely to strongly agree that patient areas were kept clean (40.5% vs. 60.2%; p < 0.001) or that all personnel took responsibility for answering alarms (25.5% vs. 44.8%; p < 0.001).

Table 2.

Patient safety-related work experiences among US dialysis care providers

RoleN (%) reporting “in the last year” or more recentlyN (%) reporting “strongly agree” (vs. “agree/disagree/strongly disagree”) on item
I made a major error that could have resulted in patient harmI made an error that did result in patient harmpatient areas are kept clean hereall personnel take responsibility for answering patient alarms
N 1,236 1,233 1,234 1,233 
Overall, n (%) 108 (8.7) 74 (6.0) 642 (52.0) 487 (39.5) 
Physician, n (%) 27 (30.7) 18 (20.5) 35 (39.3) 32 (36.4) 
APP, n (%) 7 (9.7) 4 (5.6) 25 (35.2) 23 (32.4) 
Nurse manager or clinic  coordinator, n (%) 30 (11.6) 24 (9.3) 165 (64.2) 138 (53.3) 
RN, n (%) 18 (9.8) 10 (5.5) 86 (47.3) 74 (40.9) 
LVN/LPN, n (%) 2 (1.7) 3 (2.5) 79 (67.0) 66 (55.9) 
Social worker, n (%) 8 (3.7) 6 (2.8) 112 (50.9) 70 (32.0) 
Dietitian, n (%) 9 (4.4) 8 (3.9) 85 (41.5) 50 (24.4) 
PCT, n (%) 7 (7.7) 1 (1.1) 55 (59.8) 34 (37.0) 
p value* <0.001 <0.001 <0.001 <0.001 
RoleN (%) reporting “in the last year” or more recentlyN (%) reporting “strongly agree” (vs. “agree/disagree/strongly disagree”) on item
I made a major error that could have resulted in patient harmI made an error that did result in patient harmpatient areas are kept clean hereall personnel take responsibility for answering patient alarms
N 1,236 1,233 1,234 1,233 
Overall, n (%) 108 (8.7) 74 (6.0) 642 (52.0) 487 (39.5) 
Physician, n (%) 27 (30.7) 18 (20.5) 35 (39.3) 32 (36.4) 
APP, n (%) 7 (9.7) 4 (5.6) 25 (35.2) 23 (32.4) 
Nurse manager or clinic  coordinator, n (%) 30 (11.6) 24 (9.3) 165 (64.2) 138 (53.3) 
RN, n (%) 18 (9.8) 10 (5.5) 86 (47.3) 74 (40.9) 
LVN/LPN, n (%) 2 (1.7) 3 (2.5) 79 (67.0) 66 (55.9) 
Social worker, n (%) 8 (3.7) 6 (2.8) 112 (50.9) 70 (32.0) 
Dietitian, n (%) 9 (4.4) 8 (3.9) 85 (41.5) 50 (24.4) 
PCT, n (%) 7 (7.7) 1 (1.1) 55 (59.8) 34 (37.0) 
p value* <0.001 <0.001 <0.001 <0.001 

*Across role, by χ2 test.

Most (67.1%) strongly agreed that they treated patients the way they would like to be treated; LVNs/LPNs (83.8%) and PCTs (80.4%) were the most likely to strongly agree, while physicians were the least likely (55.1%). Fewer strongly agreed that they tried to keep patients’ routines in place (44.8%) or that their patients gave them a reason to come to work every day (48.6%). Nurse managers/clinic coordinators (60.0%), social workers (51.2%), and PCTs (59.8%) were the most likely to strongly agree that their patients gave them a reason to come to work every day (online suppl. Table 2). Only 24.9% and 30.5% strongly disagreed with the statements “sometime our staff take out their bad days on the patients” and “some staff act hostile toward patients.” PCTs were the most likely to strongly disagree (35.9% and 43.5%), while nurse managers/clinic coordinators were the least likely (15.1% and 18.5%; online suppl. Table 2). Workers at US government clinics were more likely than workers at not-for-profit and for-profit clinics to strongly agree that patients gave them a reason to come to work every day (75.8% vs. 64.7% and 65.9%; p = 0.02) and that patients’ routines were kept in place (66.5% vs. 55.9% and 34.0%; p < 0.001); they were also most likely to strongly disagree that staff sometimes took out their bad days on patients (46.2% vs. 21.1% and 30.4%; p < 0.001) or acted in a hostile manner toward patients (40.1% vs. 16.2% and 25.0%; p < 0.001).

In this cross-sectional survey, reported work experiences varied by dialysis clinic role, dialysis organization type, and patient caseloads, but most US dialysis staff responding to our survey reported being generally satisfied with their jobs. However, only about half met criteria for being professionally fulfilled, and one-third met criteria for burnout, driven by high scores in the work exhaustion domain. Related issues, including high workloads, lack of respect, lack of autonomy, and suboptimal patient environments (in terms of both safety and patient centeredness), were commonly reported among dialysis care providers. Our results suggest that the dialysis workforce may be at a critical point and that it is essential to prevent further staff burnout, which could lead to even greater staffing shortages and worse working conditions among those who continue to provide dialysis care.

We found that, although overall satisfaction was high, there were indicators of at least some dissatisfaction with pay (a theme we found in prior work with physicians [27] and, particularly, PCTs [28]), job security, and opportunities for promotion across dialysis clinic roles, all of which could erode job satisfaction over time. Physicians, along with PCTs, social workers, and particularly dietitians, were the least likely to report professional fulfillment, which may reflect suboptimal levels of autonomy and reduced intrinsic rewards for these workers. While previous studies of professional fulfillment among these workers are sparse, increasing caseloads and administrative burden may contribute [11, 13, 15, 27, 29]. In fact, we found that workers with higher caseloads were more likely to report burnout (and less likely to report professional fulfillment). Specifically for dietitians and social workers, it is likely that high patient caseloads (reported median of 40 patients per day for both) contribute to less face-to-face time with patients and more administrative burden [28, 29], which may increase the gap between expectations and reality and decrease the intrinsic rewards of the job, ultimately reducing professional fulfillment. We also found that physicians in the dialysis setting were the most likely to report burnout (47%), far higher than our previous, pre-pandemic estimate (23%). This difference may be partially explained by our specific focus on dialysis providers (vs. all nephrologists) and different instruments to measure burnout [11], in addition to effects of the pandemic or greater awareness of burnout among providers over time. In contrast, we found far lower levels of burnout among PCTs than we found in a similar survey of NANT members performed earlier in 2022 (30% vs. 58%) [27]. The time gap between surveys or differences in measurement might partially explain this discrepancy. It is also likely that our recruitment materials for this study, which emphasized dementia care among patients receiving dialysis, might not have attracted a similar group of PCTs as the prior survey, for which we emphasized burnout in the recruitment materials.

Interestingly, LVNs/LPNs reported very low burnout (6%) and very high professional fulfillment (91%), and their patterns of positive work experiences were consistent across all survey items. While it is possible our LVNs/LPNs were a highly selected group relative to the other respondents, this phenomenon may reflect the unique role of the LVN/LPN in the dialysis setting (generally with higher pay and more autonomy than PCTs but without the overseeing RN’s accountability for patient outcomes [30]). It is also possible that clinics that employ LVNs/LPNs have different processes of care and work cultures that better support worker well-being.

Reported workloads were high: half of all dialysis care providers reported working 40 or more hours per week (with PCTs, dietitians, and APPs being most likely to report ≥40 h) and the median number of patients seen per day among non-physician dialysis providers was 15. Dietitians and social workers both reported a far higher median of 40 patients per day. Only about a third reported that staff were always cross-trained and about half reported that staff always came together to cover shifts (and those with higher caseloads were even less likely to report cross-training or shift-covering), suggesting that insufficient training and understaffing are contributing to a greater workload among dialysis staff. Nurse managers/clinic coordinators were far more likely than others (excluding LVNs/LPNs) to report cross-training and covering of shifts, suggesting that those who are overseeing day-to-day staffing have different perceptions than the providers who are bearing the consequences of staffing decisions.

Perceived lack of respect was frequently reported. Only about half of dialysis staff agreed that their supervisor treated them as an equal member of the team and that their supervisor listened carefully to their observations and opinions. Interestingly, physicians and PCTs were the least likely to agree with these statements, consistent with our findings that PCTs named lack of respect from their colleagues as a major driver of burnout and lack of fulfillment [27] and that physicians did not feel respected by administrators and their institutions [11]. Experiences of hostility and violence from other team members or patients and their family members, which represent extreme forms of disrespect, were not rare, with about one-quarter feeling humiliated or ridiculed or being the target of spontaneous anger or shouting at least some of the time; physicians, PCTs, and nurse managers/clinic coordinators were the most likely to have these experiences. Additionally, nearly one in five experienced discrimination based on personal characteristics or threats, actual abuse, or violence at least some of the time; these were most commonly reported by physicians, APPs, and nurse managers/clinic coordinators. Together, these results suggest that any interventions to increase dialysis care providers’ sense of respect will have to target administrative policies, healthcare team dynamics, and patient-provider relationships.

Our results also suggested that many dialysis care providers feel a lack of autonomy, which is a recognized risk factor for healthcare worker burnout [31]. Fewer than half strongly agreed that it was their responsibility to decide how their job got done or that they had input into patient care planning. Physicians and PCTs were the least likely to agree with these statements, which again is consistent with our prior studies suggesting that perceptions of the lack of autonomy were a driver of burnout among these providers [11, 27]. The potentially surprising observation that physicians feel they do not have input into care planning likely reflects the sense that dialysis care is driven more by administrative policies than patients’ best interests, which emerged as a theme in our nephrologist burnout survey [11]. As with lack of respect, it is likely that interventions at multiple levels (providers, facilities, regional and national policymakers) would be needed to improve sense of autonomy among these workers.

Finally, we found that the patient environment at the dialysis clinic was less than ideal. While ∼6 and 9% of dialysis care providers reported they had made medical errors that had or could cause patient harm in the last year, physicians reported far higher proportions than other dialysis care providers: 21% and 31%. This may reflect truly higher error rates (potentially due to greater severity of burnout [32]), better recognition of what errors lead to patient harm, and/or higher levels of accountability for errors among physicians. Additionally, about half of providers (and even fewer among those with higher caseloads or working at for-profit clinics) did not strongly agree that patient areas were kept clean or that everyone took responsibility for answering patient alarms, which could also compromise patient safety. Providers also indicated potential issues with patient centeredness of care, although they were far more likely to strongly agree that they personally treated patients as they would like to be treated (67%) and that patients gave them a reason to come to work every day (49%) than they were to strongly disagree that other staff took out their bad days on patients (25%) or were hostile to patients (31%). This discrepancy likely reflects some level of social desirability bias, as well as differences in work environments and level of transparency within dialysis organizations.

There are several limitations that deserve mention. First, a response rate cannot be calculated due to unknown denominators (i.e., read status of recruitment emails could not be tracked; unknown number of individual email addresses included in listservs might be inactive; and recipients may have shared the recruitment emails outside of the listserv). However, the rate is likely low given the numbers of emails sent and responses received, limiting generalizability to NKF and NANT memberships. Additionally, providers were recruited to answer questions primarily about dementia care, not work experiences, which may have resulted in less generalizability to NKF and NANT members. Also, because of this primary interest, we minimized participant burden by omitting several items that may be important to the outcomes examined here. For example, we did not collect information on US- versus foreign-born status, size of clinic, numbers and types of shifts, or types of clinic-required training (e.g., safety or harassment training), which may have influenced providers’ behaviors or perceptions about their clinic environment. Differences in training may partially explain some of the strong differences by dialysis organization type that we observed in this study. Data collected from NKF and NANT members may not be representative of all US dialysis staff. As with all cross-sectional studies, temporal trends cannot be captured. Finally, comparisons with previous studies are complicated by the lack of standard measurements of work experiences.

Despite these limitations, this study provides an initial, concurrent, and comprehensive snapshot of work experiences among all types of dialysis providers. While surveys conducted by other means, such as distribution by dialysis organizations, might improve response rates of dialysis provider surveys, our anonymized survey design allows for feedback without fear of reprisal or retaliation by supervisors or administrators who might have access to the data. Further, these hypothesis-generating results address the surgeon general’s recent urgent call for measurement of healthcare worker burnout across settings [20] and the National Academy of Medicine’s National Plan for Health Workforce Well-Being [19], specifically targeting the unique and often overlooked dialysis workforce.

In conclusion, our results suggest that lack of fulfillment and burnout are highly prevalent and that there are common features of the dialysis clinic work environment that may drive further loss of fulfillment and burnout, leading to potentially devastating consequences for the already overtaxed dialysis workforce and for their patients. Further studies of the correlates and consequences of the work experiences of the dialysis workforce, as well as development of interventions at multiple levels to address these issues, are urgently needed.

We thank Meghan Fiely of NANT for assistance with the distribution of the survey.

This study protocol was reviewed and approved by the Emory University Institutional Review Board, approval number STUDY00004571. As approved by the Emory University Institutional Review Board, online informed consent was obtained from all participants and was required to complete the survey.

The authors have no conflicts of interest to declare.

This work was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of Award Number U1QHP33070 totaling $3.75 M with 0% percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US government.

L.C.P., A.A.B., M.U., J.C.M., and B.G.J. conceived the study; L.C.P., A.A.B., M.U., and J.C.M. drafted and reviewed the survey; L.C.P., C.H., J.J., K.D., F.R., and C.J.D.-A. were responsible for recruitment and data collection; L.C.P. performed the quantitative data analysis. All authors contributed important intellectual content during manuscript drafting and/or revision.

The data that support the findings of this study are not currently publicly available due to ongoing analyses but are available from the corresponding author [L.C.P.] upon reasonable request.

1.
Centers for Medicare & Medicaid Services
.
Medicare and medicaid programs; conditions for coverage for end-stage renal disease facilities. Final rule
.
Fed Regist
.
2008
;
73
(
73
):
20369
484
.
2.
Centers for Medicare & Medicaid Services
.
End-stage renal disease quality incentive program. Final rule
.
Fed Regist
.
2011
;
76
(
3
):
627
46
.
3.
Centers for Medicare & Medicaid Services
Dialysis facility compare
Baltimore (MD)
2003
. Available from: https://www.medicare.gov/care-compare/?guidedSearch=DialysisFacility&providerType=DialysisFacility.
4.
Weisbord
SD
.
Patient-centered dialysis care: depression, pain, and quality of life
.
Semin Dial
.
2016
;
29
(
2
):
158
64
.
5.
Bowling
CB
,
Plantinga
LC
.
When all you have is a hammer: the need for tools to define and apply patient-centered outcomes in hemodialysis
.
Clin J Am Soc Nephrol
.
2017
;
12
(
3
):
382
4
.
6.
O’Hare
AM
.
Patient-centered care in renal medicine: five strategies to meet the challenge
.
Am J Kidney Dis
.
2018
;
71
(
5
):
732
6
.
7.
Thomas-Hawkins
C
,
Denno
M
,
Currier
H
,
Wick
G
.
Staff nurses’ perceptions of the work environment in freestanding hemodialysis facilities
.
Nephrol Nurs J
.
2003
;
30
(
4
):
377
86
.
8.
Gardner
JK
,
Thomas-Hawkins
C
,
Fogg
L
,
Latham
CE
.
The relationships between nurses’ perceptions of the hemodialysis unit work environment and nurse turnover, patient satisfaction, and hospitalizations
.
Nephrol Nurs J
.
2007
;
34
(
3
):
271
81
; quiz 282.
9.
Cao
X
,
Chen
L
.
Relationships between resilience, empathy, compassion fatigue, work engagement and turnover intention in haemodialysis nurses: a cross-sectional study
.
J Nurs Manag
.
2021
;
29
(
5
):
1054
63
.
10.
Agrawal
V
,
Plantinga
L
,
Abdel-Kader
K
,
Pivert
K
,
Provenzano
A
,
Soman
S
.
Burnout and emotional well-being among nephrology fellows: a national online survey
.
J Am Soc Nephrol
.
2020 Apr
31
4
675
85
.
11.
Nair
D
,
Brereton
L
,
Hoge
C
,
Plantinga
LC
,
Agrawal
V
,
Soman
SS
.
Burnout among nephrologists in the United States: a survey study
.
Kidney Med
.
2022 Mar
4
3
100407
.
12.
Yoder
LA
,
Xin
W
,
Norris
KC
,
Yan
G
.
Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities
.
Am J Kidney Dis
.
2013 Dec
62
6
1130
40
.
13.
Wolfe
W
.
The festering crisis of inadequate nephrology social work staffing: what are the options for improvement
.
J Nephrol Soc Work
.
2014
;
38
(
1
):
10
9
.
14.
Hand
RK
,
Albert
JM
,
Sehgal
AR
.
Structural equation modeling to explore patient to staff ratios as an explanatory factor for variation in dialysis facility outcomes
.
J Ren Nutr
.
2018
;
28
(
5
):
309
16
.
15.
Zheng
GQ
,
Hand
RK
.
Registered dietitian staffing in dialysis: impact on quality ratings in mandate and nonmandate states
.
J Ren Nutr
.
2021
;
31
(
5
):
523
8
.
16.
Jones
ER
,
Goldman
RS
.
Managing disruptive behavior by patients and physicians: a responsibility of the dialysis facility medical director
.
Clin J Am Soc Nephrol
.
2015
;
10
(
8
):
1470
5
.
17.
Allon
M
,
Thornley-Brown
D
,
Rizk
DV
,
Carrasquillo
AJ
.
Second-chance placement of hemodialysis patients after involuntary discharge for disruptive behavior
.
Am J Kidney Dis
.
2019
;
74
(
4
):
544
8
.
18.
Boyle
SM
,
Washington
R
,
McCann
P
,
Koul
S
,
McLarney
B
,
Gadegbeku
CA
.
The nephrology nursing shortage: insights from a pandemic
.
Am J Kidney Dis
.
2022
;
79
(
1
):
113
6
.
19.
National Academy of Medicine
. In:
Dzau
VJ
,
Kirch
D
,
Murthy
V
,
Nasca
T
, editors.
National plan for Health workforce well-being
Washington, DC
National Academies Press
2022
.
20.
The U.S. Surgeon General’s advisory on building a thriving Health workforce
. In:
Addressing Health worker burnout
Washington, DC
U.S. Department of Health & Human Services
2022
.
21.
Harris
PA
,
Taylor
R
,
Thielke
R
,
Payne
J
,
Gonzalez
N
,
Conde
JG
.
Research Electronic Data Capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support
.
J Biomed Inform
.
2009
;
42
(
2
):
377
81
.
22.
Trockel
M
,
Bohman
B
,
Lesure
E
,
Hamidi
MS
,
Welle
D
,
Roberts
L
.
A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians
.
Acad Psychiatry
.
2018
;
42
(
1
):
11
24
.
23.
Bott
M
,
Dunton
N
,
Gajewski
B
,
Lee
R
,
Boyle
D
,
Bonnel
W
,
Rachlin
R
Culture change and turnover in Kansas nursing homes
Topeka (KS)
Kansis Department on Aging
2009
.
24.
Einarsen
S
,
Hoel
H
,
Notelaers
G
.
Measuring exposure to bullying and harassment at work: validity, factor structure and psychometricproperties of the negative acts questionnaire-revised
.
Work Stress
.
2009
;
23
(
1
):
24
44
.
25.
Dill
JS
,
Morgan
JC
,
Marshall
VW
,
Pruchno
R
.
Contingency, employment intentions, and retention of vulnerable low-wage workers: an examination of nursing assistants in nursing homes
.
Gerontologist
.
2013
;
53
(
2
):
222
34
.
26.
Dill
JS
,
Morgan
JC
,
Weiner
B
.
Frontline health care workers and perceived career mobility: do high-performance work practices make a difference
.
Health Care Manage Rev
.
2014
;
39
(
4
):
318
28
.
27.
Plantinga
LC
,
Rickenbach
F
,
Urbanski
M
,
Hoge
C
,
Douglas-Ajayi
C
,
Morgan
JC
.
Professional fulfillment, burnout, and turnover intention among U.S. dialysis patient care technicians: a national survey
.
Am J Kidney Dis
.
2023
S0272-6386(23)00559-0
. In press.
28.
Hand
RK
,
Burrowes
JD
.
Renal dietitians’ perceptions of roles and responsibilities in outpatient dialysis facilities
.
J Ren Nutr
.
2015
;
25
(
5
):
404
11
.
29.
Merighi
JR
,
Zheng
M
,
Browne
T
.
Nephrology social workers’ caseloads and hourly wages in 2014 and 2018: findings from the National Kidney Foundation Council of Nephrology Social Workers professional practice survey
.
J Nephrol Soc Work
.
2018
;
42
(
1
):
31
59
.
30.
Cahill
ML
,
Painter
DR
,
Branch
JL
.
The authority for certain clinical tasks performed by unlicensed patient care technicians and LPNs/LVNs in the hemodialysis setting: an update and invitation to take action
.
Nephrol Nurs J
.
2021
;
48
(
2
):
119
29
.
31.
Meredith
LS
,
Bouskill
K
,
Chang
J
,
Larkin
J
,
Motala
A
,
Hempel
S
.
Predictors of burnout among US healthcare providers: a systematic review
.
BMJ Open
.
2022
;
12
(
8
):
e054243
.
32.
Garcia
CL
,
Abreu
LC
,
Ramos
JLS
,
Castro
CFD
,
Smiderle
FRN
,
Santos
JAD
.
Influence of burnout on patient safety: systematic review and meta-analysis
.
Medicina
.
2019
;
55
(
9
):
553
.