Dialysis Technician Burnout: An Opportunity for Empowerment

Related Article, p. ∗∗∗ Related Article, p. ∗∗∗ Burnout among health care workers has long been recognized as a barrier to creating a stable workforce that can provide high-quality care to patients. Defined by Maslach and Jackson1Maslach C. Jackson S.E. The measurement of experienced burnout.J Organ Behav. 1981; 2: 99-113https://doi.org/10.1002/job.4030020205Crossref Scopus (6344) Google Scholar in 1981, burnout is divided into 3 components: emotional exhaustion, depersonalization, and personal accomplishment. The issue has recently garnered more attention in the wake of the COVID-19 pandemic, when many perceived a new risk to their own health2Pawłowicz-Szlarska E. Forycka J. Harendarz K. Stanisławska M. Makówka A. Nowicki M. Organizational support, training and equipment are key determinants of burnout among dialysis healthcare professionals during the COVID-19 pandemic.J Nephrol. 2022; 35: 2077-2086https://doi.org/10.1007/s40620-022-01418-6Crossref PubMed Scopus (2) Google Scholar while caring for more patients with fewer resources and less support. Throughout the pandemic, health care workers often had to fight to provide quality care in a pressurized, inflexible system. Even after the crisis of COVID-19 faded, the “great resignation” plunged the health care industry into further distress with widespread staffing shortages and increased labor costs for temporary workers. In 2022 the Surgeon General published an advisory on health worker burnout, warning of dire consequences for the health care system, including increased medical errors, labor shortages, and worsening health disparities nationwide, if not addressed quickly.3Addressing health worker burnout: The U.S. Surgeon General’s advisory on building a thriving health workforce. U.S. Surgeon General. 2022.https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.htmlDate accessed: February 20, 2023Google Scholar The dialysis sector is not immune to this, and in many ways has amplified the structural and organizational shortcomings that are prevalent throughout the health care industry because they are embedded in the outpatient hemodialysis delivery paradigm in the United States.2Pawłowicz-Szlarska E. Forycka J. Harendarz K. Stanisławska M. Makówka A. Nowicki M. Organizational support, training and equipment are key determinants of burnout among dialysis healthcare professionals during the COVID-19 pandemic.J Nephrol. 2022; 35: 2077-2086https://doi.org/10.1007/s40620-022-01418-6Crossref PubMed Scopus (2) Google Scholar As a result, burnout among nephrologists and dialysis nurses has been studied for more than 15 years, particularly as a means to increase patient satisfaction.4Argentero P. Dell’Olivo B. Ferretti M.S. Staff burnout and patient satisfaction with the quality of dialysis care.Am J Kidney Dis. 2008; 51: 80-92https://doi.org/10.1053/j.ajkd.2007.09.011Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar However, there remains a paucity of data regarding burnout in dialysis patient care technicians, the focus of a survey by Plantinga et al5Plantinga L, Rickenbach F, Urbanski M, et al. Professional fulfillment, burnout, and turnover intention among US dialysis patient care technicians: a national survey. Am J Kidney Dis. Published online March 9, 2023. https://doi.org/10.1053/j.ajkd.2022.12.017Google Scholar in this issue of AJKD. This national survey, organized through the National Association of Nephrology Technicians (NANT), elicited responses from 228 members of the society, most of whom were actively working as dialysis technicians. The survey is well conducted and well analyzed, focusing mainly on the 3 domains of burnout. In general, survey respondents represent an experienced group of technicians, with 76.8% of them working in the field for more than 5 years. The respondents were all members of NANT, which, as the authors acknowledge in their discussion of study limitations, may have led to under-reporting of burnout and turnover intent. The survey results are notable for fair professional fulfillment scores, with an average score of 2.6 out of 4. Professional fulfillment scores in this survey were a measure of satisfaction with and meaningfulness of work. Highest scores in this category were seen in older respondents and those treating fewer patients per day. More alarming results were high levels of work exhaustion, especially among younger technicians and those working more than 40 hours per week. Additionally, more than 50% of participants had high burnout composite scores. Respondents reported dissatisfaction with salary (66.5%), supervisor support (64.0%), and respect from other staff (57.8%) as significant contributors to burnout. Only about half (52.6%) of respondents felt they would still be working as a technician in 3 years, a statistic that is particularly disturbing when considering the experience and professional involvement of the population surveyed. Free text responses from survey respondents highlight the dissatisfaction with pay and colleague interactions, while emphasizing the positive feelings that many health care workers have toward patients and time spent in direct patient care. The factors contributing to technician burnout are summarized in Fig 1. Few of the findings should be surprising for those who practice in outpatient dialysis units, but they do highlight issues specific to the technician role, as well as overlap with other positions, such as physicians and nurses. For example, physician burnout is undoubtedly prevalent, with 63% reporting at least 1 symptom of burnout at the end of 20216Shanafelt T.D. West C.P. Dyrbye L.N. et al.Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic.Mayo Clin Proc. 2022; 97: 2248-2258https://doi.org/10.1016/j.mayocp.2022.09.002Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar and 44% of nephrologists reporting burnout in 2023.7Kane L. ‘I cry but no one cares’: Physician burnout & depression report 2023. Medscape.https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058Date accessed: February 16, 2023Google Scholar The main symptoms of burnout in physicians have consistently been emotional exhaustion and depersonalization.6Shanafelt T.D. West C.P. Dyrbye L.N. et al.Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic.Mayo Clin Proc. 2022; 97: 2248-2258https://doi.org/10.1016/j.mayocp.2022.09.002Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,8Pawłowicz E. Nowicki M. Burnout syndrome among nephrologists - a burning issue - results of the countrywide survey by the Polish Society of Nephrology.BMC Nephrol. 2020; 21: 177https://doi.org/10.1186/s12882-020-01829-2Crossref PubMed Scopus (7) Google Scholar Among dialysis nurses, research describes high levels of burnout frequently attributed to the work environment.9Moisoglou I. Yfantis A. Tsiouma E. Galanis P. The work environment of haemodialysis nurses and its mediating role in burnout.J Ren Care. 2021; 47: 133-140https://doi.org/10.1111/jorc.12353Crossref Scopus (9) Google Scholar Interventions focus on providing structural and psychological empowerment for nursing staff, or creating a workplace where nursing staff can access information and support in order to care for patients.10O’Brien J.L. Relationships among structural empowerment, psychological empowerment, and burnout in registered staff nurses working in outpatient dialysis centers.Nephrol Nurs J. 2011; 38 (quiz 482): 475-481Google Scholar Similarities to the current study include higher rates of burnout in those working more hours and those with less confidence in their knowledge. Technician burnout in this survey is more affected by long hours, low pay, and poor professional relationships. These survey results should be a springboard for further research, focusing on specific interventions aimed at mitigating dialysis technician burnout, and more qualitative data collection to give a voice to a stakeholder group that is frequently excluded from this type of research. This should also serve as a reminder to nephrology leaders of the critical role we play in establishing professional culture for each dialysis unit, and how this culture can exacerbate or heal burnout in dialysis workers at every level. Technician empowerment can be accomplished with bottom-up policy- and procedure-making models, engaging technicians in the development of protocols that affect their performance and providing greater ownership. Additionally, feedback has been shown to be a valuable tool in increasing employee engagement and promoting interpersonal relationships within the workplace, and could be a subject for future research and interventions in this field.11Kersten M. Vincent-Höper S. Nienhaus A. Stress of dialysis nurses-analyzing the buffering role of influence at work and feedback.Int J Environ Res Public Health. 2020; 17: 802https://doi.org/10.3390/ijerph17030802Crossref Scopus (5) Google Scholar Models of care that strengthen the technician-patient relationship should be explored, such as technicians providing education and vascular access training to patients, although this would have to be balanced with the number of patients each technician can care for during a shift. A vascular access lead technician in each facility should undergo additional training and receive hands-on reinforcement supervised by a nurse access manager. A technician champion in other touchpoints such as immunization, modality selection, and transplant referral should receive training by a corresponding nurse manager. The training should include triggers for the technician to refer the patient to the dialysis nurse for further education. Finally, every person involved in the care of dialysis patients deserves a living wage, especially those spending the most time in direct patient care. As the cost of living continues to increase, it comes as no surprise that salary is at the forefront of technicians’ concerns. Indeed, the starting wage in many fast-food restaurants is higher than that of hemodialysis technicians. Technicians are given a high degree of responsibility, and errors on their part can considerably impact patient safety. Additionally, employer-sponsored benefits such as insurance and childcare may be equally valuable, especially for those with children, in recruitment and retention of a diverse and loyal workforce. Plantinga et al5Plantinga L, Rickenbach F, Urbanski M, et al. Professional fulfillment, burnout, and turnover intention among US dialysis patient care technicians: a national survey. Am J Kidney Dis. Published online March 9, 2023. https://doi.org/10.1053/j.ajkd.2022.12.017Google Scholar correctly demonstrate that the dialysis technician role is often overlooked but crucial in determining the quality of care and patient satisfaction in chronic dialysis. In the United States, technicians are the primary interface between the patient and the dialysis facility and patients are not blind to technician disengagement or job dissatisfaction. It is clearly in the best interest of dialysis providers to increase technician fulfillment and retention while decreasing burnout. Results such as those reported in this survey5Plantinga L, Rickenbach F, Urbanski M, et al. Professional fulfillment, burnout, and turnover intention among US dialysis patient care technicians: a national survey. Am J Kidney Dis. Published online March 9, 2023. https://doi.org/10.1053/j.ajkd.2022.12.017Google Scholar suggest we will see a high rate of technician attrition in the coming years, even from those who are experienced and professionally involved, which should be disturbing to anyone involved in providing dialysis care. This research serves as a wake-up call to the dialysis industry to improve the sense of purpose of hemodialysis technicians and to compensate them commensurate with the additional responsibilities they assume over flipping burgers. Failure to do so will inevitably lead to a workforce crisis in the outpatient dialysis setting (which has already begun in some parts of the country) that will adversely impact patient access to and quality of care. Hanna Webb, MD, and Jay B. Wish, MD. None. Dr Wish is medical director of a DaVita outpatient dialysis facility. Dr Webb declares that she has no relevant financial interests. Received February 21, 2023, in response to an invitation from the journal. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form March 22, 2023. Professional Fulfillment, Burnout, and Turnover Intention Among US Dialysis Patient Care Technicians: A National SurveyAmerican Journal of Kidney DiseasesPreviewHigh professional fulfillment and low burnout and staff turnover are necessary for a stable dialysis workforce. We explored professional fulfillment, burnout, and turnover intention among US dialysis patient care technicians (PCTs). Full-Text PDF