thesis topics on hemodialysis

Impact of hemodialysis on the wellbeing of chronic kidney diseases patients: a pre-post analysis

Um-e-Kalsoom 1 na1 ,
Sabiha Khan 1 na1 &
Israr Ahmad 2

Middle East Current Psychiatry volume 27 , Article number: 54 ( 2020 ) Cite this article

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Hemodialysis may have serious psychological impact upon patients suffering from chronic kidney diseases. The aim of the present study is to investigate the impact of hemodialysis on the wellbeing of individuals with chronic kidney diseases (CKD).

A sample consists of ( N = 100) CKD patients referred from neurology ward of Leady Reading Hospital Peshawar. Data was collected from both male (50%) and female (50%) in 2017. Participants were divided into two groups on the basis of pre-set criteria. In group I, individuals with 4–5 stage of CKD referred first time for dialysis treatment were recruited. Group II comprised of CKD patients with 1–3 stage. Demographic data sheet, Pakistan Anxiety and Depression, WHO Quality of Life scale, and Perceived Social support scale (PSS) were used to test the hypotheses. Paired sample t test was use to see the difference between pre- and post-analysis of depression, anxiety, QOL, and PSS in group I (experimental group). Results suggests significant difference on depression ( p > .001), anxiety ( p > .001), and QOL ( p > .001), while no significant difference was reported on perceived social support ( p <.673). Findings also indicate no significant difference between group I and group II on QOL depression, anxiety, and PSS.

The findings concluded that patients under hemodialysis treatment suffered from depression, anxiety, and poor quality of life.

Chronic kidney disease (CKD) is defined as a progressive and irreversible loss of kidney function. As per glomerular filtration rate (GFR), an adult reports 60 ml/min/1.73 m 2 or less than that indicates a loss of half or more of normal kidney functioning. According to GFR there are five stages of CKD. The first three stages (1–3), i.e., from mild to moderate, whereas stages (4–5) considered as severe therefore recommended for dialysis [ 1 ]. CKD is considered a public health problem worldwide and about 50 million people suffering from chronic kidney disease worldwide [ 2 ]. African Americans, American Indians, Hispanics, and South Asians, specifically, people from Pakistan, Sri Lanka, Bangladesh, and India, are at great possibility of experiencing CKD. In Pakistan CKD was found in 75(25.60%) out of 293(97%) subjects [ 3 ]. Usually, majority of patients with CKD require replacement treatments including hemodialysis, peritoneal dialysis, and kidney transplantation [ 4 ], among which hemodialysis are the most common replacement modalities. Patients under hemodialysis suffer from different physical and mental problems [ 5 ]. Depression and anxiety are commonly observed in such patients [ 6 ]. A study reported that prevalence of depression in patients with end-stage renal diseases (ESRD) is higher than in the general population [ 7 ]. Similarly, a meta-analysis of 249 studies reported that prevalence of depression was 22.8% among patients undergoing dialysis as compared to placebo group [ 8 ]. Chiang et al. concluded the rudimentary prevalence of depression was 22.6% in the Taiwan sample. The findings further reported religious belief, CD stage IV and above, physical activity, and sleep disturbance were the correlates of developing depression in CKD patients [ 9 ]. Anxiety is another commonly co-occurring psychopathology with CKD/ESRD. The rate of anxiety in patients with ESRD was estimated to be around 12 to 52% [ 10 ] . A longitudinal study following 159 patients for the outcome of depression and anxiety reported that 36.6% had developed depressive symptoms while 31.8% had symptom of persistent anxiety [ 11 ]. Another study investigated gender role in quality of life, depression, and anxiety in chronic kidney diseases sufferers. The study concluded that depression and anxiety is more prevalent in male while female shows poor quality of life as compared to male [ 12 ]. Hemodiyalsis comprised of complex treatment for CKD sufferers which requires focus visits to dialysis center or hospital, usually visiting hospital 2–3 times per week. Therefore, these patients may feel significant changes in their routine life. Additionally, treatment includes constraints on dietary intake and physical activity. Subsequently, these physical and mental symptoms of patients likely to influence the degree of the personal satisfaction or quality of life. A study reported that clinical and social demographic variables may affect QOL of CKD patients on dialysis treatment [ 13 ]

Social connections are significant for patients with chronic diseases; since these connections have noteworthy advantages and positively affect their wellbeing. Those individuals who get to more social help can deal with their mental stress in better way and experience improved wellbeing results [ 14 ].

Studies show that social support is related to the quality of life (QOL) in such a way that people who receive social support and are part of a large social networking enjoy higher QOL [ 15 ]. CKD is progressing rapidly in Asian countries as compared to other continents of the world. This rapid growth of the disease not only alert physical health professionals but also grasps attention of mental health experts. However, in Pakistan, mental health problems related to CKD has not been extensively investigated. Therefore the present study aims to investigate the impact of hemodialysis on the wellbeing of patients suffering from CKD.

The research was conducted at the dialysis center of the department of Nephrology, Leady Reading Hospital Peshawar in 3 months (June–September 2017). The study got approved by the from advance study and research board (ASRB) of Shaheed Benazir Bhutto Women University, Peshawar. Later permission from medical director and approval institutional ethics and review board (IERB) was also obtained. The study included those patients who were above 18 years of age diagnosed as CKD patients, native language Urdu, volunteer participation, and signed consent form. Whereas any previous psychiatric illness history, patients with previous dialysis history, education less than matriculation, patients unable to provide participation consent were excluded from the study. All patients were referred by nephrologists to participate in the study on the basis of biochemical results of the patients. Participants were informed of the volunteer participation and have right to withdraw any time from this study. Total of 100 patients, 50 in each group were recruited during 3 months period conveniently based on the predetermined criteria as given below.

Group I = In group I recruited individuals suffering from kidney diseases with stage 4–5 and

send to dialysis treatment first time ( n = 50)

Group II = In group II CKD Patients from stage 1–3 were included and not recommended for

dialysis ( n = 50)

These two groups were not matched for gender and age.

Once written consent was obtained from the participants, they were given brochure of questionnaires to fill out. The booklet comprised of scales and a demographic sheet. These scales were (1) WHOQOL-BREF developed by World Health Organization Quality of life. It is a 5 point Likert scale based on 26 items with four subscale, i.e., physical wellbeing, mental wellbeing, societal relation, and ecological wellbeing [ 16 ]. (2) Pakistan Anxiety and Depression Scale contain two subscale, i.e., depression and anxiety. Each subscale comprised of 15 items, and scores 6 or above is considering as depression and anxiety [ 17 ]. (3) Multidimensional Scale of Perceived Social Support (MSPSS) use to assess perceived support by family, peers, and significant others 7-point Likert scale was developed. It consists of 12 items with 3 subscales. Each subscale comprised of 4 items and to calculate its mean score sum items of each subscale and divide by 4. For total item, sum of all 12 items and then divided by 12. Score 1–2.9 consider low support, 3–5 as moderate, and 5.1–7 as high support [ 18 ]. Demographic sheet consists of the items which have significant relation with CKD. Both groups were given set of questionnaires and briefed about the study objectives along with instructions “how to fill out questionnaire.” Group I participants filled in questionnaires before dialysis started again after completing 10 numbers of dialysis. However, participants of group II were given the booklet of questionnaire only once.

Statistical analysis

The analyses were performed in SPSS v20. The descriptive statistics were performed on 100 patients suffering from chronic kidney disease. Differences in mean were assessed by using independent sample t test and paired sample t test.

The average age of the participants in this study was 43.46 ± 16.29, both male (50%) and female (50%) equally participated. Majority had 93.1% has elementary school level, while 87.1% were married population. Among these, 87.1% have nuclear family system. Employment status was 41.6% for male whereas 27.7% females were house wife. In addition, 18.8% consume CKD family history. A comparison between pre- and post - dialysis for QOL, depression, anxiety, and perceived social support (PSS) among the patients in group I is shown in Table 1 . The result of paired sample t test of group I suggested significant difference on depression, anxiety, and QOL while PSS values were not significantly different. The findings of the present study further reported no significant difference between group I and group II results on QOL, depression, anxiety, and PSS through computing independent sample t test. Figure 1 illustrates mean difference on QOL, depression, anxiety, and PSS of group I. The results demonstrated poor QOL, while slightly reduction in depression and anxiety values. On the other hand, PSS level remain intact. Whereas group I and II results are not different on QOL,depression, anxiety and PSS (Table 2 ).

Mean scores for QOL, depression, anxiety, and perceived social support of pre and post dialysis patients (group I)

The current study revolves around the impact of dialysis on the wellbeing of CKD sufferers. It was aim at exploring depression, anxiety, QOL, and PSS in CKD patients. Information from CKD patients of nephrology ward of Leady Reading Hospital was gathered. Results of Table 1 indicate that there is a significant difference on QOL, depression, anxiety, and PSS between pre- and post-test analysis. Mean difference (Fig. 1 ) of anxiety was high (24.02) at pre-test (before hemodialysis) as compared to post-test (22.68), QOL score was (81.42) at pre-test time, and (73.28) at post-test. Mean score on pre-test of depression was (22.12) and at post-test was (21.18). No significant mean difference of PSS was reported on pre-test (68.62) and post-test (68.34). Treating CKD is related to receiving long-term conventional and dialysis therapy by patients which could significantly changes their lives and routine activities. A cohort study conducted by Ng et al. [ 11 ] reported that 39.6% patients undergoing dialysis treatment have depression and 31.8% had anxiety. Another study reported data from Morocco on depression and anxiety, suicidal risk, and QOL in chronic hemodialysis, the finding endorsed present study results [ 19 ]. A review by Lee et al. [ 20 ] stated that both anxiety and depression were prevalent in pre-dialysis CKD sufferers and related with poor QOL. Health-related QOL significantly predicts death and hospitalization which could affect the prognosis and progression of the illness. This reduction of QOL could be due to the presence of depression and anxiety in pre-dialysis patients [ 21 ]. Another possible explanation behind poor QOL could be advance age, low SES, and education of the current sample. Secondly, certain complications are also associated with hemodialysis treatment, e.g., dry skin, itching, blood pressure fluctuations, headache, and back pain [ 13 , 22 , 23 ]. It is interesting to note that the present study did not report significant difference on PSS before and after the treatment of dialysis. It seems that in our culture we still intact with social norms and care patients who usually are close/immediate family members (parents/spouse). Independent sample t test was used to see the difference on QOL, depression, anxiety, and PSS between group I and group II. The findings indicate no difference on QOL, depression, anxiety, and PSS between both groups. A study reported that CKD patient with elevated depression and anxiety may perceive less social support from family and significant others [ 24 ]. A qualitative study suggests that prolong dialysis treatment effects negatively on the CKD patients. They furthers conclude that to get substantial treatment outcome, it is imperative to improve social support of family and significant others [ 25 ]. However, in the present study, these results may be due to the fact that both group participants have kidney diseases. Group I were suffering from intense level therefore they have depression, anxiety, and poor QOL while group II have the same level of mental health, which may be because they may develop the fear that their disease could convert into intense stages.

Realizing the seriousness of depression, anxiety, and poor QOL among CKD patients is of genuine concern. Unnecessary delay to treat mental health problems among these patients will affect the CKD management outcome.

The results of the study showed that CKD patients suffer from depression, anxiety, and poor QOL. In addition, pre- and post-test further suggested that dialysis treatment reduces depression, anxiety, and significantly affect QOL, while no effect has been observed on PSS.

Availability of data and materials

Soft data may be provided upon reasonable request.

Abbreviations

Chronic kidney diseases

Quality of Life

End-stage renal disease

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Acknowledgements

The authors sincerely thank all hospital administration, and participants to complete this study.

The study did not receive any funding from local/ international resources.

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Um-e-Kalsoom, Sabiha and Khan Israr Ahmad contributed equally to this work.

Authors and Affiliations

Department of Psychology, Shaheed Benazir Bhutto Women University, Peshawar, Pakistan

Um-e-Kalsoom & Sabiha Khan

Pakistan Health Research Council, Research Centre Khyber Medical College, Peshawar, Pakistan

Israr Ahmad

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Idea conceived, design, and manuscript write up was done by UK, data collection, data analysis by SK, while IA helped in data interpretation and editing. All authors have read and approved the manuscript.

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Correspondence to Um-e-Kalsoom .

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Um-e-Kalsoom, Khan, S. & Ahmad, I. Impact of hemodialysis on the wellbeing of chronic kidney diseases patients: a pre-post analysis. Middle East Curr Psychiatry 27 , 54 (2020). https://doi.org/10.1186/s43045-020-00060-x

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Perceived Social Support

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Published: 28 March 2023

Mental health and its influencing factors of maintenance hemodialysis patients: a semi-structured interview study

Junjun Wen 1 , 2 , 3 ,
Yuan Fang 1 ,
Zhongyan Su 1 , 2 ,
Jimin Cai 1 , 2 &
Zhiyan Chen 1

BMC Psychology volume 11 , Article number: 84 ( 2023 ) Cite this article

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Maintenance hemodialysis (MHD) is a commonly used renal replacement therapy for end-stage renal disease patients. MHD patients have undergone multiple physiological stressors, which may cause physical problems and affect their mental health; however, few qualitative studies have been done on the mental health of MHD patients. Such qualitative research becomes the basis for further quantitative research and is critical to validating its results. Therefore, the current qualitative study used a semi-structured interview format, and aimed to explore the mental health and its influencing factors of MHD patients who are not receiving intervention treatment to determine how best to ameliorate their mental health.

Based on the application of Grounded Theory, semi-structured face-to-face interviews were conducted with 35 MHD patients, following consolidated criteria for reporting qualitative studies (COREQ) guidelines. Two indicators (emotional state and well-being) were used to assess MHD patients’ mental health. All interviews were recorded, after which two researchers independently performed data analyses using NVivo.

Acceptance of disease, complications, stress and coping styles, and social support were found to be the influencing factors of MHD patients’ mental health. High acceptance of disease, healthy coping styles, and high social support were positively correlated with mental health. In contrast, low acceptance of disease, multiple complications, increased stress, and unhealthy coping styles were negatively correlated with mental health.

One’s acceptance of the disease played a more significant role than other factors in affecting MHD patients’ mental health.

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Chronic kidney disease (CKD) is a public health problem worldwide, with incidences of end-stage renal disease (ESRD) increasing yearly [ 1 , 2 ]. As the most commonly used renal replacement therapy (RRT) for ESRD, maintenance hemodialysis (MHD) is in increasing demand by patients [ 3 ]. In RRT, MHD patients must receive continuous treatment sessions at a specific hemodialysis center at fixed time intervals. Conventional treatment generally takes place 2 to 3 times a week, with each session lasting 3 to 4 h [ 4 ]. If they are not able to adopt a different RRT method, such as kidney transplant or peritoneal dialysis, MHD patients require lifelong hemodialysis treatments [ 5 ]. Therefore, these patients must make lifestyle changes including dietary adjustments, strict control of water intake, regular application of hemodialysis-related drugs, and exercise training interventions [ 6 , 7 , 8 ]. Furthermore, loss of appetite [ 9 ], fatigue [ 10 ], pruritus [ 11 ], muscle weakness [ 12 ], and vascular access complications [ 13 ] may also occur in MHD patients undertaking long-term hemodialysis. All these complications can affect a patient’s quality of life (QOL) [ 14 , 15 ] as well as their mental health. MHD patients experience different degrees of acceptance of their own disease and hemodialysis treatment. After undergoing lifestyle changes, experiencing and understanding the disease itself, and facing family and economic burdens, many MHD patients experience depression and anxiety symptoms [ 16 ], cognitive dysfunction [ 17 ], alexithymia [ 18 ], and other mental health problems.

The World Health Organization defined mental health as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity” [ 19 ]. Depression, anxiety, and negative emotions are used widely as indicators of negative mental health [ 20 , 21 ]. Well-being, life satisfaction, and positive emotions are deemed as indicators of positive mental health [ 22 , 23 , 24 , 25 ].

Previous quantitative studies on the mental health of MHD patients have focused mainly on the prevalence of depression and anxiety symptoms, and on corresponding intervention methods such as drug therapy, cognitive behavioral therapy, and complementary therapy [ 26 , 27 , 28 , 29 , 30 ]. Meanwhile, few qualitative studies on this topic exist, despite qualitative research being the basis of quantitative research and critical to validating the results of quantitative research, as it can reflect patients’ thoughts or experiences more directly than quantitative research. Previous qualitative studies of MHD patients have focused mainly on symptoms, QOL perceptions of psychological problems, and related factors affecting hemodialysis specifically [ 31 , 32 , 33 , 34 ], but there are few qualitative studies on the mental health of MHD patients, making it difficult to identify its influencing factors and clarify the complex relationships between the different influencing factors. More qualitative studies are therefore required in order to better understand the mental health of MHD patients, as well as to be able to combine these findings with those of quantitative studies to offer more effective interventions to improve MHD patients’ mental health.

This qualitative study aimed to address these gaps in the current literature using semi-structured interviews to explore the mental health and its influencing factors of MHD patients. The explored factors could be used later as reference points when proposing clinical interventions to improve patients’ mental health. Emotional state and well-being were used as indicators to measure patients’ mental health.

Participants were recruited through convenience sampling from the first author’s hospital between April and June 2022. The inclusion criteria were (1) patient was diagnosed with ESRD and had been on maintenance hemodialysis for more than three months; (2) patient age ≥ 18 years; (3) patient was receiving hemodialysis three times a week, for four hours each time. The exclusion criteria were (1) patient had severe complications or experienced major traumatic events (such as bereavement, divorce, unemployment) occurring within the previous three months; (2) patient was unconscious, was uncapable of normal language expression, and was unable to agree to sign the informed consent form. This study was conducted in accordance with the Helsinki Declaration and was approved by Zhanlanlu Hospital, Beijing, China.

Study design and data collection

Each participant was invited to participate in a face-to-face semi-structured interview at the hemodialysis center on a routine hemodialysis day. Each participant signed an informed consent form and had completed a demographic survey before the interview began. They were each informed about the purpose of the study and the requirement that the interview be recorded.

The interview questions were based on a summary of previous literature [ 35 , 36 , 37 , 38 ]. Previous studies have identified several factors affecting different aspects of mental health, including complications affecting patients’ QOL [ 35 ], multiple stresses causing physical and mental burdens [ 36 ], perceived social support which had a significant impact on patients’ mental health [ 37 ], and acceptance of disease which played a particularly important role in the QOL and mental health of MHD patients [ 38 ]. Combined with the researchers’ experience with MHD patients and the review of previous studies, the interview questions focused on: (1) the MHD patient’s acceptance of their disease and hemodialysis treatment; (2) the physical changes they had experienced and the impact of these on the patient’s QOL; (3) their stress levels and emotional state, as well as their methods of stress release; (4) the patient’s feeling of well-being and what increased their level of happiness; (5) the social support the MHD patient experienced, particularly from their primary caregiver(s); and (6) their amount of help they expected to receive from medical staff. In this study, we used patients’ emotional state and well-being to assess their mental health.

Before beginning the formal interview part of the study, one trial interview was conducted to ensure the suitability of the questions and the length of time the interview would take. After this, the formal process began and interviews were scheduled. The formal interview lasted approximately 20 min and was recorded and transcribed verbatim using iFLYTEK Hearing software. After the interview had been processed, each transcription was proofread by two researchers independently.

Data analyses

Following the principles of Grounded Theory [ 39 ], the sorted transcription documents were input into QSR International NVivo12 software for data analyses. First, nodes were created in the software to store ideas and excerpted content from the transcripts, with each node matching a memo. Second, initial coding took place after comparing the data. To improve the analytical reliability of the coding, another physician was invited to conduct independent coding of a sample of the transcripts (10% of the total transcription files). Third, data collection and analysis were conducted. Finally, constant comparative analysis and category identification of the interview content was completed. The guidelines for consolidated criteria for reporting qualitative research (COREQ) were followed during the whole study procedure [ 40 ].

Sample description

A total of 35 MHD patients who met the participant inclusion criteria took part in the study, comprising 10 women (28.6%) and 25 men (71.4%). The mean age was 63.6 years.

Table 1 lists the demographic and clinical characteristics of the 35 participants.

MHD patients’ mental health and its influencing factors

Influencing factors on MHD patients’ mental health were recorded by examining the mental health history of each participant, starting from when they began to receive hemodialysis treatment up until the moment of the interview. Four themes had been identified to assess the diverse states of mental health: (1) acceptance of disease, (2) complications, (3) stress and coping styles, and (4) social support.

Examples of representative quotes are provided in Table 2

Theme 1: acceptance of disease

Acceptance of disease refers to a patient’s acceptance of their disease and hemodialysis treatment, which includes their capability of gradually adapting to living with the disease, receiving routine treatment for the disease, grasping the development process of the disease, and accepting the uncontrollable consequences of the disease. Patients were divided into two groups according to the degree of their current acceptance of disease during the interview: a high acceptance group and a low acceptance group. The high acceptance group included both patients who actively treated their disease at the beginning of hemodialysis, as well as those who had experienced a low degree of acceptance at the beginning of hemodialysis, but whose acceptance increased as their physical condition improved through medical treatments, thus, they experienced more positive emotions. Patients in the low acceptance group were characterized by living with negative emotions and who felt they were being forced to accept their disease and the necessary treatments against their desires.

Some of the MHD patients with a high acceptance of disease had a thorough understanding of their disease from an early stage of hemodialysis. These individuals showed a high degree of acceptance of disease and hemodialysis treatment, and actively cooperated with medical staff, following the medical instructions during hemodialysis treatment and drug adjustment, which meant that their physical conditions were more quickly stabilized. For the other patients in the high acceptance of disease group, although they initially had demonstrated a low degree of acceptance of the disease, after their physical conditions gradually improved through the hemodialysis and drug treatments, they began to accept their disease and the related treatments, including the hemodialysis. This transition improved their acceptance of the disease.

The MHD patients who accepted their disease at the early stage of hemodialysis could be divided into three categories. The first category was those living with familial diseases, who already had a relatively in-depth understanding of their diseases before receiving hemodialysis. It was thus easier for them to cooperate with medical staff when receiving medical treatments. The second category had an accepting attitude toward everything after having experienced general ups and downs in life, thus they also positively accepted the medical treatments. The third category demonstrated strong religious beliefs, believing that everything was arranged by God, therefore, they could accept their disease and follow medical instructions for treatment.

Patients who accepted their disease gradually throughout the process of hemodialysis were unable to have a high degree of acceptance of disease at the start of hemodialysis, and thus suffered a heavy psychological burden. Through explanation of and analysis of hemodialysis by medical staff and with the support of their families and friends, these patients were reluctantly able to accept a period of regular hemodialysis treatment. Once accompanied by their significantly improved physical conditions, these participants were able to truly accept their disease and began to accept the hemodialysis treatment and regular medication.

For the patients with a low acceptance of disease, the first category included those who understood they required hemodialysis treatment to stay alive, yet were still not able to accept this fact. They thought that fate was unfair and kept asking why they contracted this disease and needed hemodialysis treatment, while others did not. With this idea of the unfairness of it all forefront in their minds, despite requiring hemodialysis to survive, these patients demonstrated a low level of adherence to the treatment, and did not actively cooperate with medical staff. These patients were unable to psychologically take initiative to improve their acceptance of the disease.

The second category of patients with a low acceptance of disease said that they would yield to fate; they felt forced to accept their disease and the hemodialysis treatments to survive, but their attitude one of constant passivity and negativity. This hopeless attitude caused their emotional state to be terrible, and they would give up easily in the face of difficulty, and demonstrated a low degree of adherence to treatments. These patients often did not follow the advice received from medical staff, which led to a minimal or lack of improvement in their physical situation.

Theme 2: complications

When assessing complications experienced by MHD patients, the probability of their occurrence depended on their age, primary disease, and years on hemodialysis. Elderly patients and patients who had been on hemodialysis for a longer period had a higher probability of contracting more acute or chronic complications. Furthermore, different primary diseases could lead to varying complications.

In the early stage of hemodialysis, MHD patients would often experience obvious improvements in their physical symptoms due to the rapid removal of excess toxins and volume load in the body. However, some patients might have also experienced acute complications during the hemodialysis process, thought these generally had a short duration and soon relieved. Acute complications can occur in the middle and late stages of the hemodialysis session, or even a few hours after the session has ended. During the interview, the acute complications mentioned most often by MHD patients included hypotension, muscle spasms, nausea, vomiting, headaches, and fatigue. Some of the long-term hemodialysis patients also experienced chronic complications, such as pruritus, cardiovascular complications, protein malnutrition, muscle weakness, or vascular access complications.

These acute or chronic complications were all associated with a low QOL. Moreover, patients who experienced more complications or more severe health conditions also experienced more frequent negative emotions as well as symptoms of anxiety and depression. Some of them suffered substantial pain because of these complications, causing them to lose any sense of happiness in anything.

Theme 3: stress and coping styles

Most of the MHD patients undergoing routine hemodialysis experienced multiple forms of stress composed of varying degrees of physical, psychological, and economic pressures. This stress was closely related to their emotional state, in that as their stress level increased, their negative emotions would also increase, while their positive emotions would decrease. Some of the patients in the low acceptance of disease group tended towards regularly presenting obvious negative emotions, while patients with a higher degree of acceptance of disease and a more stable health condition tended to experience a lower level of stress and less emotional fluctuation, presenting higher appreciation for their current living conditions, family support, and medical conditions.

Different patients had quite different coping styles when it came to relieving stress. Patients with an optimistic attitude tended to adopt healthier coping methods, such as chatting with family members and friends, exercising, going for walks, gardening, singing, watching TV, reading, listening to music, or resting. In contrast, patients with a more pessimistic attitude tended to adopt more unhealthy coping methods such as smoking, drinking, or staying up late to play mahjong. Healthier coping styles tended to afford MHD patients more benefit in improving their physical condition, while unhealthy coping styles tended to increase the burden on patients’ physical fitness levels.

Theme 4: social support

Social support was shown to play an important role in regulating the mental health of the MHD patients. During the interviews, patients reported that social support came primarily from family members, friends, and medical staff. Among these, family members were the ones most frequently involved in the MHD patients’ treatment and care – usually spouses, then followed by children. A few younger patients reported that their parents were their caregivers, and very few patients reported that they were taken care of by other relatives. Higher level of support from family members was related to both higher QOL and a better sense of well-being than that with lower level. Patients who lived alone were able to take care of themselves when they were in good physical condition, Though when they were in poor health they would hire a nurse or part-time worker for daily care. Patients’ friends mainly provided them with spiritual support, which included encouragement, sharing happiness, and visiting them to chat and engage with them. The MHD patients reported finding happiness through these interactions with their friends. Medical staff mainly provided patients with medical support, such as working with them to formulate treatment plans, diet and drug adjustments, exercise interventions, psychological counseling, offering them or educating them about new technologies and drugs, providing them with hemodialysis-related information, and so forth. Support from medical staff was also associated with patients’ good physical condition and quicker adaptation to accepting the disease and treatment.

This qualitative study, using a semi-structured interview format, aimed to explore the mental health and its influencing factors of MHD patients not currently undertaking interventional treatment in the hope of finding ways to improve their mental health. Based on Grounded Theory, semi-structured face-to-face interviews were conducted with 35 MHD patients, following the COREQ guidelines. Two indicators were used to assess MHD patients’ mental health, emotional state and well-being. All interviews were recorded and then analyzed using NVivo by two researchers, independently. Interview questions regarding the MHD patients’ state of mental health covered four themes: (1) acceptance of disease, (2) complications, (3) stress and coping styles, and (4) social support. Our findings suggest that all of these themes are significant influencing factors of MHD patients’ mental health. High degrees of acceptance of disease, healthy coping styles, and high levels of social support were positively correlated with MHD patients’ mental health. In contrast, low degrees of acceptance of disease, multiple complications, increased stress levels, and unhealthy coping styles were negatively correlated with MHD patients’ mental health.

For MHD patients, acceptance of disease was shown to play an important role in affecting their psychological state. The degree of one’s acceptance of disease could be changed, but the direction in which this attitude can change is not fixed. It is unclear when or whether MHD patients in the low acceptance group might shift into the high acceptance group, as there can be many influencing factors at play. Patients with a high degree of acceptance of disease often show more positive emotions. When acute or chronic complications occur, these patients tend to respond proactively, seeking solutions, asking for help from others, and cooperating with medical staff to address the problems. They also demonstrate a more optimistic attitude towards daily life. Despite being sick, they nonetheless still feel that their lives are no worse than those of others. Some patients are able to reduce their stress level and increase their positive emotions through healthy coping styles, such as moderate physical exercise. While undergoing treatment, they take medical staff seriously, and follow their advice while communicating well with their family members and friends. These positive activities bring these MHD patients a higher sense of well-being.

The findings of the current study are consistent with those of previous studies, in that the higher a patient’s acceptance of disease, the better their adherence to treatment and medication. The higher their degree of cooperation, the more stable their physical condition, and patients with a more stable condition will experience reduced self-perceived stress, improved QOL, and increased positive emotions [ 38 , 41 , 42 ] and well-being [ 43 ].

While undergoing treatment, MHD patients might experience both acute and chronic complications, which can cause intermittent or persistent physical discomfort and pain, which can lead to increased negative emotions [ 44 ]. The severity of these complications will affect the patient’s mental health both directly and indirectly [ 45 ]. Furthermore, studies have shown that an increased prevalence of complications is associated with a lower sense of well-being [ 45 , 46 ]. For example, patients with systemic itching tend to demonstrate more obvious characteristics of a state of negative emotion than those who do not experience systemic itching [ 47 ].

Previous studies have also shown that the stress of MHD patients comes from numerous aspects, and is negatively correlated with their emotions, that is, the greater their stress, the more negative emotions they experience [ 48 ]. Other studies have shown a negative correlation between stress and well-being, with higher levels of stress resulting in lower levels of well-being [ 49 ]. In other words, reducing patients’ stress helps increase their positive emotions and sense of well-being.

Finally, previous research has found that patients with family members as part of their social support experience a high sense of well-being [ 50 , 51 ]. Furthermore, patients with higher marital satisfaction experience less stress and feel more emotionally supported by their spouses [ 37 ]. Medical care provided by medical staff is also an influential part of a patient’s social support, meaning that the doctor-patient relationship plays a very important role in a patient’s sense of well-being [ 52 ]. When patients have more harmonious relationship with their doctor, they engage in more effective communication and cultivate mutual trust, thereby increasing the patient’s satisfaction and adherence to treatment and medication, reducing their negative emotions [ 53 , 54 ].

Limitations

This study does have several limitations. First, participants in this study came from only one hospital in Beijing, China, making this a single-center qualitative study. Thus, future research should use random sampling in a multi-center study design. Second, the interviews in this study employed a cross-sectional design. Dynamic changes in MHD patients’ level of acceptance of disease could not be observed during the single-time point interview. A longitudinal interview design should be considered in future studies to observe shifts in the relationship between changes in patients’ disease acceptance and level of mental health to further clarify the dynamic correlation between them.

This study explored the mental health and its influencing factors of MHD patients. We found that acceptance of disease played an important role in the state of mental health of MHD patients, while the effects of complications, stress level, and coping styles, as well as the impact of social support were also shown to be related to MHD patients’ mental health. High acceptance of disease, healthy coping styles, and high social support were positively correlated with MHD patients’ mental health. Low acceptance of disease, multiple complications, increased stress, and unhealthy coping styles were negatively correlated with MHD patients’ mental health. The degree of acceptance of disease may be changed by the other three influencing factors. In future, more attention should be given to increasing MHD patients’ acceptance of disease to improve their mental health during hemodialysis treatment.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to confidentiality and privacy related issues but are available from the corresponding author on reasonable request.

Abbreviations

Chronic kidney disease

Renal replacement therapy

End stage renal disease

Quality of life

Maintenance hemodialysis

World Health Organization

Consolidated criteria for reporting qualitative research

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Junjun Wen, Yuan Fang, Zhongyan Su, Jimin Cai & Zhiyan Chen

Department of Psychology, University of Chinese Academy of Sciences, Beijing, 101408, China

Junjun Wen, Zhongyan Su & Jimin Cai

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JW has made contributions to the Conceptualization, Methodology, Investigation, Data Curation, Writing-Original Draft, Writing-Review & Editing, Project administration. YF has made contributions to the Conceptualization, Methodology, Writing-Review & Editing. ZS has made contributions to the Writing-Review & Editing. JC has made contributions to the Writing-Review & Editing. ZC has made contributions to the Writing-Review & Editing, Supervision, Project administration. All authors have read and approved the final manuscript.

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Wen, J., Fang, Y., Su, Z. et al. Mental health and its influencing factors of maintenance hemodialysis patients: a semi-structured interview study. BMC Psychol 11 , 84 (2023). https://doi.org/10.1186/s40359-023-01109-2

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The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study

Nahid Shahgholian 1 &
Hojatollah Yousefi 2

BMC Nephrology volume 19 , Article number: 338 ( 2018 ) Cite this article

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Providing patient-centered care needs in patients with chronic renal failure undergoing hemodialysis is important in inspiring their confidence to continue their treatment and promote their mental and social health. Therefore, recognizing the concept of care from the viewpoint of these patients can be helpful in designing the care programs of this vulnerable group. Accordingly, the aim of this study was to reveal the meaning and concept of care based on the experience of patients with chronic renal failure undergoing hemodialysis.

Using a descriptive phenomenological method, this study was conducted on 17 patients who were undergoing hemodialysis. Purposive sampling was performed and data was collected through 30 to 60 min, face-to-face and in-depth semi-structured interviews. Data analysis was performed using Colaizzi’s method.

Seventeen patients (9 women 8 men) aged between 24 and 83, and a minimum of 10 and maximum of 168 months history of hemodialysis participated in the study. After data analysis, 4 themes and 9 sub-themes were extracted, and the concept of care emerged for the participants as empathy, companionship in everyday needs, social support and concern, and good-quality dialysis.

Conclusions

Based on the results of this study, the concept of care from the viewpoint of patients emerged in the form of empathy, companionship in everyday needs, social support and concern, and good-quality dialysis. It is recommended that caregivers of patients consider these concepts in the design of patient-centered care programs.

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Hemodialysis is the most common treatment for the end-stage chronic renal failure in Iran and in the world [ 1 ], so that by the end of 2016, the number of patients undergoing dialysis is estimated to be 2,989,000, 89% of which are hemodialysis patients. In Iran, by the end of 2016, the number of patients undergoing hemodialysis has been estimated to be 29,200 [ 2 ]. Hemodialysis increases patients’ longevity but, at the same time, imposes many restrictions on these patients and leads to many physical, mental, social and economic complications. Minimizing these complications need a comprehensive care for these patients.

Care is divided into three groups of professional care by the health care team including nurses, home care by the family members, and social care. However, regardless of who provides the care, there is still no specific meaning for this concept which can be used in all situations [ 3 ]. Additionally, in spite of the care provided by the health care team, family and society to these patients, they still believe that they don’t receive enough care [ 4 ]. The word “care” has many meanings in Persian, such as the provision of what is necessary for the health, welfare, maintenance, protection, attention, guard,, lookout on, and watch of someone. Accordingly, it seems that the point of view of the patients towards this concept is different from the caregivers. Any successful planning and intervention for these patients need to familiarity with this concept based on the lived experience of the hemodialysis patients. The reason is that receiving this concept from the viewpoint of patients can develop the care provided for them and, using this concept, the care team can design a realistic patient-centered care plan and provide an effective intervention.

Many conducted studies have focused on how to care for these patients in order to reduce the complications of disease and treatment, increase the quality of life, reduce stress and improve the mechanisms of compatibility in these patients. However, none of these studies have investigated or considered the viewpoint of patients [ 5 , 6 ]. Shafiee et al. compared the barriers of blood glucose monitoring in diabetic patients from the viewpoint of patients, healthcare staff and family of the patients. They found significant differences and argued that such difference or disagreement results in the failure of diabetes control in these patients [ 7 ].

Atashzadeh et al. also compared the concept of nursing quality in the group of patients, doctors and nurses. In this study, the researchers emphasized the disagreements among these three groups and believed that these disagreements made the healthcare staff not be able to improve the quality of care expected by the patients and, hence, the patients were not satisfied with the quality of the provided care [ 8 ]. Because of having a different treatment process, patients undergoing hemodialysis have a different experience of the concept of care. However, studies that investigated the experience of patients undergoing hemodialysis [ 9 , 10 ] did not cover the concept of care from the viewpoint of the patients and based on their experiences. Accordingly, it seems that conducting a qualitative research in this area, through a deep understanding of the concept of care from the viewpoint of the patients and their experience of care, can help approaching the view of the patients to that of professional, home and social caregivers. It also improve the quality of care, increase the effectiveness of care, provide better services, and promote the patients’ health and quality of life.

Phenomenology is one of the qualitative research methods suitable for understanding the depth of experience and the concept of a phenomenon [ 11 , 12 ]. According to Thorne (2016), phenomenology is a good method for discovering obscure concepts, including the concept of care, in nursing and other health-related professions [ 13 ]. Accordingly, using the descriptive phenomenological method, the researcher decided to investigate the concept of care from the viewpoint and based on the experiences of the patients with chronic renal failure undergoing hemodialysis.

Given its purpose of revealing the meaning and concept of care based on the experience of the patients with end-stage renal disease undergoing hemodialysis, this study was a qualitative research with descriptive phenomenological method. This method is used to study experience and describe the concept from the perspective of patients who have lived with the illness, and creates a comprehensive description of the experienced phenomenon in order to achieve an understanding of its essential structure and, beyond its description, provides an interpretation of the phenomenon [ 11 ]. Seventeen patients with end-stage renal disease, with purposive sampling, participated in the research. Inclusion criteria: at least three month have elapsed from the start of hemodialysis, no speech and hearing problems, speak fluent Persian, undergo hemodialysis in the hemodialysis unit of Al-Zahra hospital affiliated to Isfahan University of Medical Sciences, Isfahan, Iran, and have a fixed and active medical file in this unit. This unit covers 40 patients permanently. The patients were interviewed one day after dialysis time, in a stable condition, in a room that in an agreement with all patients had been selected next to the dialysis unit. Sampling began from October 23, 2015 and continued to reach saturation, when no new code was extracted, on February 20, 2016.

In order to collect data and access valid and real information, a semi-structured in-depth interview (face-to-face) was used as the main approach. Each interview lasted for 30–60 min.

Each interview started with general questions and was followed up with a calm and flexible format. The interview process actually depended on the respondents’ level of participation. A few questions were used as the interview guide (Table 1 ). At the same time, some exploring questions such as “could you please explain it more?” or “can you clarify what you mean with an example?” were asked to achieve rich and clear data.

The first researcher then heard each recorded interview several times and transcribed to verbatim and gave a number to each interview. In the same time, using Colaizzi’s seven-step approach, data analysis was performed as follows. 1) The descriptions of the participants were repeatedly read in order to feel them out; 2) 200 important expressions were extracted and numbered; 3) Important expressions were written in scientific language and the meanings were formulated; 4) The constructed concepts/themes were grouped based on their similarity; 5) Nine sub-themes were formed; 6) Similar sub-themes were organized in larger clusters and four main themes were obtained; 7) In order to ensure the accuracy of his/her impressions, the researcher returned them again to the participants, but there was no need to review and repeat the interviews. The researcher reached the data saturation after 17 interviews.

To evaluate validity and reliability of the data, Guba and Lincoln evaluative criteria were used [ 14 ]. Accordingly, in order to make the research believable, the review of the co-researchers and participants was also used.

Likewise, to ensure the reliability of the data, after hearing, and analyzing the interviews, the peer review, PhD in nursing, reread and refined the data. The research team used the described methods to minimize the influence of their pre-existing ideas and beliefs on the current research findings.

To provide transferability in this research, the researcher used the full introduction of the research, described the background and stages of the research fully and tried to choose samples in maximum variations.

This research was approved by the Ethics Committee of Isfahan University of Medical Sciences No. 293333. After receiving the necessary permission from the university, the researcher entered the research site. While introducing herself and providing the necessary information to the patients, the researcher explained the purpose and process of the research. After filling out the written informed consent form, the time and place of the interview was determined by an agreement between the participants and the researcher. During the interview, feedback and oral consent were also obtained. Additionally, to maintain anonymity, each interview was given a number. Before beginning the interviews, the participants’ permission was obtained, and they were assured that their names and information would remain confidential. The participants had the absolute discretion to leave the study whenever they wished.

Seventeen patients (9 female and 8 male) aged between 24 and 83, and minimum of 10 and maximum of 168 months of treatment duration participated in the research. In terms of education, the participants ranged from illiterate to master’s degree; seven were married and their spouses took care of them; and, diabetes was the most common underlying disease causing chronic renal failure (Table 2 ).

Analyzing interviews, 200 inferential codes, 9 sub-themes and 4 main themes were extracted. From the perspective of the hemodialysis patients, the care phenomenon was defined through the formation of concepts such as empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis.

The concept of empathy was shaped by the feeling of receiving psychosocial support from the treatment team and emotional support from the family. Help with daily activities and the provision of adequate nutrition were the sub-themes that formed the theme of accompaniment in meeting daily needs. Social support and concern, was another theme that, in explaining the phenomenon of care, was formed by a sense of society’s understanding of the patient’s condition, provision of employment opportunities and financing. High-quality dialysis was another theme which included the sub-themes of meticulous care during dialysis and advanced or unbroken dialysis machine (Table 3 ).

Emotional support

Because of numerous dialysis sessions, the participants spent a lot of time with healthcare staff including nurses and doctors. As such, they expected the medical staff to support them psychologically and emphasized their empathy:

‘When nurses listen to me, I’m sure they care for me.’ (Participant 5)

‘When I was hospitalized for my heart condition, I’d like to visit the staff of my own ward (hemodialysis); I was very alone.’ (Participant 7)

Emotional support of the family was another extracted concept and participants stated that emotional support of family members is an integral part of care:

‘I’d like my wife and my children to listen to me and spend more time with me; when they are with me, I’m not afraid of the disease.’ (Participant 3)

What the statements of the participants implied was that the empathy of the health staff, especially the nurses, and the emotional support of family members made the patients feel secure and less worried and, thus, they considered empathy as a concept of care.

Accompaniment in meeting daily needs

The participants stated that because of their old age, underlying diseases, fatigue and boredom, they often need the help and support of their family for doing daily activities including healthcare activities:

‘I have a blurred vision and can’t see clearly; I can’t shave my face or trim my fingernails; my wife or my children have to do these for me.’ (Participant 10)

Providing an adequate nutrition by the family was another sub-theme of accompaniment in meeting daily needs. Because of their illness, nutritional restrictions are necessary for these patients, and because of their physical conditions, the provision of a special diet requires the collaboration and support of their family:

‘My wife knows which kinds of foods contain phosphorus and potassium, and when it comes to cooking, she is careful and controls my regimen; I can’t do it myself.’ (Participant 2)

‘My family should make me a meal, I can’t do it myself’ (Participant 3)

Participants’ statements indicated that family accompaniment was essential for daily activities such as providing personal health and support in going on a diet. Hence, in the opinion of the participants, accompaniment was one of the concepts of care.

Social support and concern

Increasing the society’s understanding of the condition of the patients was another theme. The patients expressed their dislike of the pity of others and stated that they wanted others to understand them. Thus, instead of pity that might annoy them, they expected others to help and support them when necessary:

‘People don’t understand us; if they did, they would, for example, give up their seat to us in the bus, or give us they turn in the pharmacy or doctor’s office.’ (Participant 12)

‘Everyone is very busy and there is no support. Many people pity us but I don’t like it.’ (Participant 10)

Providing job opportunities and financing were the sub-themes emphasized by the participants. Because of frequent dialysis sessions, job loss, insufficient ability to work hard and continuously, medical expenses, transportation costs and disproportion between income and treatment or life costs, the patients had economic problems. As such, they believed that having a suitable job and being secured financially is a kind of care:

‘I lost my job because of dialysis; charity doesn't help much; I wish the association helped more and the insurance covered the cost of all drugs; or at least we could have a good job.’ (Participant 3)

Participants’ remarks implied that the society has to change its attitude towards the condition of these patients. As the lack of an organized program to support patients has led to a lot of economic problems for them, providing a job in proportion with the physical condition and dialysis time of these patients can help them benefit from a systematic economic support.

High-quality dialysis

Since hemodialysis is very sensitive process, patient care and control during dialysis is important. Thus, a meticulous care during dialysis is highly important for the participants:

‘Some personnel don’t set up the machine based on my condition and my blood pressure drops.’ (Participant 7)

‘Every time during dialysis they control my blood pressure five times; I’m afraid of drops in my blood pressure during dialysis; I have spasm in my legs.’ (Participant 13)

An unbroken or advanced dialysis machine was another issue that the participants referred to and stated that a high-quality dialysis is almost impossible without a well-functioning dialysis machine:

‘The machines are broken and don't lose weight well; we’re thirsty between two dialysis; we drink water and get short of breath; our pressure drops under the dialysis; they disconnect us quickly from the machine and going home we are not well.’ (Participant 4)

Accordingly, the participants considered high-quality dialysis as a part of care and emphasized the importance of a meticulous care during dialysis and the proper functioning of the dialysis machines.

Based on the results of the research, the lived experience of dialysis patients shows that care for these patients means empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis. These concepts thus have to be considered in the care plans designed for these patients by the medical staff, domiciliary caregivers and social agents.

The four main themes of emotional support, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis were considered by the participants as the concepts of care; and, it seems that the participants of the present study emphasized the psychological aspects of care more than its physical aspects.

The results of the study conducted by Georgia showed that most hemodialysis patients suffer from a heavy burden of psychological problems [ 15 ].

The empathy of the medical staff was one of the concepts of care and the participants emphasized the effectiveness of the relationship with the nurses and doctors and remarked that this relationship can be soothing and reassuring for them. Davison and Simpson believe that the role of personnel in communicating with the patients and their family is very important and can raise their hope. They argue that the nurse’s speaking to the patients about their situation can sometimes be the source of relief and hope for the health and well-being of the patients [ 16 ].

The participants’ statements in the present research suggested a significant role of the empathy of the family members in the care and support for the patients. In this regard, a research has shown that family members, especially one’s spouse, have the most important role in providing mental health services to a patient with chronic illness. The patients considered their spouse as the key person in supporting them, that is, the support of the patient’s spouse was the most important source of support during the illness [ 17 ]. Asgari et al. also obtained the two concepts of family unification and empathy and responsible accountability of nurses [ 18 ], which is in line with the results of this research.

Therefore, it can be concluded that although hemodialysis patients are exposed to mental stressors, empathy and psychological support can help them with these stressors. Empathy from different sources such as family and health care staff can reduce the physical and psychological problems of these patients, thereby helping the patients to cope with the illness more easily, keep away from isolation and gain more vitality and energy.

Accompaniment in meeting daily needs of the patients was another extracted main theme and the participants emphasized that accompanying them with daily activities and providing appropriate nutrition is a concept of care. These patients usually suffer from pain, energy shortages, insomnia and heart condition, and limitation in their physical activity disrupts their physical functioning in such a way that they have difficulty in doing their daily activities [ 1 ]. Uremia causes irritability, loss of appetite, insomnia, fatigue, memory loss, impaired judgment and poor concentration and, consequently, these patients sometimes need help in doing their simplest daily tasks [ 19 , 20 ].

Another need of these patients is the provision of food by the family and based on the prescribed diet. Most of the participants stated that, because of fatigue and decreased energy, they are not able to prepare the recommended food, do not have the incentive to follow the diet, and need the support of their family. Haririan et al. showed that supporting the patients increases their compliance with therapeutic regimen, especially food regimen, thereby improving the quality of life in them [ 21 ]. In a qualitative research investigating the barriers of adherence to therapeutic regimen in the patients with type 2 diabetes, the participants have stated that one of the factors impeding the compliance with therapeutic regimen has been inadequate family support [ 7 ].

From the statements of the participants and the mentioned studies it can be concluded that accompaniment in meeting the daily needs of the patients is a very important factor that should be considered in designing a care plan for these patients.

From the viewpoint of the participants, support through increasing the society’s understanding of the patients’ condition, providing appropriate jobs and financing were other care-related concepts. The type of the support and the patient’s perception of it contribute to its effectiveness, so that the participants stated that they dislike pity and expect others to understand their conditions, and believed that effort to achieve this goal is related to the concept of care. Siegert et al. found that dialysis exerts a pressure on the patients and their family, but the reaction of others can have a significant impact on their mental status [ 22 ]. Therefore, it seems that changing society’s attitudes and understanding towards these patients would help to support these patients instead of pity them.

The necessity of employment and financing were two other sub-themes extracted from the statements of the participants and emphasized by most of them. As these patients spend a considerable amount of time doing dialysis and medical care and are often not in a good condition, they often encounter many limitations with regard to their employment, lose their jobs and have many economic problems. Accordingly, they expect the government and the association for the support of kidney patients to provide the ground for their employment and believe that such a support is one of the concepts of care. Rafiee and Rambod also showed that many hemodialysis patients had lost their jobs and experienced many economic and social problems and were unable to provide some of their own and their family needs [ 23 ]. However, it should be noted that financial problem of the patients is not specific to our country, as Hui-Dan et al. also found that most hemodialysis patients have a lot of financial problems [ 24 ].

The support of social organs for patients, especially economic support, reduces the problems of these patients and plays an important role in tolerating the disease. Most of the participants of this study were satisfied with the support of social organizations, but did not consider it enough and expected more support, especially more financial support [ 9 ]. Therefore, designing a social support program, including economic support for these patients seems to be essential.

High-quality dialysis was another extracted main theme and, in this regard, a meticulous care during dialysis and using a well-functioning dialysis machine were emphasized by the participants. They stated that care during dialysis, including minute adjustment of the dialysis machine, blood pressure control, precise weight control and having sufficient skill in dialysis, is of particular importance. Kaba et al. wrote that patients undergoing hemodialysis always suffer an anxiety caused by possible problems and the likelihood of death during dialysis and, hence, dialysis nurses should have the sufficient knowledge and skill to prevent such problems [ 4 ].

The nurse should have enough information about the patient and the dialysis machine in order to implement a safe and high-quality dialysis program [ 25 ]. Therefore, meticulous care during dialysis was considered by the participants to be essential. The participants complained about broken machines, their frequent alarms and their inability to lose weight and believed that the existence of unbroken dialysis machines is the proof of a high-quality dialysis. Dialysis machine is an integral part of treatment for these patients and the proper function of the machine can directly affect the outcome of the treatment and complications of the dialysis [ 26 ]. Thus, according to the participants, high-quality dialysis was one of the concepts of care that should be considered in the design of a care program for these patients.

Although qualitative research gives us a deep understanding of the phenomenon, because of the expansion of different topics, one cannot get all the dimensions of a topic in interviews with a limited number of individuals. Accordingly, revealing new themes is likely only through conducting more interviews with a diverse sample of participants not captured in this study. Therefore, although data saturation in this research was reached, additional participants in future studies may address more dimensions of the concept of care.

According the findings, we can answer the research question that “what is the lived experience of hemodialysis patients with the concept of care?” From the viewpoint of the patients, empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis constitute the concept of care. One of the unique results of the present study, compared with other similar ones, was the emphasis of the participants on the mental aspects of care. Accordingly, these aspects have to be considered in the care plans designed by the healthcare team for these patients.

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Acknowledgements

The current article resulted from the research project No. 293333 which was approved by the Isfahan Kidney Disease Research Center. Hence, it is incumbent upon us to express our gratitude for the genuine cooperation of the chairman and the members of this center and all those who helped us in this research, especially the participants.

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Mrs. NS contributed in interview, analyzing, and interpreting the patient data and writing the manuscript. Dr. HY contributed in Data interpretation, manuscript writing and editing, and all authors have read and approve the final version of manuscript.

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Shahgholian, N., Yousefi, H. The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study. BMC Nephrol 19 , 338 (2018). https://doi.org/10.1186/s12882-018-1138-4

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De, Pascale Matilde <1992&gt. "Novel membranes for hemodialysis application." Doctoral thesis, Alma Mater Studiorum - Università di Bologna, 2021. http://amsdottorato.unibo.it/9605/1/DE%20PASCALE_MATILDE_TESI.pdf.

Arnold, Tava L. "Predicting fluid adherence in hemodialysis patients via the illness perception questionaire - revised." unrestricted, 2007. http://etd.gsu.edu/theses/available/etd-11122007-020016/.

Fredriksson, Victor, and Nataša Pljevaljčić. "Faktorer som bidrar till fatigue hos patienter som mottar hemodialysbehandling : En litteraturöversikt." Thesis, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-439335.

Sawatzky, Dale James. "Adjustment to hemodialysis : a relationship study with demographic variables." Thesis, University of British Columbia, 1987. http://hdl.handle.net/2429/26913.

Luik, A. J. "Blood pressure control in hemodialysis patients." [Maastricht : Maastricht : Universiteit Maastricht] ; University Library, Maastricht University [Host], 1998. http://arno.unimaas.nl/show.cgi?fid=5947.

Slatculescu, Andreea M. "Immune Dysfunction Associated with Hemodialysis Modalities." Thèse, Université d'Ottawa / University of Ottawa, 2014. http://hdl.handle.net/10393/30493.

Hemasilpin, Nat. "Toward Optimal Adaptive Control of Hemodialysis." University of Cincinnati / OhioLINK, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1378112378.

Rondinelli, Victoria J. "Caloric requirements in the hemodialysis subject." Thesis, Virginia Polytechnic Institute and State University, 1986. http://hdl.handle.net/10919/101144.

Mahlıçlı, Filiz Yaşar Altınkaya Sacide Alsoy. "Preparation And Characterization of Hemodialysis Membranes/." [s.l.]: [s.n.], 2007. http://library.iyte.edu.tr/tezler/master/kimyamuh/T000605.pdf.

Singleton, Andrea Dawn Mitchell 1953. "Subjective sleep evaluation in hemodialysis patients." Thesis, The University of Arizona, 1990. http://hdl.handle.net/10150/291855.

Irvin, Renee A. "Quality of care, asymmetric information, and patient outcomes in U.S. for-profit and not-for-profit renal dialysis facilities /." Thesis, Connect to this title online; UW restricted, 1998. http://hdl.handle.net/1773/7489.

Curren, Sheila C. "Problem solving and coping strategies leading to salutary outcomes of hemodialysis in well functioning adults." Click here for text online. The Institute of Clinical Social Work Dissertations website, 1997. http://www.icsw.edu/_dissertations/curren_1997.pdf.

Farley, Donna O. "Effects of competition on dialysis facility service levels and patient selection." Santa Monica, CA : Rand, 1993. http://catalog.hathitrust.org/api/volumes/oclc/29674158.html.

Wramneby, Joel, and Carl Hagström. "Att leva med hemodialys vid kronisk njursjukdomEtt patientperspektiv : Living with hemodialysis with chronic kidney disesaseA patient perspective." Thesis, Örebro universitet, Institutionen för hälsovetenskaper, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-84368.

Xu, Yunnan. "Statistical Methods for In-session Hemodialysis Monitoring." Diss., Virginia Tech, 2020. http://hdl.handle.net/10919/99037.

Ferro, Paula Luz, and Fernandez Gloria Del. "Spirituality and compliance correlates of hemodialysis patients." CSUSB ScholarWorks, 2005. https://scholarworks.lib.csusb.edu/etd-project/2663.

Ricci, Davide <1977&gt. "Uremic Neuropathy: Epiemiological Study in Hemodialysis Patients." Doctoral thesis, Alma Mater Studiorum - Università di Bologna, 2012. http://amsdottorato.unibo.it/4452/1/Davide_Ricci_tesi.pdf.

Ricci, Davide <1977&gt. "Uremic Neuropathy: Epiemiological Study in Hemodialysis Patients." Doctoral thesis, Alma Mater Studiorum - Università di Bologna, 2012. http://amsdottorato.unibo.it/4452/.

Nyholm, Cecilia, and Marie Ohlsson. "Hälsa - en möjlighet trots kärlaccess och hemodialys." Thesis, Högskolan i Halmstad, Sektionen för hälsa och samhälle (HOS), 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:hh:diva-17417.

Wall, Susanne, and Camilla Henriksson. "Närstående till hemodialyspatienter - litteraturens beskrivning av deras situation och det stöd de efterfrågar." Thesis, Högskolan i Gävle, Avdelningen för hälso- och vårdvetenskap, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:hig:diva-19758.

Henriksson, Camilla, and Susanne Wall. "Närstående till hemodialyspatienter : litteraturens beskrivning av deras situation och det stöd de efterfrågar." Thesis, Högskolan i Gävle, Avdelningen för hälso- och vårdvetenskap, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:hig:diva-19716.

Morales, Morales Christel, and Paima Karina Arrieta. "Erfarenheter av stöd hos patienter som behandlas med hemodialys." Thesis, Högskolan i Halmstad, Akademin för hälsa och välfärd, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:hh:diva-38225.

Liu, Wa-ling. "A preliminary study into the level of knowledge, attitudes and perceptions of dialysis patients on kideny [sic] transplantation /." View the Table of Contents & Abstract, 2005. http://sunzi.lib.hku.hk/hkuto/record/B39915153.

Morley, David B. "The kinetics of middle and small molecule adsorption by collodion-coated activated charcoal /." Thesis, McGill University, 1987. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=66258.

Li, So-ching Janet. "Assessing the cognitive function among the elderly dialysis patients a single center study /." Hong Kong : University of Hong Kong, 2002. http://sunzi.lib.hku.hk/hkuto/record.jsp?B2594907x.

Lawson, Thomas Kyle Beard Thomas R. "Impact of the dialysis industry on kidney transplants." Auburn, Ala., 2009. http://hdl.handle.net/10415/1988.

Reid, Deborah Jane. "Folate and zinc status of chronic hemodialysis patients." Thesis, University of British Columbia, 1990. http://hdl.handle.net/2429/29786.

Tordoir, Johannes Hendrik Marie. "Noninvasive diagnostic studies of arteriovenous fistulas for hemodialysis." Maastricht : Maastricht : Datawyse ; University Library, Maastricht University [Host], 1989. http://arno.unimaas.nl/show.cgi?fid=5509.

Olson, Jeffrey Carter. "Design and modeling of a portable hemodialysis system." Thesis, Atlanta, Ga. : Georgia Institute of Technology, 2009. http://hdl.handle.net/1853/28250.

LEE, MEI-CHEN, and 李美貞. "Effect of Lactic Acid Bacteria on Hemodialysis Quality of Hemodialysis Patients." Thesis, 2019. http://ndltd.ncl.edu.tw/handle/hb6s74.

Chi-Pin, TSENG, and 曾啟斌. "Study on the Factors Contributing to The Effects of Hemodialysis Among Hemodialysis Patients." Thesis, 1999. http://ndltd.ncl.edu.tw/handle/52125430794158815128.

Chen, Lin-hui, and 陳玲慧. "Fuzzy Hemodialysis Quality Support System -Example of Hemodialysis Data Base in Area Hospital." Thesis, 2003. http://ndltd.ncl.edu.tw/handle/15494051891369569601.

Chen, Hsiao-Chin, and 陳曉瑾. "Is Changing Modality from Peritoneal Dialysis to Hemodialysis More Economic Than Just Hemodialysis?" Thesis, 2011. http://ndltd.ncl.edu.tw/handle/02100813541740016076.

Chen, Ying Shun, and 陳盈勳. "Clinical Evaluation of Optimal Hemodialysis." Thesis, 1999. http://ndltd.ncl.edu.tw/handle/83319111615454242005.

Wu, Ching Wen, and 吳錦玟. "Symptom clusters of hemodialysis patients." Thesis, 2010. http://ndltd.ncl.edu.tw/handle/76748794732561045638.

Lun, Huang Mei, and 黃美倫. "Symptom Clusters in Hemodialysis Patients." Thesis, 2009. http://ndltd.ncl.edu.tw/handle/13461545880834730937.

Moreira, Hugo Miguel Gouveia Pais. "Vitamin K in hemodialysis patients." Master's thesis, 2021. https://hdl.handle.net/10216/134483.

Moreira, Hugo Miguel Gouveia Pais. "Vitamin K in hemodialysis patients." Dissertação, 2021. https://hdl.handle.net/10216/134483.

Buss, Mary Lou. "Use of self-efficacy and brief interventions to improve adherence in dialysis patients." 2009. http://proquest.umi.com/pqdweb?did=1932327681&sid=5&Fmt=2&clientId=14215&RQT=309&VName=PQD.

Dang, Thi-Loan, and Thi-Loan Dang. "The Vietnamese Hemodialysis Stressor Scale and Jalowiec Coping Scale for Hemodialysis Patients:Translation and Psychometric Testing." Thesis, 2014. http://ndltd.ncl.edu.tw/handle/ug7y6n.

Lee, Chia Jung, and 李佳容. "The investigation on Hemodialysis Patient's Switching Cost, Switching Intention and After Switch Satisfaction in Hemodialysis Center." Thesis, 2013. http://ndltd.ncl.edu.tw/handle/99905110112229355005.

Wolff, Susanne Hawthorne. "Effects of reprocessing on hemodialysis membranes." 2005. http://etda.libraries.psu.edu/theses/approved/WorldWideIndex/ETD-873/index.html.

Ning, Gangmin Henning Günter. "Online detection of hemodialysis induced hypotension /." 2001. http://www.gbv.de/dms/ilmenau/toc/333273583ning.PDF.

Shy, Hung Pin, and 施鴻斌. "Quantitative Study of Long-Term Hemodialysis." Thesis, 1994. http://ndltd.ncl.edu.tw/handle/81728167017260811940.

Huang, Kuan-Sung, and 黃冠崧. "The Behavior of Solutes in Hemodialysis." Thesis, 2012. http://ndltd.ncl.edu.tw/handle/50068415622561048543.

Chiu, Yi-Fang, and 邱怡芳. "The association between HemoDialysis Eating Index（HDEI) and the risk factors of cardiovascular disease in hemodialysis patients." Thesis, 2013. http://ndltd.ncl.edu.tw/handle/74407515739254838146.

Chuang, Li-Ching, and 莊莉菁. "The effectiveness of exercise program during hemodialysis on fatigue,physical activity and physical capacity in hemodialysis patients." Thesis, 2006. http://ndltd.ncl.edu.tw/handle/89816490478003219164.

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Showing result 1 - 5 of 50 swedish dissertations containing the words thesis on hemodialysis .

1. Glucose degradation products in patients on hemodialysis : interventional studies

Author : Bernd Ramsauer ; Bernd Stegmayr ; Henrik Hadimeri ; Bengt Lindholm ; Umeå universitet ; [] Keywords : MEDICIN OCH HÄLSOVETENSKAP ; MEDICAL AND HEALTH SCIENCES ; Hemodialysis ; advanced glycation end products ; skin autofluorescence ; plasma autofluorescence ; glucose degradation products ;

Abstract : Hemodialysis (HD) is the most frequently used treatment for end-stage renal disease. Despite all efforts to improve the outcomes, the mortality of patients on HD is still high, and this especially is related to cardiovascular diseases (CVD). READ MORE

2. Studies on treatment of renal anemia in patients on chronic hemodialysis

Author : Bergur V. Stefánsson ; Göteborgs universitet ; [] Keywords : hemodialysis ; IV iron ; oxidative stress ; erythropoietin ; hepcidin ;

Abstract : In patients with chronic kidney disease, treatment with erythropoiesis-stimulating agents (ESA) effectively corrects anemia. Most of these patients also need supplementation with regular iron injections to secure iron availability for proper erythropoiesis. READ MORE

3. Haemodialysis Treatment Monitored On-line by Ultra Violet Absorbance

Author : Fredrik Uhlin ; Lars-Göran Lindberg ; Martin Magnusson ; Bernd Stegmayr ; Linköpings universitet ; [] Keywords : MEDICIN OCH HÄLSOVETENSKAP ; MEDICAL AND HEALTH SCIENCES ; Dialysis ; Hemodialysis ; Proteins ; Metabolism ; Renal dialysis ; Ultraviolet spectrophotometry ; Urea ; Uremia ; Kidney diseases ; Njursjukdomar ;

Abstract : This thesis describes and evaluates an optical method utilizing ultra violet (UV) absorbance for on-line monitoring of haemodialysis treatment. Increased efficiency of haemodialysis treatment is considered to correlate to decreased morbidity and mortality when urea clearance (Kt/V) is elevated. READ MORE

4. Impact of renal dysfunction on serum Prostate-Specific Antigen

Author : Laila Bruun ; Internmedicin - epidemiologi ; [] Keywords : MEDICIN OCH HÄLSOVETENSKAP ; MEDICAL AND HEALTH SCIENCES ; Urologi ; hK2 ; Urology ; intra-individual variation ; elimination ; peritoneal dialysis ; renal dysfunction ; kidney transplantation ; hemodialysis ; nefrologi ; nephrology ; PSA ;

Abstract : Measurement of prostate-specific antigen (PSA) in blood is an important tool in detection for prostate cancer. PSA occurs in several molecular forms in blood: mainly as a free form with a molecular mass of 28 kDa; and as PSA complexed to alpha-1-antichymotrypsin, complexed PSA, with a molecular mass of 90 kDa. READ MORE

5. Influence of bone-associated and cardiovascular biomarkers on vascular events and mortality in relation to renal dysfunction

Author : Ping-Hsun Wu ; Östen Ljunggren ; Bengt Fellström ; Torbjörn Linde ; Jonas Spaak ; Uppsala universitet ; [] Keywords : MEDICIN OCH HÄLSOVETENSKAP ; MEDICAL AND HEALTH SCIENCES ; MEDICIN OCH HÄLSOVETENSKAP ; MEDICAL AND HEALTH SCIENCES ; biomarkers ; bone markers ; cardiovascular markers ; proteomics ; vascular event ; mortality ; renal function ; hemodialysis ; Medicinsk vetenskap ; Medical Science ;

Abstract : Biomarkers can help physicians identify subjects with an increased cardiovascular risk. Apart from the clinical factors, some biomarkers have been recognized as important predictors and risk factors for cardiovascular disease in renal disease. READ MORE

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Experience of Nurses in Hemodialysis Care: A Phenomenological Study

This study aimed to describe the experiences of nurses in hemodialysis care. In this phenomenological study, purposive sampling began and continued until data saturation. The research environment was the Hemodialysis unit. Data was collected through semi-structured interviews. Finally, two main classes and four sub-classes were identified, including factors effective on care (inhibitors and facilitators) and care outcomes (the negative effects of care on the nurse and the positive effects of care on the patient), and “challenging care” as the main theme. As the results show, nurses suffer from several physical and mental harm, and this harm even extends to their family environment, and their families are indirectly affected by the negative effects of this care. Therefore, strengthening management approaches to eliminate the inhibitor factors is essential in order to prevent nurses’ burnout or quitting while improving the quality of care provided by them.

1. Introduction

Chronic kidney disease (CKD) includes a spectrum of various pathologic processes that can lead to irreversible reduction of renal function [ 1 ]. The prevalence of chronic kidney disease is increasing in the world [ 2 ]; the average global growth rate of this disease was 8% per year in the past five years. In Iran, this growth is higher than the global average and is about 12% [ 3 ]. Many patients with end-stage kidney disease (ESKD) cannot get kidney transplants and undergo hemodialysis for many years [ 4 ]. Since the first hemodialysis in humans by Hess in 1924, it is still considered the most important treatment for these patients [ 5 ]. In 2009, 92.9% of patients in the United States underwent hemodialysis [ 6 ]. In Iran, hemodialysis is the most common treatment for renal failure, and 50% of patients are treated with this method [ 7 ]. Although, hemodialysis reduces the disease symptoms and improves patients’ lifestyle, their quality of life is affected by the disease and its complications that lead to disability [ 8 ]. Meanwhile, hemodialysis imposes great stress on the patient, and patients undergoing it usually experience higher levels of psychological than physical stress [ 9 ]. Hemodialysis, therefore, requires specialized nursing care, including establishment of a therapeutic and interpersonal relationship, treatment of physical symptoms, and attention to the functional limitations, mental disorders, and educational needs of these patients [ 5 ]. Basically, nurses are the main people who provide care for these patients, and their most important responsibility is to identify the essential care of these patients [ 10 ]. Hemodialysis patients need mental support to adapt to their current status, and nurses can help them become accustomed to their problems and fears of the disease by reducing anxiety, enhancing adaptability, supporting decision making, and providing emotional support and education [ 11 ]. Therefore, nurses’ awareness of high quality of care can affect the care of these patients and increase patients’ satisfaction; notably, the quality of the provided nursing care is an important indicator of nurses’ involvement in the care program [ 9 ]. Shafipour reported in their qualitative study that patients receive comfort from humans more than environment and modern facilities [ 12 ]. This issue reflects the important role of nursing and human nursing in contrast to the need for technical nursing and modern specialized facilities [ 8 ]. Sometimes, however, nursing care lacks the necessary adequacy and safety of patients. Future studies should therefore aim to clarify the dimensions of nursing care plan and place the nursing care structure into standard care [ 13 ]. This, of course, requires identification of barriers to nursing care, as working in hemodialysis unit makes many nurses exhausted due to factors such as heavy workload and lack of resources [ 5 ]. Although nephrology nurses play an important role in determining the adequacy and quality of care in hemodialysis patients, few studies in Asia have examined the quality of nursing care. Meanwhile, adequacy of the provided care is assessed by quantitative measures rather than qualitative ones, while qualitative studies provide the best tool for understanding human experiences and is more appropriate for assessing the experiences and views of a group of people on a particular topic [ 9 ]. Qualitative research is based on the hypothesis that there is a dynamic truth and proposes a perspective for searching and understanding human elements that cannot be measured through quantitative research methods [ 14 ]. Therefore, considering the importance of the quality of nursing care and understanding deep experiences of nurses, as well as the literature review that indicated few studies on experiences of hemodialysis patients, this study aimed to describe the living experiences of nurses in hemodialysis care.

2. Experimental Section

This study was reported according to COREQ guideline [ 15 ]. This qualitative research used descriptive phenomenology with a Colaizzi approach. Descriptive phenomenology is a method for analyzing and describing specific phenomena free of any pre-judgment that shapes an understanding of living experiences at the time of attention and focuses on the richness, breadth, and depth of these experiences [ 16 ].

In this study, the research environment is the Hemodialysis Department of Amiralmomenin Hospital in Zabol, which was selected due to the cooperation of the relevant authorities and easier access to the research units. To select participants, purposive sampling began and continued until data saturation. In qualitative research, data saturation determines the sample size in phenomenology research [ 17 ]. The criterion for selecting nurses that participated in this study was having a bachelor’s degree and at least one year of work experience in hemodialysis department. The main data collection method in this study was semi-structured interviews. Open questions such as “Please describe the care you provide for hemodialysis patient during your work?” and “Define the memories you remember about this?” were used as interview guide question that were earlier tested on two persons as pilot. Interview is considered as the main method of data collection in phenomenological research and provides a situation for participants to describe their views on the world as they have experienced in their own language and vocabulary [ 17 ]. The interviewers (H.S. and M.R) had a lot of experience in qualitative research on spiritual care and conducted face to face interviews individually in one of the rooms of the hemodialysis units in a quiet environment. The duration of each interview was 45 min to 1 h in one or two sessions depending on the free time and the patience of the nurse, using audio recorder device. In total, until data saturation, nine participants were interviewed. The interviews were conducted in January 2017. All the selected nurses participated in interviews. The authors tried to maximize the diversity of participants (in terms of work history, age, gender, and marital status). All interviews were recorded and then handwritten immediately for analysis. Usually, those who work with descriptive phenomenological methods use Colaizzi technique for data analysis [ 16 ]. The seven-step Colaizzi technique involves studying participants’ descriptions in order to understand them, extracting the important sentences, formulating known meanings, categorizing the data, compiling results in the form of a comprehensive description, a clear statement of the basic structure of the studied phenomenon, and a final validation of the findings [ 14 ]. The same approach was used to analyze the data in this study. During this study, methods used to ensure the accuracy and robustness of data, including credibility, transferability, dependability, and confirmability, were considered as scientific accuracy criteria in qualitative research [ 14 ]. In order to confirm the findings’ acceptability, the researcher involved the research subject extensively, and the research findings were reviewed by the participants and other colleagues for approval. To confirm the transferability of the findings, the authors tried to use nurses with different demographic characteristics and different experiences. To confirm the coherence, the research findings were provided to another researcher who was not involved in this research, and his conclusions were compared with that of the study researcher. For confirmability, the findings were commonly evaluated by three faculty members and the researcher tried not to interfere with the assumptions in the process of data collection and analysis, as much as possible.

This study was approved by the University’s Ethics Committee (code: Zbmu.1.REC.1396.209). Before beginning the study, the consent of relevant authorities was obtained. At the beginning of the interview, the research objectives and the interview method were explained to the participants, and they were ensured about the confidentiality of their information and their choice to participate in the study. Then, informed consent was obtained from them. The interview time was adjusted based on the coordination and willingness of the participant so that it would not interfere with their daily schedules. MAXQDA 12 (VERBI Software Sozialforschung GmbH, Berlin, Germany) was used for data management.

The demographic characteristics of the participants are presented in Table 1 . Analysis of the data obtained from nurses regarding hemodialysis patient care led to the extraction of two main categories and four sub-class, including mutual factors effective on care (care inhibitors and facilitators) and care outcomes (negative effects of care on the nurse and positive effects of care on the patient), and “challenging care” was identified as the main theme ( Table 2 ).

Demographic characteristics of participants (nurses in hemodialysis department).

Main theme, main classes, and subclasses derived from data.

3.1. Mutual Factors Affecting Care

Nurses encounter two factors when caring for hemodialysis patients, which includes “care inhibitors” and “care facilitators”.

3.2. Care Inhibitors

Nurses’ experience in the hemodialysis department showed that they had many inhibitory factors in the process of providing care to patients. Some of them were related to nurses (shortage of nurses, nurses’ financial and family problems, inexperienced nurses, nurses’ fatigue and mental stresses, and heavy work shifts), while some factors were related to patients (patient’s emotional sensitivity and difficulty in attracting patients’ trust), and some factors were due to poor management (inadequate ventilation of the department, lack of equipment technician, shortage of devices and equipment, and weak cooperation of head nurse with nurses).

“If the number of devices and nurses increase proportional to the number of patients, it can greatly affect the quality of care” (A 38-year-old woman with 10 years of work experience).

“When I first came to hemodialysis department, early in my career, the patients did not accept me and did not trust me, so they did not let me do my job” (A 29-year-old woman with 2.5 years of work experience).

“The nurse’s experience has a positive effect on dialysis patients. For example, once an inexperienced nurse enters, she wants to detach the patient from the machine, and the patient needs resuscitation” (A 40-year-old woman with 18.5 years of work experience).

3.3. Care Facilitators

“Assessing nurses’ experience revealed that some factors can help in care of hemodialysis patients, including nurse’s experience, the emotional relationship between the nurse and patient, nurse’s high educational level, and a safe environment” (A 35-year-old woman with 10 years of work experience).

“I can gain my patient’s satisfaction by creating a safe and secure environment, and a close relationship with the patient” (A 38-years-old man with eight years of work experience).

“We need to raise our literacy level, provide training and retraining courses for care of dialysis patients, which has a great influence on perfect and high-quality care of these patients” (A 38-year-old man with eight years of work experience).

3.4. Mutual Care Outcomes

Nurses’ experience in hemodialysis department showed that there were pleasant and unpleasant outcomes, including “negative effects of care on the nurse” and “positive effects of care on the patient”.

3.5. The Negative Effects of Care on the Nurse

The experiences expressed by nurses suggest that taking care of hemodialysis patients is associated with negative personal effects (facing physical damages), mental effect (misconduct, bad temper), feelings of burnout, obsessive thoughts regarding health, feelings of depression and anxiety, tendency to leave the department, and negative family effects (neglecting children, inability to meet spouse’s needs, inability to perform housekeeping duties, and interference of professional with family responsibilities).

“We have a lot of work pressure in this department which makes us feel tired and angry; when I go home, I do not pay enough attention to my children, I cannot meet the needs of my spouse, and I have less patience in my housekeeping duties” (A 38-year-old woman with 10 years of work experience).

“Because we are dealing with patients’ blood in hemodialysis and take care of patients with hepatitis, we should be careful not to get needle stick” (A 38-year-old woman with 14 years of work experience).

“When I came to this department and saw the problems of these patients, I lost my mood and I feel I’m getting depressed” (A 27-year-old woman with four years of work experience).

3.6. Positive Effects of Care on the Patient

Examining nurses’ experiences showed the positive effects of care provided by nurses on patients including routine care (care before, during and after dialysis; education; referral), reduction of physical problems, reduction of complications, improvement of the patient’s mental state and sense of safety, increase in the patient’s life expectancy, and interdependencies between the patient and nurse.

“When we take good care of patients, it affects their general condition and makes them feel safer” (A 29-year-old woman with 2.5 years of work experience).

“When you take care of patients well, it has a great impact on their physical condition and reduction of complications, and even the patients’ mood” (A 27-year-old woman with four years of work experience).

“Our nursing care offers joy and life expectancy to patients” (A 32-year-old woman with four years of work experience).

4. Discussion

Nurses’ experience in hemodialysis department showed that this care was influenced by mutual factors, some of which were “inhibitors” and some “facilitators”, and the care outcomes included “positive effects of care on the patient” and “negative effects of care on the nurse”. This section discusses the research findings.

In the present study, several factors were identified as care inhibitors; some were related to nurses and patients, and some were related to management failure. Several studies have suggested these inhibitory factors. Namnabati pointed to inadequate nursing skills as one of the care challenges [ 18 ], Ebadi referred to the shortage of nurses in Iran as a serious challenge [ 19 ], and Novoboar pointed at the end of their study that the shortage of nurses and lack of staffing, called nurse assistance, are inhibitory factors in the care of hemodialysis patients [ 20 ]. Masoumi referred to heavy workloads, various job shifts, and lack of mental support as nurses’ stressors, which reduced the quality of patients’ care [ 21 ]. Ndambuki also emphasized that hospitals should increase the number of nurses and their devices in order to maintain the level of satisfaction in renal patients [ 22 ]. Dehghan Naiery mentioned in their research that providing adequate nursing staff and equipment are important factors in the prevention of missed nursing care that refers to undone and delayed care [ 23 ].

It was shown that high levels of nurse’s experience, the emotional relationship between the nurse and patient, high educational level of the nurse, and safe environment can facilitate care. Several studies have identified these facilitators. Confirming the importance of the emotional relationship between the nurse and patient, Zamanzadeh referred to compassionate care as the constructive interaction between the nurse and patient, during which the nurse places himself in the patient’s shoes and understands his circumstances, to discover his concerns [ 24 ]. Moreover, Atashzadeh and colleagues identified meeting the patients’ needs through communication, support, and mutual respect between the nurse and the patient as purposeful care [ 25 ], and Baljani declared, as a result of their study, that in order to meet the patients’ needs, it is necessary to emphasize the emotional and social aspects of care in nursing education and planning [ 26 ]. Moran, in their study on the need for increasing nurses’ awareness, pointed out the importance of effective communication in providing supportive care for renal patients [ 27 ]. Confirming the importance of the nurse’s work experience, Mohammadi declared that more experienced people in the workplace can have a stronger supportive role than other people in therapeutic team, especially those with low experience [ 28 ], and regarding the need for a safe healthcare environment, Nobahar in their qualitative study aimed at explaining the experiences of patients, nurses, caregivers, and doctors in hemodialysis department in the quality of nursing care mentioned environment as one of the important factors in this regard [ 9 ]. Mahdavi Shahri also suggested that the quality of care can improve through environmental monitoring and creating a pleasant environment with the least stress possible [ 29 ].

Confirming the importance of educational level of the nurse, Nobahar named nurses’ basic knowledge as a facilitator of hemodialysis patient care [ 20 ]. As a result of their study, Berzou also identified nurses’ knowledge as an effective factor in providing patient’s comfort during hemodialysis [ 30 ].

In the present study, the nurses stated that providing care in hemodialysis department has negative personal effects, including physical and mental harm. Confirming this conclusion, Naidoo stated that intensive care unit nurses need to provide care and give physical and psychological support [ 31 ]. Depression was another experience of the nurses in the present study. Kazemi Golghahi also suggested that the prevalence of depression was significantly higher in the studied nurses than the general population. They concluded that as far as nurses are at high levels of stress and severe workload, planning for reducing the prevalence of depression plays an important role in patients’ health [ 32 ]. Also, Letvak reported that the prevalence of depression was higher than normal in the studied nurses [ 33 ]. Feeling exhaustion was another experience of nurses in the present study. Covermasi reported a moderate level of burnout among nurses in the hemodialysis department in their study [ 34 ]. Negative family effects included negative job effects of the studied nurses. Tavangar also confirmed these negative job effects in their study. Nurses, while being familiar with various forms of work/family conflicts, should learn methods to confront them in order to minimize their negative consequences [ 35 ].

The experience of nurses showed that the outcome of the care provided by them was positive for patients. Confirming this conclusion, Castner reported that nephrology nurses can be effective in reducing patients’ problems by performing interventions before, during and after dialysis [ 36 ]. Khoieniha also emphasized that nurses are the largest occupational healthcare group with a significant potential for influencing the quality of healthcare services [ 37 ]. Asgari suggested in their qualitative research that, from the perspective of hemodialysis patients, appropriate nurses’ supportive behavior plays an important role in feelings of relaxing and comfort, safety and confidence, and speeds up adaptation to hemodialysis [ 38 ]. The interdependence between the patient and the nurse was one of the findings of this study, but it is contrast to the results of Moran on hemodialysis patients who were not satisfied with nurses’ communication and stated that nurses rarely communicated with them and mainly paid attention to the physical and technical aspects of care [ 27 ]. The differences in the research environments and cultural differences may play a role in this difference.

5. Conclusions

The experience of nurses that participated in this study provided a clear picture of the care provided in the hemodialysis department of Amir al-Momenin Hospital in Zabol and clarified that the care provided by these nurses was a challenging one, which is influenced by mutual factors, some of which are inhibitors and some facilitators. The mutual influence of these factors prevents the care outcome from being completely positive. In addition to reducing the physical and psychological problems of patients and increasing their sense of safety and hope, which leads to a sense of dependency between patients and nurses, the caring nurses suffered many physical and mental harms, and this damage even extends to their family environment: their family members were also indirectly affected the negative effects of this care. Therefore, strengthening managerial approaches toward eliminating the inhibitory factors by addressing deficiencies (shortage of manpower, eliminating department’s shortages, and providing them with new equipment) can help resolve nurses’ problems, and increasing nurses’ knowledge and experience in communication with hemodialysis patients seems necessary to resolve the challenges in the care of hemodialysis patients in order to improve the quality of care provided by nurses and prevent burnout.

Author Contributions

H.S. and M.R. designed the experiments; H.S. performed the interview; H.S. analyzed the data; M.R. wrote the paper.

Conflicts of Interest

The authors declare no conflict of interest.

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Mental health and its influencing factors of maintenance hemodialysis patients: a semi-structured interview study

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MHD patients’ mental health and its influencing factors

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The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study

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Emotional support

Accompaniment in meeting daily needs

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