dialysis nursing...i want to run fast and far away

[RN yogi]

hello all, i am a new nurse and 6 weeks into my training at an outpatient dialysis clinic. let's just training has been hell. the culture at the clinic is intolerable. i have worked in healthcare for almost ten years and i have never experienced coworkers being so disrespectful and down right mean to one another. my preceptor goes so quickly that i can't even learn. every patient i have seems to bleed all over the place after treatment or is so hypotensive that it is unsafe to let them leave. then i get reprimanded for not getting them out the door quickly enough. one morning, without notice, my preceptor told me that i was expected to prime the whole bay. she said there was no reason it should take me so long to prime 10 machines. she wrote on my weekly review last week that i lacked initiative. umm...i just busted my ass for two years to get an rn degree so i doubt it's that. regardless, instead of taking it personally i showed up every morning this week 15 minutes early to get a head start. the faster she pushes me the more i **** up and the worse and incompetent i feel. she is frustrated with me and i am equally as frustrated with her. i questioned whether or not a patient should be put on the machine today bc they were hypotensive and very close to their dry weight. she told the manager. she no longer wants to work with me and spoke with the manager. i spoke with the manager immediately afterwards and told her my side of the story. i have serious concerns about pt safety. i have worked so hard to get my license and i feel that my question re: pt safety are valid even if my preceptor has worked in the field a year longer than i have. she's a tech mind you and not an rn. i cried today for the first time ever at work. i am not a crier, but i can't take the speed i'm expected to perform at while ensuring patient safety. yesterday i was reprimanded by a tech for saying something to a patient that i never even spoke to. everyone seems to have an ego bigger than the room they occupy and tongues like daggers. at this point i'm thinking that i just want to put in applications elsewhere and get the heck out while the getting is good. i want to succeed, but i want to be happy more.

has anyone else had such experiences working dialysis? did you leave? would you stay?

[Chisca, RN]

Being oriented by a tech is NOT abnormal nor wrong. It's how it's done where I work.

The OP describes a clinic where techs are making clinical judgements as to whether or not patients are stable enough to tolerate a dialysis treatment and whether or not they are stable enough to leave the clinic after a treatment. This is outside their scope of practice and dangerous to the patients. I cannot believe the manager of the unit allows this to take place.

[SmilingBluEyes]

Where I work, technicians are pretty darn good at initial vital signs and knowing when to bring up to us a potential instability of a patient. They do not make the clinical decision as to whether a patient should start, continue or end dialysis, but are a tremendous resource to bring our attention to situations that require nursing judgment. Again, they are not making the clinical decisions, but their information and data-gathering sure do help me in making these decisions myself.

I don't work in the perfect environment, but I consider myself lucky to have some very astute and experienced technicians who "have my back". But then, I have THEIRS too. When they need help stringing machines or cannulating patients, they know they can count on me to jump in. It's a really good thing we have going.

THAT is why I know, OP, you can definitely do better.

[SmilingBluEyes]

One more thing, I may have missed that part about techs making clinical decisions. OP, it would be so helpful if you would break down your post into easier to read paragraphs. Just an observation.

I re-read the post and upon doing so, reinforce my belief that it would be best for you to cut your losses and get the hell out of there. It sounds like a very toxic and dangerous work environment. NO WAY would I take the abuse you are and be sane.

[Erikadawn RN]

Being a dialysis nurses, is either or you like it or you hate it. I was oriented by techs until I learned the machines, and how to stick. I never had an abusive tech , and yes I quite frequently wanted to walk off the job. I stuck with it, and I learned. It was one of the most difficult jobs I ever had, and I felt dumb every day for about 6 months straight. Now after almost 3 years of being a dialysis Nurse, I still have my good and really bad days. That's dialysis, I have done treatments on patients with bp's in the basement. I don't run from low bp's I work with them and they get there needed treatment. That's just the dialysis business, if I have my doubts I call the physician . If it's just a job, until you get another one, then you won't like it.

[Chisca, RN]

Let's not kid ourselves as to why there are any techs in a dialysis clinic. It is not to improve the quality and it's not because they possess skills that a nurse doesn't have. It is so Kent Thiry can make 26 million a year.

[Guttercat, ASN, RN]

Let's not kid ourselves as to why there are any techs in a dialysis clinic. It is not to improve the quality and it's not because they possess skills that a nurse doesn't have. It is so Kent Thiry can make 26 million a year.

As much as I am not a fan of Corporate Dialysis, the move to make techs the predominant presence in outpatient units is not KT's fault alone. He is brilliant, and was poised to not only ride the wave, but own it and direct it too.

[Chisca, RN]

Kent Thiry succeeds in an environment where productivity trumps quality. As long as his model dominates the practice of dialysis in the United States we can expect high mortality as the cost of companies like his being profitable. Look at the one year mortality rates in Japan, 6.6%, Europe, 15.6 %, and the United States, 21.7%. Which country would you rather be a dialysis patient? Davita's corporate model won't fly outside the US because other countries won't tolerate 20% mortality rates among dialysis patients.

[Guttercat, ASN, RN]

Kent Thiry succeeds in an environment where productivity trumps quality. As long as his model dominates the practice of dialysis in the United States we can expect high mortality as the cost of companies like his being profitable. Look at the one year mortality rates in Japan, 6.6%, Europe, 15.6 %, and the United States, 21.7%. Which country would you rather be a dialysis patient? Davita's corporate model won't fly outside the US because other countries won't tolerate 20% mortality rates among dialysis patients.

You are correct. KT is successful because he is a brilliant, opportunistic businessman thriving in a window of a financial niche that is now ruled by who has the most $$ to buy attorneys, and politicians.

Dialysis was a cash cow for a time, and it drew the likes of really, really smart people like KT. We now have what we have. Instead of the best niche in healthcare, we are dancing to the bullets fired by The Big Two.

I do remember the days when there was no "Big Two," and it was better on many fronts. That's not to say the competition between these guys hasn't led to improved practice standards across the spectrum, because in some ways it has. But had there not been the opportunity for large financial gains, this current mess would not even be an issue. Right now, KT is just riding the wave. He'll ride it until it's no longer profitable, which is just around the corner here in the states (and why I surmise that Davita is branching out to primary care here, and dialysis abroad).

I'm interested in those mortality rates you mentioned. There is a LOT that goes into mortality rates including the prevailing socio-economics of any given country, and prevailing ESRD etiologies. For example, what is the rate of IDDM in Japan's population of ESRD patients as opposed to the U.S.A? An ESRD patient with poorly controlled IDDM is not as likely to do well over the long haul than a patient with an etiology that is less catastrophic to overall health. What is the rate of drug/alcohol abuse and indigence or poverty in the Japan ESRD patients as opposed to their USA counterparts?

There is a lot more to the "stats" than the numbers generated in an excel graph.

[Chisca, RN]

One of the things I hate about a tech driven dialysis model is the lack of education patients receive when they are in the dialysis unit. They do absolutely no education when they are with the patients as they are task driven. My belief is that one of the reasons our patients do poorly because of the lack of knowledge about their disease and the options they have to control the process. My 15 bed unit has one tech and 7 nurses on a shift. If a patient has a desire that high nurse ratio gives them ample opportunity to interact with an RN who can answer any questions and help them. If the ratio was 7 techs and 2 nurses I don't think there would be the same outcome. Nurses are the key. I can't prove it with a study but every time a patient asks me can to do their dialysis at my hospital based unit instead of their clinic I know we are providing a higher quality experience than any Davita clinic.

[westieluv]

I'm interested in those mortality rates you mentioned. There is a LOT that goes into mortality rates including the prevailing socio-economics of any given country, and prevailing ESRD etiologies. For example, what is the rate of IDDM in Japan's population of ESRD patients as opposed to the U.S.A? An ESRD patient with poorly controlled IDDM is not as likely to do well over the long haul than a patient with an etiology that is less catastrophic to overall health. What is the rate of drug/alcohol abuse and indigence or poverty in the Japan ESRD patients as opposed to their USA counterparts?

There is a lot more to the "stats" than the numbers generated in an excel graph.

That's a good point, because in my experience, while I avoid at all costs that tired, judgmental cliche' that, "They did it to themselves", it does seem that the overall unhealthiness of the American lifestyle combined with the excessive numbers of people who are addicted to drugs and/or alcohol might drive those mortality rates up when compared to other countries like Japan, where we are led to believe that the overall lifestyle and substance abuse rates are better.

If most ESRD patients in Japan reached that point through things like hereditary polycystic disease or acute incidents that had nothing to do with their lifestyle, such as Gent toxicity, etc., then they aren't also struggling with the comorbidities that often contribute to early death in our patient population here in the U.S.

In the case of Japan, the stereotype is that the Japanese eat a much healthier diet than Americans and get more physical exercise, which would explain why their obesity rates are much lower than ours. Sometimes I wonder, though, if that stereotype is outdated, since the Japanese have been so imfluenced in recent years by our culture, for better or for worse. It makes you wonder if any of this is figured into those numbers.

I agree with Chisca that a higher ratio of nurses in the dialysis setting would improve overall results, I just don't see that ever happening because of what it would do to the profit margin. What I did see when I was working in a chronic dialysis unit that was staffed with five techs and two nurses for twenty chairs, was that a lot of opportunities for education and meaningful dialogue were lost because we, the nurses, were just too busy to give good, one on one, education and care to our patients, and the techs, who had the time but not the training in the disease process, would build more of a social relationship with the patients wherein they would chit chat about everything else but their illness. That, to me, is one of the greatest failures of the modern day, "Big Two" dialysis culture.

[Guttercat, ASN, RN]

Guttercat, to answer your questions i'm not even sure i like dialysis. i'm not sure i particularly enjoy the patients. some are fun and nice, others are miserable and not afraid to let you know it. i can't say i really blame the miserable ones. i'd be miserable too if i had to live their lifestyle. i've been thinking over the weekend and i've come to the conclusion that i'm going to try to stick it out at least until the RN training is complete. however, i can tell you that i am not in this specialty for the long haul.

One of the problems is that you haven't been given a chance to like dialysis. If the first time I tried pie was because someone hit me in the face with it and then shoved it down my throat until I choked, I probably would come away not liking pie.

Keep in mind the preceptor still has to accomplish their full workload while trying to train you at the same time. That's squishing 18 hours of work into ten or twelve.

"Back in the day," one had a full month of classroom, and was gradually trained to the floor by a dedicated nurse educator. The floor nurse or tech did not get you until you were at least 60%+ functional on your own.

[Guttercat, ASN, RN]

That's a good point, because in my experience, while I avoid at all costs that tired, judgmental cliche' that, "They did it to themselves", it does seem that the overall unhealthiness of the American lifestyle combined with the excessive numbers of people who are addicted to drugs and/or alcohol might drive those mortality rates up when compared to other countries like Japan, where we are led to believe that the overall lifestyle and substance abuse rates are better. If most ESRD patients in Japan reached that point through things like hereditary polycystic disease or acute incidents that had nothing to do with their lifestyle, such as Gent toxicity, etc., then they aren't also struggling with the comorbidities that often contribute to early death in our patient population here in the U.S. In the case of Japan, the stereotype is that the Japanese eat a much healthier diet than Americans and get more physical exercise, which would explain why their obesity rates are much lower than ours. Sometimes I wonder, though, if that stereotype is outdated, since the Japanese have been so imfluenced in recent years by our culture, for better or for worse. It makes you wonder if any of this is figured into those numbers.I agree with Chisca that a higher ratio of nurses in the dialysis setting would improve overall results, I just don't see that ever happening because of what it would do to the profit margin. What I did see when I was working in a chronic dialysis unit that was staffed with five techs and two nurses for twenty chairs, was that a lot of opportunities for education and meaningful dialogue were lost because we, the nurses, were just too busy to give good, one on one, education and care to our patients, and the techs, who had the time but not the training in the disease process, would build more of a social relationship with the patients wherein they would chit chat about everything else but their illness. That, to me, is one of the greatest failures of the modern day, "Big Two" dialysis culture.

Very astute observations.You made some excellent points, especially that last paragraph. It seems so obvious now, but I hadn't thought of it in those exact terms until you described it that way. As someone that began working in HD back in 1993-- back when healthy and diverse business competition ruled-- I can attest that the work environment today for frontline staff has taken an abysmal nosedive. The patients are better off in some respects, but that is (in my opinion) due to advances in medical knowledge and treatment modalities.We'll have to give some credit to the corporate model for funding some of the research.