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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Nephrol Nurs J. Author manuscript; available in PMC Mar 26, 2010.
Published in final edited form as:
Nephrol Nurs J. 2008 Mar–Apr; 35(2): 123–131.
PMCID: PMC2845981
NIHMSID: NIHMS107210

Relationships Between Registered Nurse Staffing, Processes of Nursing Care, and Nurse-Reported Patient Outcomes in Chronic Hemodialysis Units

Charlotte Thomas-Hawkins, PhD, RN, Linda Flynn, PhD, RN, and Sean P. Clarke, PhD, CRNP, FAAN

Abstract

Little attention has been given to the effects of registered nurse (RN) staffing and processes of nursing care on patient outcomes in hemodialysis units. This research examined the effects of patient-to-RN ratios and necessary tasks left undone by RNs on the likelihood of nurse-reported frequent occurrences of adverse patient events in chronic hemodialysis units. Study findings revealed that high patient-to-RN ratios and increased numbers of tasks left undone by RNs were associated with an increased likelihood of frequent occurrences of dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints in hemodialysis units. These findings indicate that federal, state, and dialysis organization policies must foster staffing structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses.

The achievement of quality patient outcomes for persons with end stage renal disease (ESRD) is a major focus of the nephrology community. Considerable effort has gone into identifying and addressing factors that have a potential for exerting negative effects on the health outcomes of these individuals. While much has been written about the nursing shortage in hospitals and its effects on the outcomes of inpatients, little attention has been given to the influence of registered nurse (RN) staffing levels on outcomes of patients receiving chronic hemodialysis treatments.

There is a large body of literature indicating that higher RN staffing, and hence lower patient-to-RN ratios, are associated with superior patient outcomes and fewer adverse patient events (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Estabrooks, Midzozi, Cummings, Ricker, & Giovannetti, 2005; Rafferty et al., 2007). These studies have been conducted primarily in hospitals. Few studies have investigated associations between RN staffing levels and patient outcomes in chronic hemodialysis units. Using survey methodology, this study examined the effects of RN staffing levels and processes of nursing care on nurse-reported patient outcomes in chronic hemodialysis units.

Background and Significance

According to the Nursing Organization and Outcomes Model (Aiken, Clarke, & Sloane, 2002), as depicted in Figure 1, RN staffing levels influence the ability of RNs to care for patients, therefore affecting surveillance and other processes of care. Processes of care, in turn, directly affect patient outcomes. Consequently, higher levels of RN staffing are proposed to result in better patient outcomes and fewer adverse patient events. Recent studies have provided support for the model’s propositions, quantifying an association between higher RN staffing and fewer adverse patient events, including mortality (Aiken et al., 2002; Estabrooks et al., 2005; Rafferty et al., 2007).

Figure 1
Nursing Organization and Outcomes Model

These studies, however, have been conducted predominately in hospitals, and the impact of RN staffing on patient outcomes in hemodialysis centers is largely unknown. The scant data that do exist, however, indicate that hemodialysis units with higher RN staffing levels have a lower odds of experiencing skipped dialysis treatments (Saran et al., 2003), and hepatitis C and seroconversion rates (Fissell et al., 2004) among the patients they treat.

In 2005, nearly 350,000 individuals were receiving long-term hemodialysis treatments for ESRD, a rate of growth of 3.3% from the previous year (U.S. Renal Data System [USRDS], 2007). It is expected that the hemodialysis population in the United States (U.S.) will continue to grow. Thus, it is important to identify the impact of RN staffing levels on the safety and health outcomes of patients receiving hemodialysis treatments. The purpose of this study was to test a subset of relationships depicted by the Nursing Organizations and Outcomes Model by determining the effects of RN staffing and processes of nursing care on the odds of nurse-reported adverse patient events. The following research questions were investigated:

  • What is the relationship between RN staffing levels and necessary tasks left undone in chronic hemodialysis units?
  • What is the impact of RN staffing levels on the odds of frequent adverse patient events in chronic hemodialysis units?
  • What is the impact of necessary tasks left undone on the odds of frequent adverse events in chronic hemodialysis units?

Research Design and Methods

This study, employing a cross-sectional, correlational design, used a modified Dillman (2000) survey method for data collection. A key methodological feature of previous staffing and outcomes research has been the use of nurse surveys as a source of accurate data regarding RN staffing levels, patient workloads (Aiken, Clarke, & Sloane, 2002; Aiken, Clarke, Sloane, Sochalski et al., 2002) and nurse-reported patient outcomes (Sochalski, 2001, 2004). Staff RNs have been identified as reliable informants regarding their workloads as well as patient outcomes because of their close proximity to patients and knowledge of their working conditions. The current study surveyed staff RNs using survey items and measures that have been demonstrated as reliable and valid in previous hospital-based research (Aiken, Clarke, Sloane, & Sochalski, 2001; Aiken, Clarke, Sloane, Sochalski, Busse, et al., 2001; Sochalski, 2001, 2004).

Sample

Two thousand RNs who identified themselves as staff nurses in hemodialysis settings in the U.S. were randomly selected from the American Nephrology Nurses’ Association (ANNA) membership list to receive a survey packet. Packets were mailed to nurses’ homes with follow-up reminders in accordance with a Dillman (2000) method. To ensure the rights of nurses who volunteered to participate in this study, the Rutgers University Institutional Review Board reviewed and approved the protocol prior to data collection. A cover letter described the purpose of the study and indicated that completion of the survey questionnaire served as consent to participate. One thousand and fifteen nurses (1,015) returned a completed survey, representing a 52% response rate. Since there are important differences in the level of RN staffing, characteristics and needs of patients, and nature of adverse patient events in acute hemodialysis units compared to chronic hemodialysis units, this article reports an analysis of survey data from the subset of 422 RN respondents who completed all survey items and identified their work setting as a chronic hemodialysis unit that was either a corporate- or hospital-owned freestanding or hospital-based facility. Sample demographics are listed in Table 1.

Table 1
Sample Characteristics (n = 422)

Survey Instruments

Demographic data were collected to describe the study sample including age, gender, ethnicity, years worked in nursing, years worked in nephrology nursing, years worked in the current position, highest nursing degree completed, specialty certifications by the Nephrology Nursing Certification Commission and/or the American Nurses Credentialing Center (yes/no), and work setting.

RN staffing was operationalized as nurses’ responses to a series of questions regarding RN staffing levels and numbers of patients receiving hemodialysis during the respondent’s most recent workday. These questions, were derived from items developed and tested in previous research and used to calculate patient-to-RN ratios (Aiken, Clarke, & Sloane, 2002; Aiken, Clarke, Sloane, Sochalski, et al., 2002). Slight modifications were made to the language of some of the staffing items to reflect hemodialysis environments. For example, references to “total number of patients on the inpatient unit” in the original items were replaced with “total numbers of patients on a hemodialysis patient shift.” Patient-to-RN ratios were calculated by dividing the total number of patients on a hemodialysis shift by the total number of staff RNs who worked during that shift.

Processes of nursing care were measured using an innovative series of survey items developed and tested for the exclusive purpose of measuring key processes of nursing care (Aiken, Clarke, Sloane, Sochalski, Busse, et. al, 2001). These items, which were slightly modified to reflect a hemodialysis care setting, elicited nurses’ responses regarding necessary processes of nursing care, such as patient monitoring during dialysis treatment, that were left undone during the last shift worked because the nurse did not have time to complete them. Nurses were asked to select all tasks, from a list of seven items, that they left undone on their last shift worked. Task-left-undone items pertain to surveillance of patients, coordination of care, supervision of staff, patient education, and documentation. Total scores are computed as a sum of all necessary tasks left undone and can range from 0 to 7 tasks. Construct validity of the process of nursing care measure has been demonstrated in that process scores have been found to be associated in the theoretically expected direction with measures of RN staffing, quality care, and frequency of adverse patient events in studies of nursing care in hospitals (Sochalski, 2001; 2004).

A measure of patient outcomes was operationalized as a series of questions designed to capture the frequency with which adverse patient events occur in the practice setting (Aiken, Clarke, Sloane, Sochalski, Busse, et al., 2001). The adverse patient events reported in this study were (a) emergency room visits due to volume overload; (b) hospitalizations due to pneumonia; (c) vascular access infection; (d) vascular access infiltration; (e) vascular access thrombosis; (f) unusual bleeding from the vascular access; (g) falls in the dialysis center without injury; (h) falls in the dialysis center with injury; (i) medication errors; (j) dialysis hypotension; (k) shortened dialysis treatments; (l) skipped dialysis treatments; and (m) patient complaints. Event frequency was rated on a 7-point scale ranging from 1 (never) to 7 (every day). The adverse events selected for this study are common among patients on hemodialysis, sensitive to organizational support and nursing care, and their reduction has been identified as important quality indicators in hemodialysis practice environments (Holly, 2006; National Quality Forum, 2004; Port et al., 2004; Saran et al., 2003). Analysis was limited to the four adverse events that RN respondents reported as occurring most frequently and included (a) dialysis hypotension, (b) shortened dialysis treatments, (c) skipped dialysis treatments, and (d) patient complaints.

Data Analysis

Bivariate correlation coefficients were computed to examine relationships among the study variables. To test the Nursing Organization and Outcomes Model propositions, logistic regression models were estimated to determine the effects of (a) RN staffing on processes of nursing care, and (b) RN staffing and processes of nursing care on frequent adverse patient events. Frequencies of patient-to-RN ratios, necessary tasks left undone, as an indicator of care processes, and adverse patient event variables were collapsed into categories for logistic regression analysis. To compare the effects of the lowest patient-to-RN ratios (i.e., best RN staffing) to the highest patient-to-RN ratios (i.e., least RN staffing) the measured ratios were collapsed into quartiles (up to 4.61 patients/RN; 4.62 to 7.99 patients/RN, 8 to 11.99 patients/RN; 12 or more patients/RN). The number of necessary tasks left undone were also collapsed into quartiles (no tasks left undone, 1 task left undone, 2 tasks left undone, 3 or more tasks left undone) based on the number of necessary tasks left undone reported by the respondents and the distribution of these reports in the sample (approximately 25% of RNs in the sample for each quartile). The bottom and top quartiles were compared. The frequency of the four adverse patient events were examined as dichotomized variables (0 = never to a few times a month; 1 = once a week to daily).

Results

Descriptive data for study independent variables are shown in Table 2. The mean patient-to-RN ratio, M = 9.58 (SD = 7.14), reflects both direct and indirect patient care responsibilities. During their last shift worked, on average, RNs left 2.07 tasks left undone, with 34% of RNs reporting three or more tasks left undone. Respondents also reported frequent occurrences of dialysis hypotension, shortened and skipped dialysis treatments, and patient complaints. For example, two-thirds of RNs reported that dialysis hypotension and shortened treatments occurred daily to once a week; one-half of RNs reported that skipped treatments occurred daily to once a week; and one in five RNs reported the occurrence of patient complaints at least once a week to daily.

Table 2
Descriptive Statistics For Study Variables

Bivariate correlation coefficients between study variables provide evidence that there are significant relationships between RN staffing, processes of nursing care, and adverse patient events in chronic hemodialysis settings (see Table 3). As anticipated, patient-to-RN ratios were positively correlated with adverse patient events. Higher patient-to-RN ratios (lower levels of RN staffing) were significantly related to higher reported frequencies of shortened dialysis treatments, skipped dialysis treatments, and patient complaints. Study findings revealed, however, that patient-to-RN ratios were not related to reported frequencies of dialysis hypotension. Higher patient-to-RN ratios were positively correlated with necessary nursing tasks left undone. Necessary tasks left undone were positively correlated with reported frequencies of adverse patient events. Higher numbers of tasks left undone on the last shift worked were significantly associated with higher reported frequencies of dialysis hypotension, shortened and skipped dialysis treatments, and patient complaints.

Table 3
Correlation Coefficients Among Study Variables

To further determine the impact of RN staffing levels on processes of nursing care, logistic regression was used to estimate the effect of patient-to-RN ratios on the odds of three or more necessary tasks left undone. Findings indicate that RN staffing levels have a significant influence on processes of nursing care in that, compared to patient-to-RN staffing ratios of 4.61 or less, respondents reporting patient loads of 12 or more were three and half times as likely to report that three or more necessary tasks were left undone during their last shift worked, O.R. = 3.55 (1.98, 6.34), p < .001.

Logistic regression models also estimated the gross or unadjusted effects of (a) patient-to-RN ratios and (b) necessary tasks left undone on adverse patient events (see Table 4). Findings, as presented in Table 4, indicate that respondents reporting higher patient-to-RN ratios, or “least” RN staffing, are (a) more than twice as likely to report frequent patient complaints; (b) more than two and half times as likely to report frequent skipped dialysis treatments; and (c) over four times more likely to report frequent shortened dialysis treatments when compared to RNs reporting the “best” RN staffing, or lower patient-to-RN ratios. The effect of patient-to-RN ratios on dialysis hypotension was not significant.

Table 4
Effects of Heaviest Patient-to-RN Ratios and Highest Levels of Tasks Left Undone on Last Shift Worked on Odds of Nurse Reports of Frequent (i.e., Once a Week or More Frequent) Adverse Patient Events

Similarly, the unadjusted effects of tasks left undone are also associated with higher odds of reports of frequent adverse patient events (see Table 4). When compared to no tasks left undone, RNs reporting three or more tasks left undone were (a) three and half times more likely to report frequent patient complaints; (b) two times more likely to report skipped dialysis treatments; (c) almost three times more likely to report frequent shortened dialysis treatments, and (d) over two and half times more likely to report frequent episodes of dialysis hypotension.

The net (adjusted) effects of each of these two predictors, RN staffing levels and tasks left undone, controlling for the other predictor, are also important (see Table 4). Controlling for tasks left undone, lower RN staffing levels continue to be significantly associated with higher odds of frequently shortened and frequently skipped dialysis treatments. Tasks left undone, when controlling for RN staffing, continues to be significantly associated with higher odds on all four adverse patient events. These findings indicate that lower RN staffing levels and the failure to complete key processes of nursing care each uniquely, and independently of the other, contribute to a higher likelihood of adverse patient events.

Discussion

Findings from this study support the Nursing Organizations and Outcomes Model proposition that RN staffing levels have a significant impact on patient outcomes, operationalized in this study as adverse patient events in chronic hemodialysis units. Wide variations in RN staffing levels were noted (see Table 5). While the mean patient-to-RN ratio was 9.58 patients per RN, 25% of nurses cared for 4.61 patients or less, and 31% of nurses cared for 12 patients or more. Patient-to-RN ratios of 12 or more patients per RN were significantly associated with higher odds of frequent occurrences of shortened and skipped dialysis treatments and patient complaints compared to RNs with the lowest patient-to-RN ratios (i.e., 4.61 or less patients per RN).

Table 5
Sample Distribution of Patient-to RN Ratios by Quartile

The association between RN staffing and adverse patient events in this study is not surprising. Numerous studies in hospitals have consistently demonstrated a significant relationship between low RN staffing levels and adverse patient outcomes, including higher mortality rates and lower levels of patient satisfaction (Aiken, Clarke, Sloane, Sochalski et al., 2002; Aiken, Smith, & Lake, 1994; Estabrooks et al., 2005; Rafferty et al., 2007), pneumonia (Kovner & Gergen, 1998; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002), patient falls (Blegen & Vaughn, 1998; Sovie & Jawad, 2001), urinary tract infections, longer lengths of stay, upper gastrointestinal bleeding, shock, failure to rescue (Aiken, Clarke, Sloane, Sochalski, et al., 2002; Needleman et al., 2002), and wound infections (Hall, Doran, & Pink, 2004). The significant relationship between RN staffing and patient outcomes in this study adds to a small but growing body of empirical evidence that demonstrates a link between RN staffing and patient outcomes in hemodialysis centers (Fissell et al., 2004; Gardner, Thomas-Hawkins, Fogg, & Lathum, 2007; Saran et al., 2003). Notably, the relevance of the relationship between RN staffing and RNs’ reports of frequent occurrences of skipped and shortened dialysis treatments in this study is underscored by findings from the Dialysis Outcomes and Practice Patterns Study (DOPPS) which revealed that, with every 10% increase in the number of RNs in dialysis units, the odds of patients skipping one or more dialysis treatments a month is reduced by 16% (Saran et al., 2003). Equally as important, the DOPPS data revealed that skipped dialysis treatments are independently associated with a 30% increased risk for mortality and a 13% increased risk for hospitalization for patients on hemodialysis (Saran et al., 2003).

While the evidence of the effect of RN staffing on patient outcomes in hospitals is clear, the mechanism by which RN staffing exerts its effect is less clear. The Nursing Organizations and Outcomes Model posits that processes of nursing care are a mechanism through which RN staffing exerts an indirect effect on patient outcomes, and several analyses of data from hospital-based research have supported this proposition (Sochalski, 2004; Tourangeau et al., 2006). Findings from this current study likewise provide support for this proposition in that higher patient-to-RN ratios (i.e., less RN staffing) in chronic hemodialysis units was significantly associated with more tasks left undone by RNs. This finding is not only consistent with the Nursing Organizations and Outcomes Model, but it also makes sense intuitively — the less RN staffing, the busier RNs become during their workday. Consequently, they are not able to complete all of the necessary patient care tasks, resulting in higher numbers of necessary tasks left undone. Succinctly stated, lower levels of RN staffing have a negative impact on patient care processes in that RNs simply do not have the time to complete their important work.

Thus, the relationship between RN staffing levels and processes of nursing care in this study reveals an important structure-process mechanism that is consistent with the Nursing Organizations and Outcomes Model and that explains, in part, the likelihood of adverse patient events in hemodialysis units. Study findings indicate that, while RN staffing levels as a “structure” factor in hemodialysis units directly affect the odds of adverse patient events, this structure factor also affects “process” in that RNs’ ability to carry out needed patient care tasks is reduced. Needed patient care tasks left undone by RNs, in turn, increase the odds on the occurrence of adverse patient events. Consequently, findings indicate that RNs’ reports of higher numbers of tasks left undone were associated with reports of frequent occurrences of dialysis hypotension, skipped and shortened dialysis treatments, and patient complaints.

Findings also indicate, however, that RN staff levels have a unique effect on adverse patient events that is independent of tasks left undone. Clearly, RNs’ contributions to patient safety and outcomes extend beyond the “tasks” that were measured in this study. The expert assessment skills of professional registered nurses, no doubt, have a profound influence on the early detection and prevention of patient complications during hemodialysis treatments. Further empirical explication of the interrelationships between RN staffing structures and processes of nursing of care in hemodialysis units is warranted to fully understand the operant mechanisms by which RN staffing levels and processes of nursing care interact to affect patient outcomes in hemodialysis units. Although the measure of unfinished tasks utilized in this study does not fully represent the entire spectrum of care rendered by registered nurses in hemodialysis units, study findings linking unfinished tasks to adverse events indicate that the measure may serve as a reasonable indicator of quality of RN care in hemodialysis units.

Findings from this study provide evidence that RN staffing in hemodialysis units and processes of nursing care are, indeed, associated with RNs’ reports of frequent adverse patient events, and they emphasize the need for evidence-based decisions regarding RN staffing levels in hemodialysis practice environments. Staffing in hemodialysis units, however, can be a contentious issue because of a lack of consensus in the nephrology community regarding appropriate levels of RN staffing. For example, the proposed change to the Centers for Medicare and Medicaid Services ESRD Conditions for Participation staffing provisions (Centers for Medicare and Medicaid Services, 2005), which stipulates the presence of one RN in the hemodialysis facility at all times while hemodialysis services are provided, is viewed by many nephrology stakeholders as having a negative impact on the operating costs of dialysis facilities (Levy, 2006). The current staffing skill mix in a majority of hemodialysis centers in the U.S. is approximately 20% to 30% licensed (including RNs and LPNs) and 70% unlicensed personnel (Bednar, Steinman, & Street, 2002). In contrast, findings from this study indicate that the more RNs present during hemodialysis (i.e., a richer RN skill mix), the less likely frequent adverse patient events will occur. Indeed, the findings from this study are of utmost importance as healthcare institutions, like dialysis organizations, continue to experience a growing shortage of RNs.

Dialysis organizations are challenged to develop and implement policies that strengthen RN staffing structures and processes of care to minimize adverse patient events. Solutions by dialysis organizations to address registered nurse staffing in hemodialysis units must not only include strategies to increase the numbers of new RNs entering hemodialysis settings, but must also include efforts to retain RNs and provide leadership supports so that the hemodialysis practice environment fosters effective processes of nursing care (Gardner et al., 2007; Thomas-Hawkins, Denno, Currier, & Wick, 2003). In addition, dialysis organizations must also identify and implement effective models of care in hemodialysis units that support RNs in their efforts to provide quality patient care (e.g., the use of advanced practice nurses that are part of the nursing team in dialysis units).

Limitations

The study sample was drawn from RNs who were members of a professional organization (ANNA). There may be characteristics of this group that differ uniquely and significantly from staff RNs in hemodialysis units who do not belong to ANNA. A replication of this study is needed with a representative sample of RNs drawn from the population of staff nurses who work in hemodialysis units.

Secondly, the occurrence of adverse patient events in this study was determined through nurse reports. While prior research has established that staff RNs are reliable informants regarding patient outcomes (Aiken, Clarke, Sloane, & Sochalski, 2001; Aiken, Clarke, Sloane, Sochalski, Busse, et al., 2001; Sochalski, 2001, 2004), a replication of this study with facility-and patient-level data is needed.

Finally, minor modifications were made to the language of some of the staffing survey items to reflect hemodialysis settings. In addition, this is the first time the tasks left undone items were used in a sample of nephrology nurses. While total scores for these items in this study were found to be associated in the theoretically expected direction with RN staffing and frequency of adverse patient event variables, repeated use of these items in samples of nephrology nurses will help to confirm the construct validity of this measure and staffing items for this population of nurses.

Conclusion

Research dating back several decades has culminated in consistent and conclusive evidence affirming the effect of RN staffing on patient outcomes in hospitals. Findings from this study support the position that, similar to hospital environments, the presence of professional registered nurses is crucial in hemodialysis units as well. This study provides empirical evidence that RN staffing, as well as the processes of care provided by RNs, are essential to reducing the odds of adverse patient events in dialysis units. Therefore, in order to promote the health and safety of the growing numbers of patients with ESRD, policies and procedures at the federal, state, and dialysis organization levels must foster structures and processes of care in dialysis units that effectively utilize the invaluable skills and services of professional, registered nurses.

Goal

To investigate the relationship between RN staffing and processes of nursing care and adverse patient events.

Objectives

  1. Summarize the results of a study of staff nurses and adverse patient events in hemodialysis settings.
  2. Analyze the findings related to RN staffing and adverse patient events in the study.
  3. Describe the identified relationships and highlight the need for federal, state, and dialysis organizational policies to effectively utilize the skills and services of professional RNs.

Summary of Key Study Findings

  • Higher patient-to-RN ratios (i.e., less RN staffing) were significantly associated with RN reports of frequent adverse patient events, including skipped dialysis treatments, shortened dialysis treatments, and patient complaints.
  • Higher patient-to-RN ratios (i.e., less RN staffing) were significantly associated with higher numbers of necessary nursing tasks left undone on the RNs’ last shift worked.
  • Higher numbers of necessary nursing tasks left undone on the RNs’ last shift worked were significantly associated with RN reports of frequent adverse patient events, including dialysis hypotension, skipped dialysis treatments, shortened dialysis treatments, and patient complaints.
  • Higher patient-to-RN ratios (i.e., less RN staffing) and nurse reports of 3 or more of necessary tasks left undone, when considered separately or combined, significantly predicted more frequently occurring adverse patient events, as reported by the RNs providing their care.

Acknowledgments

This research was funded by the American Nephrology Nurses’ Association. The authors would like to thank the nurses who participated in this research and Dr. Linda Aiken for the permission to use her staffing and processes of care survey items in this project.

Footnotes

The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.

Nephrology Nursing Journal Editorial Board Statements of Disclosure

In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below.

Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of Clinical Trials for Roche.

Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the recipient of unrestricted educational grants from OrthoBiotech and Roche.

Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc.

Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers’ Bureau for Watson Pharma, Inc.

Sally S. Russell, MN, CMSRN, has no actual or potential conflict of interest in relation to this CNE article.

Contributor Information

Charlotte Thomas-Hawkins, Assistant Professor, College of Nursing, Rutgers, The State University of New Jersey, Newark, NJ. She is a member of ANNA’s Garden State Chapter.

Linda Flynn, Assistant Professor, College of Nursing, Rutgers, The State University of New Jersey, Newark, NJ.

Sean P. Clarke, Associate Professor of Nursing and Associate Director, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA.

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