Institutional ethnography of hemodialysis care: Perspectives of multidisciplinary health care teams in Nepal


health professionals
institutional ethnography
patient care team
renal dialysis

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Acharya, D. K., Nilmanat, K., & Boonyasopun, U. (2023). Institutional ethnography of hemodialysis care: Perspectives of multidisciplinary health care teams in Nepal. Belitung Nursing Journal, 9(4), 359–368.
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Accepted for publication: 2023-06-21
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Background: Hemodialysis is the most commonly used renal replacement therapy for end-stage renal disease. The collaborative efforts of multidisciplinary teams comprising nephrologists, nurses, pharmacists, and dietitians play a crucial role in enhancing patient outcomes, improving the quality of care, and reducing treatment costs. However, various factors such as healthcare cost reduction, limited resources, profit-driven systems, organizational structure, and involvement in patient care decisions impact the provision of hemodialysis care by the multidisciplinary teams.  

Objective: This study aimed to explore the institutional practices of multidisciplinary teams within a hemodialysis unit.

Methods: This institutional ethnography study was conducted between April 2019 to February 2020 in a hemodialysis unit of a public university hospital in Kathmandu, Nepal. Data were collected through face-to-face interviews with ten nurses (including supervisors and incharge), two nephrologists, two dietitians, two pharmacists, and two technicians. Additionally, 167 hours of observation, two focus groups with nurses, analysis of institutional texts, and field notes were conducted. Participants were purposively selected based on their ability to provide diverse information regarding institutional practices in hemodialysis care. Interviews were recorded and transcribed.

Results: The analyzed data were presented in: 1) the context of hemodialysis care, 2) textual practices: the ruling relations of hemodialysis care (staffing, protocol, job description), 3) hemodialysis decision, and 4) institutional support.

Conclusion: Hemodialysis care provided by multidisciplinary teams is constrained by limited resources, particularly in terms of physical space, dialysis machines, nurses, doctors, and dietitians. The hospital's cost-cutting policies lead to reduced investment in patient care equipment, particularly dialysis machines, which significantly impact the workload of nurses and technicians. Insufficient nurse staffing necessitates the provision of other renal care responsibilities, resulting in increased workload, reduced time available for hemodialysis care, and unfinished tasks. The absence of clear job descriptions for hemodialysis care places an additional burden on nurses, who are often required to fulfill the responsibilities of other healthcare teams. Doctors hold the authority in making care decisions, which are subsequently followed by other team members.

Supporting Agencies

This work was supported by the Graduate School, Prince of Songkla University, Thailand [Thesis grant support-2018]


Copyright (c) 2023 Devaka Kumari Acharya, Kittikorn Nilmanat, Umaporn Boonyasopun

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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Declaration of Conflicting Interest

The authors declare that there is no conflict of interest.


The authors thank the Thailand government for Thailand’s Education Hub for Southern Regions for ASEAN Countries (THE-AC) scholarship, the hospital for permission to conduct the study, and all study participants.

Authors’ Contributions

DKA: Conceived the study, participated in the design, developed the proposal, undertook observations, interviews, and focus groups, transcribed the interview audios, analyzed data, and drafted the manuscript. KN and UB: Helped to conceptualize the study and design, oversaw the study, helped with data analysis, drafted and provided critical feedback on the manuscript, and approved the final manuscript.

Data Availability

The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of Use of AI in Scientific Writing

Nothing to disclose.


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