How does organisational culture facilitate uptake of home dialysis? An ethnographic study of kidney centres in England

Objective The proportion of people having home dialysis for kidney disease varies considerably by treating centre, socioeconomic deprivation levels in the area and to some extent ethnicity. This study aimed to gain in-depth insights into cultural and organisational factors contributing to this variation in uptake. Design This is the first ethnographic study of kidney centre culture to focus on home dialysis uptake. The NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) framework was used to map factors that influence the use of home dialysis. Setting We conducted focused ethnographic fieldwork in four kidney centres in England, with average or high rates of home dialysis use, selected to represent geographic, ethnic and socioeconomic diversity. Participants Observations of patient consultations, team meetings, patient education and training sessions (n=34); and interviews with staff, patients and carers (n=72). Results We identified three themes that can support the decision to pursue home dialysis: (a) Encouraging patient voice and individualised support. Kidney care teams engaged with people’s psychosocial needs and cultural contexts, and valued peer support as part of patient education; (b) Ensuring access to home dialysis. Transparency about all treatment options, minimisation of eligibility assumptions and awareness of inequities of access; (c) Achieving sustained change based on benefits for patients. This included organisational cultures which adopted quality improvement approaches and worked with wider stakeholders to shape future policy and practice. Conclusions Willingness to pursue dialysis at home relied on patients’ and carers’ ability to place their confidence in their kidney care teams rather than how services were organised. Our study of kidney centre culture has identified approaches to patient empowerment, access to treatment and readiness for improvement and change that could be incorporated into a service delivery intervention.