18.3 Staff Training, Competency and Remediation

BONENT Certified Hemodialysis Nurse CHN

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1 Exam Orientation

1.1 Current CHN Exam Facts and Study Strategy

2 Chapter 1: Renal Anatomy, Physiology & CKD Pathophysiology

2.1 Nephron Physiology & Endocrine Functions 2.2 Acute Kidney Injury & Chronic Kidney Disease Staging 2.3 Fluid, Electrolyte & Acid-Base Imbalances in ESRD

3 Chapter 2: CKD-MBD, Uremia & Clinical Manifestations

3.1 CKD-Mineral and Bone Disorder (CKD-MBD) 3.2 Uremic Syndrome & Multi-System Complications 3.3 Dialysis Patient Education & Nutritional Management

4 Individualized Nursing Care

4.1 Nursing Assessment, Planning and Evaluation 4.2 Treatment Records and Safe Handoffs 4.3 Psychosocial Assessment, Counseling and Referral

5 Chapter 3: Principles of Hemodialysis & Dialysate Chemistry

5.1 Transport Mechanisms: Diffusion, Convection & Ultrafiltration 5.2 Dialyzer Characteristics, Membrane Biocompatibility & Flux 5.3 Dialysate Composition & Concentrate Formulations 5.4 Hemodialysis Adequacy: Urea Kinetics, Kt/V & URR

6 Chapter 4: Vascular Access: Fistulas, Grafts & Catheters

6.1 Arteriovenous Fistulas & Arteriovenous Grafts 6.2 Physical Examination, Surveillance & Monitoring of Access 6.3 Central Venous Catheters & CDC Infection Prevention

7 Chapter 5: Cannulation Practice & Access Complications

7.1 Cannulation Techniques: Rope-Ladder, Buttonhole & Needle Sizing 7.2 Vascular Access Stenosis, Thrombosis & Steal Syndrome 7.3 Access Infiltration, Pseudoaneurysms & Hemorrhage Management

8 Chapter 6: Hemodialysis Treatment Delivery & Circuit Monitoring

8.1 Pre-Dialysis Assessment, Target Dry Weight & UFR Limits 8.2 Extracorporeal Circuit Setup, Priming & Safety Alarms 8.3 Anticoagulation Management: Heparin Protocols & Citrate 8.4 Treatment Termination, Hemostasis & Post-Dialysis Assessment

9 Equipment and Laboratory Skills

9.1 Ancillary Equipment and Bedside Safety 9.2 Blood Sampling, Laboratory Trends and Critical Results

10 Chapter 7: Acute Intradialytic Complications & Emergencies

10.1 Intradialytic Hypotension & Muscle Cramping 10.2 Dialysis Disequilibrium Syndrome & Neurological Events 10.3 Dialyzer Reactions & Hypersensitivity (Type A and Type B) 10.4 Critical Emergencies: Air Embolism, Hemolysis & Blood Loss

11 Extended and Acute Treatment

11.1 Sequential UF, Hemofiltration and Hemoperfusion 11.2 Acute Kidney Injury and High-Risk Dialysis Initiation

12 Chapter 8: Nephrology Pharmacology in Hemodialysis

12.1 Anemia Management: ESAs & Intravenous Iron Therapy 12.2 CKD-MBD Pharmacotherapy: Binders, Vitamin D & Calcimimetics 12.3 Cardiovascular, Antimicrobial & Dialyzable Drug Dosing

13 Home and Peritoneal Dialysis

13.1 Home Dialysis Selection and Adult Learning 13.2 Home Setup, Monitoring and Emergency Readiness 13.3 Peritoneal Dialysis Principles and Nursing Care

14 Kidney Transplantation

14.1 Transplant Benefits, Burdens and Modality Counseling 14.2 Transplant Indications, Contraindications and Referral 14.3 Pretransplant Workup and Waiting-List Coordination 14.4 Immunosuppressants, Interactions and Patient Teaching 14.5 Returning to Dialysis After Graft Failure 14.6 New-Graft Monitoring and Urgent Changes

15 Chapter 9: Water Treatment Systems & Dialyzer Reprocessing

15.1 AAMI/ISO Water Treatment Architecture & Components 15.2 Chemical Contaminant Monitoring & Total Chlorine Testing 15.3 Microbiological Standards, Endotoxin Surveillance & Sampling 15.4 Dialyzer Reprocessing Standards, Testing & Germicide Safety

16 Clinical Unit Management

16.1 Evaluating Dialysis Technology and Supplies 16.2 Staffing, Personnel Policies and Standards of Care

17 Chapter 10: Supervision, Administration & Professional Practice

17.1 RN Delegation, Technician Supervision & Nurse Practice Acts 17.2 CMS Conditions for Coverage & Interdisciplinary Care Planning 17.3 Dialysis Unit Infection Control & Environmental Safety 17.4 Quality Improvement (ESRD QIP), Ethics & Palliative Care

18 Professional Development

18.1 Professional Literature, Organizations and Continuing Learning 18.2 Research Design, Implementation and Evidence Interpretation 18.3 Staff Training, Competency and Remediation

19 Environmental Hazards and Emergency Planning

19.1 Chemical Agents, Disinfection and Exposure Control 19.2 Biological Hazards and Occupational Injury Response 19.3 Fire, Threats and Power or Water Interruptions

18.3 Staff Training, Competency and Remediation

Key Takeaways Explain This Topic AI

Training needs come from role requirements, performance gaps and safety data.

Critical skills require observation or simulation, not attendance alone.

Remediation identifies the specific gap and verifies improvement before independent performance.

Last updated: October 2026

Identify the Task and the Gap

Training begins with what staff must know and do. Dialysis roles include assessment, cannulation, catheter care, setup, alarms, medication tasks, water testing, termination, disinfection, documentation and emergency response. Different roles need different depth and legal authorization. A generic annual lecture cannot establish competence in every task for every employee.

Use orientation requirements, direct observation, incidents, near misses, audits and staff feedback to identify gaps. A cluster of contaminated hub technique calls for a different intervention from errors in conductivity interpretation. Define the behavior precisely. 'Needs more education' is not a useful training plan unless it states what must change and how that change will be evaluated.

Write Measurable Objectives

An objective includes the action, conditions and success standard. For example, the staff member will perform catheter connection using the approved aseptic procedure without contaminating the prepared hub, or will identify a final chlorine failure and implement the stop/escalation protocol during simulation. The standard should identify critical steps, not reward completion speed over safety.

Separate knowledge, psychomotor skill and judgment. A written test can assess calculation or recognition. Return demonstration assesses handling. Simulation assesses decisions under unusual conditions. Competence in one dimension does not establish the others. A person who calculates UF correctly may still fail to recognize symptomatic instability requiring immediate action.

Teach and Practice

Explain the purpose and sequence, demonstrate correctly, provide supervised practice and give specific feedback. Use the actual device, supplies and approved procedure. Training on a different machine can create misleading assumptions about clamps, alarm behavior or rinseback. Teach staff to consult the instructions and escalate uncertainty rather than memorize one universal procedure.

• Method Suitable use
• Brief case discussion Clinical priority and interpretation
• Written calculation Units, dose or fluid-accounting knowledge
• Return demonstration Aseptic handling and equipment tasks
• Simulation Emergency communication and action
• Supervised clinical practice Integration with patient care

Avoid teaching solely through slides for skills that require physical performance. Repeat practice when errors occur and explain the mechanism. A learner who touches a cleaned hub needs feedback about contamination, not only a lower checklist score.

Assess Competency

Use a standardized checklist with observable steps and explicit critical failures. The evaluator should be qualified and familiar with the current procedure. Document the device, task, date, evaluator, results and any conditions or limits. A signed form without evidence of observed performance is not a reliable competency record.

CDC recommends access-care competency evaluation on hire and every six to twelve months. Other tasks follow applicable requirements and facility policy; do not present one schedule as a universal law for every skill. Product changes, long absence, repeated errors or new responsibilities can trigger additional assessment. A current certificate does not eliminate the need to verify a task-specific skill.

Remediation and Supervision

When a gap appears, determine whether it reflects knowledge, technique, judgment, fatigue, workflow or equipment design. Give targeted teaching and practice, then reassess. Restrict independent performance of a safety-critical task until competence is established. The supervisor should arrange safe assignments while the employee learns; assigning the same task unsupervised as a test can expose patients to avoidable harm.

A staff member who repeatedly misses a water-test failure may need both knowledge instruction and review of test-strip handling, lighting, documentation and escalation access. Training alone will not correct an expired reagent supply or a procedure that hides the final sample point. Address system contributors while retaining accountability for safe performance.

Emergency Team Training

Practice roles in bleeding, cardiac arrest, air, hemolysis, anaphylaxis, fire and utility failure. Staff need to know who stops the pump, who calls help, who brings equipment and who communicates the patient history. Simulations reveal delays and conflicting instructions without exposing a real patient. Debrief constructively, identify concrete changes and repeat the scenario after correction.

Record readiness checks and drills according to policy. A successful drill is not merely one that ends without criticism; it should show timely appropriate decisions. Do not claim that positioning an air-embolism patient is more important than stopping air entry, oxygenation and resuscitation. Emergency teaching must use the current approved protocol.

Evaluate the Training Program

Measure more than attendance. Look at observed performance, process adherence, treatment errors and relevant patient outcomes over time. Avoid attributing a change to training without considering other factors. If behavior improves but infection does not, examine exposure, surveillance and remaining system barriers. If performance remains unsafe, revise the teaching method or resources.

Scenario

A new employee passes a written catheter-care test but contaminates the connection during return demonstration. The evaluator stops the task, explains the error, provides supervised practice and repeats assessment. Independent connection is deferred until safe performance is consistent. This response protects patients and gives the learner a clear route to competence rather than treating a quiz score as sufficient proof.

Sources: CDC dialysis competency recommendations , NCSBN delegation responsibilities .