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Empowerment intervention in outpatient care of persons with chronic kidney disease pre-dialysis.

Goal

To provide an overview of how nephrology nurses can empower outpatients with chronic kidney disease pre-dialysis.

Objectives

1. Define empowerment.

2. Explain the benefits of outpatient empowerment as it relates to individuals with chronic kidney disease pre-dialysis.

3. Discuss interventions by healthcare professionals that can potentially increase outpatient empowerment in individuals with chronic kidney disease.

The incidence and prevalence of chronic kidney disease (CKD) are increasing worldwide. CKD is a progressive disease with an unpredictable trajectory. Living with CKD involves changes in lifestyle over time, and therefore, patients need to manage both the physical and psychological symptoms that are integral to having this disease (Ekelund & Andersson, 2007; Thomas-Hawkins & Zazworsky, 2005). In the early stages, vague physical symptoms obstruct patients' understanding and acceptance of the diagnosis (Thomas-Hawkins & Zazworsky, 2005; Tong et al., 2009). Patients' experiences of CKD are associated with vulnerability and a sense of powerlessness in the face of what seems to be an uncontrollable situation.

A review by the World Health Organization revealed evidence that empowerment strategies in health care have a beneficial impact on health outcomes in chronically ill persons (for example, persons with diabetes) (Wallerstein, 2006) and chronic renal disease (Tsay & Hung, 2004). In nursing, Gibson (1991) defines empowerment as a process that implies mobilization and enhancement of individuals' own resources to enable them to feel in control of their life, meet their own needs, and solve their own problems. Supporting relationships between individuals with a disease and staff can result in a sense of control that is grounded in patients' ability to cope with problems associated with their illnesses and life situations; education facilitates this (Holmstrom & Roing, 2010). Empowering interactions between individuals who are ill and their environment is important because it increases patients' ability to cope with their situation, and thus, their experience of control (Gutierrez, 1994).

Empowerment, often a professional construct (Aujoulat, d'Hoore, & Deccache, 2007), is best described by the individual it concerns (Rappaport, 1984). A previous qualitative study (Nygardh, Malm, Wikby, & Ahlstrom, 2012) concerning the empowerment of outpatients with CKD has illuminated the process of creating trust and learning through encounters with healthcare staff. The researchers found that trust and learning require accessibility to healthcare staff, a sense of security, and a feeling of being treated with respect. Through mutual learning between individuals with CKD and staff, patients acquired a greater understanding of their disease--an understanding that is essential to appropriate preparation for the future. Further, focusing on the patient's needs is a condition that allows for the patient to achieve empowerment (Aujoulat et al., 2007).

Historically, the health care of persons with disease has included rapid solutions and a perspective of the person's role as mostly passive and unimportant (Wagner et al., 2001). Today, a criterion of high-quality patient care (Berwick, 2002; Swedish National Board of Health and Welfare, 2006) is person-centered, emphasizing that the ill person has strengths and rights. Healthcare planning should take into account the patient's own plans (Ekman et al., 2011). However, paternalistic approaches still occur in health care (Anderson & Funnell, 2005; Colombo, Moja, Gonzalez-Lorenzo, Liberati, & Mosconi, 2012). Adopting the perspective that patient empowerment is a desirable feature of healthcare encounters may change the way healthcare professionals work and can result in improvement in the quality of care of outpatients with CKD (Bate & Robert, 2006).

Interactive research, which has developed from action research, is defined as constant and mutual learning through the interplay between research and practice during the research process (Aagaard Nielsen & Svensson, 2006). Interactive research is a frequently used strategy for implementing research aimed at improving health care, which has accomplished sustainable improvements in the quality of health care (Munten, van den Bogaard, Cox, Garretsen, & Bongers, 2010; Schmittdiel, Grumbach, & Selby, 2010). However, only a few studies have reported outcomes from the perspective of the ill person.

Staff members initiated this study with the objective of changing their work practices to attain better outcomes for persons with CKD. They asked whether clinically apparent improvements in empowerment would have an impact on outcomes for patients. Another rationale for this study was the scarcity of published reports concerning improvements in empowerment in patients with CKD. The hypothesis of this study was that improvement in quality of care would significantly increase a person's sense of empowerment (based on Gibson's definition). Therefore, the aim of this study was to evaluate improvement in the quality of care as a consequence of empowering interactions between healthcare staff and outpatients with CKD who were pre-dialysis. An additional aim was to study the influence of the demographic variables on their empowerment.

Methodology

Design

This study was a comparative pre- and post-evaluation of an intervention involving improvement in the quality of health care directed at increasing empowerment of individuals with CKD. The outcomes in the intervention group at the clinic that initiated quality improvement at the beginning of the study and after two years were compared to the outcomes of persons with CKD from similar clinics in two other hospitals as controls. In the comparison clinics, staff members worked according to their usual routines, which did not involve improvement in the quality of interactions.

Intervention to Improve Quality of Care and Empowerment

The quality improvement work was performed according to methods of interactive research. After repeated meetings and conversations between researchers, clinical management, and some staff members in the care unit, it was decided to initiate a project and assemble a group with responsibility for the quality improvement work. As a baseline and a source of inspiration for planning the intervention, before designing the intervention, the first author (AN) interviewed persons with CKD attending the intervention clinic regarding their experiences of empowerment (Nygardh et al., 2012). This author shared preliminary results from these interviews with the project group, and these results subsequently constituted the basis of the quality improvement work. To create an environment that would enable increased empowerment of persons with CKD, this intervention involved both staff members and persons with CKD (Batalden & Davidoff, 2007).

The intervention was performed in six steps over a period of two years. First, the lead author conducted two half-day learning seminars regarding the results of the preliminary interviews about the experiences of empowerment through the outpatient care of persons with CKD. To facilitate participation of all staff members, two additional lunch meetings were held with the physicians in the division because of difficulties in finding suitable times for all participants. Second, based on preliminary interview results and additional reading of an anthology (Thorsson, Ford, & Qulturum, 2011)describing one person's experiences of health care, a joint value-system that described how to give high-quality care in the chronic kidney care unit was created. This was formulated into a half-day workshop for all staff members, together with one representative from the hospital's Ethics Board. Third, to increase the competence of the healthcare staff working with improved quality of care, staff were trained in quality improvement science (Batalden & Davidoff, 2007). Staff members were divided into four groups that participated in training one group at a time. Facilitators from a local center for improvement of knowledge in the hospital carried out the training once a month for four months. Fourth, to introduce additional information about empowerment, one experienced researcher conducted two workshops on empowerment from the perspective of persons with a disease and from the perspective of health professionals (Wathlin, Ek, & Idvall, 2006, 2009). Fifth, to facilitate experiences of empowerment for persons with CKD, learning opportunities were created and designed to complement the general education. This was achieved by arranging four learning meetings (larcafe) moderated by a nurse from the outpatient reception. This approach, which has been used previously to educate persons with other chronic diseases (Hagberth, Sjoberg, & Ivarsson, 2008), involves person-controlled education (Vifladt & Hopen, 2004) and puts the emphasis on the person's own questions and experiences in patient education. Sixth, two staff members who had been trained to supervise reflection groups conducted four reflection meetings. Each reflection meeting focused on case stories of patients' experiences of empowerment. Staff members from three different units--the medical CKD ward, outpatient reception, and dialysis unit--attended these meetings.

Sample

A cluster sampling was applied for both the intervention and comparison groups (Shadish, Cook, & Campbell, 2002). The sample procedure started with the selection of individuals who lived in a southern county of Sweden and who were in the national register of patients with CKD (Swedish Renal Registry, 2009). The inclusion criteria were persons in the pre-dialysis phase who had not received kidney transplants and were attending one of the three outpatient care units. At the start, 116 persons did not respond, and between the baseline and follow-up assessments, an additional 36 persons dropped out. In the intervention group, 84 persons were invited to participate; 25 of them did so. For the comparison group, 114 persons who were eligible according to the inclusion criteria were invited to participate; 21 people did so. There were no significant differences in relevant patient variables or baseline scores between nonresponders (n = 116) and those who dropped out (n = 36) compared with those who remained in the study (n = 46).

Data Collection

Individuals who fulfilled the inclusion criteria were contacted individually by telephone. After giving them information about what participation would involve, they were asked about their willingness to participate. Those who agreed to participate received a letter by mail that included information about the study, contact information, a document for written informed consent, and four questionnaires to answer. The Research Ethics Committee of Linkoping University in Sweden approved the study. Data were collected for the baseline in February 2009 and follow up in February 2011.

Questionnaires

Demographic questionnaire. The participants were asked to indicate their sex, age, marital status, education level, duration of disease (CKD), employment status, and self-reported health status (EQ-5D) (Brooks, 1996).

Swedish Version of the Diabetes Empowerment Scale. The Swedish version (SWE-DES-23) (Leksell et al., 2007) of the American Diabetes Empowerment Scale (USDES) (Anderson, Funnell, Fitzgerald, & Marrero, 2000) contains 23 statements concerning the following four subscales of empowerment: identification of problems and problem-solving (10 items), self-awareness (4 items), stress management (4 items), and willingness to change (5 items). The respondents answered the items on a five-point Likert scale ranging from 5 (agree entirely) to 1 (definitely do not agree). Higher mean values indicate stronger empowerment. The US-DES has previously been used to measure empowerment in patients with CKD (Cronbach's alpha = 0.93) (Tsay & Hung, 2004). The Swedish version has been validated (Cronbach's alpha coefficient = 0.86 [Anderson et al., 2000] and 0.90 in the current study).

Ways of Coping Questionnaire-Swedish Version. The Ways of Coping Questionnaire-Swedish version (WCQ-S) (Lazarus, 1993; Lundqvist & Ahlstrom, 2006) was used to further assess the stress management aspect of empowerment. This questionnaire measures the thoughts and actions that an individual uses to manage stressful situations. The revised WCQ-S has 45 statements divided into the following eight scales: confrontive coping (6 items), distancing (6 items), self-controlling (7 items), seeking social support (6 items), accepting responsibility (4 items), escape/avoidance (8 items), planful problem solving (6 items), and positive reappraisal (7 items). The respondents answered the items on a 4-point Likert scale to indicate the extent to which they use each strategy. The options were from 0 (does not apply or not used) to 3 (used a great deal), and the scores of index were calculated as the mean. The Swedish version has been used in several studies (Ahlstrom & Wenneberg, 2002; Gustafsson & Ahlstrom, 2006). The WCQ-S total score has good internal consistency (Cronbach's alpha coefficient = 0.86 [Lundqvist & Ahlstrom, 2006] and 0.91 in the current study).

Individualized Care Scale. The Individualized Care Scale (ICS) (Suhonen, Leino Kilpi, & Valimaki, 2005) measures a person's perspectives on individualized care. The questionnaire consists of 34 statements divided into two sections: the ICS-A and ICS-B. The ICS-A assesses the person's perspective on how specific nursing interventions support and promote individuality; the ICS-B assesses how persons perceive individuality in the care they receive. The ICS-A and ICS-B have the same subscales; clinical situations (7 items), personal life situation (4 items), and decisional control over care (6 items). The participants evaluated their individual care on a Likert scale from 1 (absolutely do not agree [worst]) to 5 (agree absolutely [best]). The ICS-A and ICS-B have good internal consistency (Cronbach's alpha coefficient = 0.94 and 0.93 [Berg, Suhonen, & Idvall, 2007]); in the current study the Cronbach's alpha coefficient ICS-A was 0.91 and the ICS-B was 0.93.

Statistical Analysis

The mean values for all indexes and the total scale were used for the summation of the scores in each instrument. The Pearson Chi-Square Test was used to calculate the difference between demographic variables. For values of less than 5, Fisher's Exact Test was used. The Mann-Whitney U-Test was used to test differences in index scores between the groups. To test within groups, the Wilcoxon Signed-Rank Test was used on indexes and items. Spearman's rho was used to assess correlations of patient variables and significant indexes. Accepted internal consistency of Cronbach's alpha was considered to be 0.70 or higher (Brace, Kemp, & Snelgar, 2009). Data were analyzed with SPSS 19.0 (SPSS, Chicago, IL, USA). The level of significance was set at p < 0.05.

Results

Most aspects of the baseline participant variables were similar in the two groups. Exceptions were that significantly more persons were living alone in the intervention group than in the comparison group, and significandy more persons in the intervention group than in the comparison group had no problem with usual activities. However, group analyses at follow up showed that significantly more persons in the intervention group than in the comparison group had significantly more problems with usual activities, pain, or/and discomfort. Similarly, in the intervention group, the EQ-5D index had a significantly lower mean value at follow up than at baseline. No equivalent significant differences were found in the comparison group (see Table 1).

First, the analysis was performed at index level in the three questionnaires. In the SWE-DES-23, there were no significant differences between or within the intervention and comparison groups. However, at follow up, there was a trend toward higher scores in the intervention group than in the comparison group.

As shown in Table 2, the only differences between groups was in the ICS-A in which personal life situation scores were significantly higher in the intervention group than in the comparison group. When comparing baseline with follow-up scores, only within-group differences were found in the intervention group. At follow up, the intervention group scored significantly higher on escape-avoidance, which included wishful thinking and efforts to avoid the problem. They also felt significantly more support for individuality (ICS-A) by staff members, and had significantly higher scores on personal life situation (ICS-A and ICS-B) and decisional control over care (ICS-A).

Second, deeper analysis at item level showed that the intervention group had mostly significant differences in follow-up scores than the comparison group (see Table 3). However, participants in the intervention group scored the following item significantly lower at follow up: "I have followed the instructions received in care." In the comparison group, there were significantly lower scores for the item "I change myself in some ways."

There were significant correlations between the index level and some patient variables. In the intervention group, both the WCQ-S index of escape-avoidance ([r.sub.s] = -0.48, p < 0.05) and the ICS-A index of decisional control over care correlated moderately with pain/discomfort ([r.sub.s] = 0.47, p = < 0.05). In the comparison group, significant correlations were found between escape-avoidance and usual activities ([r.sub.s] = -0.61, p < 0.01) and between ICS-B personal life situation and anxiety/depression ([r.sub.s] = 0.69, p < 0.01).

Discussion

Results of this study verify the hypothesis that improvement in quality of care significantly increases a person's sense of empowerment, mainly regarding individualized care. At follow up, several significant changes noted in the intervention group had not occurred in the comparison group. In addition, there was a significantly higher score in the personal life situation index in the intervention group compared with the comparison group at follow up. In the intervention group, items relating to problem-focused coping, and the identification of problems and problem solutions, scored significantly higher than in the comparison group. Further, the intervention group felt more supported by interventions by staff members; in particular, regarding individuality in total and in healthcare decisions. They also perceived that healthcare staff considered their personal life situation significantly more than the comparison group.

Individualized care or person-centered care is an important dimension of quality care according to the Swedish National Board of Health and Welfare (2006). Valuation and evaluation are prerequisites for making person-centered care meaningful. One way to emphasize person-centered care is to acknowledge a person's empowerment during healthcare encounters (Holmstrom & Roing, 2010). In the 21st century, healthcare staff members are expected to empower persons with disease by offering person-centered care in accordance with the sick person's priorities. Moreover, staff members need to base their practices on evidence (Berwick, 2002)

In this study, quality of care focused on empowering persons with CKD and on evidence-based interventions to drive desired changes in healthcare encounters. Published studies have described focus on outcomes and evidence-based interventions as one of the core characteristics for successful implementation of improvement in quality of care (Ayers et al., 2005). However, it can be challenging for staff members to collectively conduct healthcare encounters in ways that are perceived as empowering by all persons with CKD. This is because the hierarchical and paternalistic tradition of healthcare organizations (Colombo et al., 2012; Goodyear-Smith & Buetow, 2001; Houston & Cowley, 2002) works against the development of empowering relationships between staff members and patients (Rappaport, 1987). Although staff members initiated the quality improvement interventions in this study, the power of the dominant organizational culture may still have an impact on their ability to change current habits and routines (Chassin & Loeb, 2011; Rycroft-Malone, Kitson et al., 2002).

Although researchers have reported inconsistencies between desired and successful quality improvement interventions in health care (Ovretveit, 2011; Scott, 2009), the interventions in this study were fully and successfully implemented. The main reason for this lies in the interactive research approach that was used, which both staff and persons with CKD experienced as positive because of the learning context it created in the clinic. Although the staff at the intervention clinic had no previous experience of systematically working with quality of care, they continued to do so after completion of this evaluation study. This indicates the need for longitudinal follow up to investigate which conditions are required for such improvement to be sustainable. The current results add evidence for factors that may promote further improvement, namely strong staff motivation for quality of care when they adopt the perspective of persons with CKD, facilitation through an interactive research approach, and appropriate contexts for accomplishing improvements in health care (Rycroft-Malone, Harvey et al., 2002).

At follow up, significantly lower scores for self-reported health status (EQ-5D-index) were found in the intervention group. In a recent study, Rohrer, Wilshusen, Adamson, and Merry (2008) found that persons who scored their health status as satisfied also reported high empowerment. However, in the intervention group in the current study, higher empowerment scores were associated with decreased scores for health status. Empowerment is defined individually and can be assessed directly by asking persons with CKD whether they feel as though they are in control of their own situation (Gibson, 1991 ; Rappaport, 1984; Rohrer et al., 2008).

It is unclear as to why, of the coping strategies, only escape-avoidance increased in the intervention group during the current study. One possible explanation is that the patients were unable to cope with experiencing more and worsening symptoms associated with their disease. Therefore, when working to improve quality of care, staff need to have insight into, and sympathetic understanding of, the patient's ability to cope with his or her life situation as the illness trajectory progresses.

Ideally, intervention research provides long-term follow-up data. However, such data are difficult to acquire because of the loss of participants through attrition (Shadish et al., 2002), which is in part related to participants' frailty. Since patients in the current study were selected from the region in the National Register of persons with CKD and their participation was voluntary, it was not possible to increase the sample size after the study had started. Low statistical power may contribute to false conclusions about improvement in quality of care regarding empowerment and its impact on the outcomes of persons with CKD (such as Type II error) (Brace et al., 2009). To increase the statistical power, a comparison cluster by aggregating two similar but distant hospitals was constructed into one group to compare with the intervention group. It is difficult to assess the influence of low power on results because there were no significant differences between non-responders and the two study groups in the available individual variables. There were no significant differences in baseline scores between dropouts and study group participants. In addition, baseline and follow-up measurements were performed at the same time in both groups to increase the internal validity. Further, the geographical separation of the three hospitals may have decreased the diffusion of the intervention (Shadish et al., 2002).

Results of the statistical methods used in this study were reported as mean values and standard deviations to facilitate comparison with the results of other published studies. Calculating median value and percentiles in this study did not change the results of the current study. Measurements in this study were selected to operationalize Gibson's (1991) definition of empowerment and psychometric properties. Hence, a maximum of 5 points in the Likert scales in the questionnaires may have made them less sensitive (for example, ceiling or floor effects) to identifying group differences. A broader range of scores is necessary to achieve high sensitivity in the measurement of changes (Kazdin, 2003). However, few questionnaires are available for measuring empowerment in persons with CKD, which makes it difficult to know how sensitive measures are due to limited longitudinal psychometric tests of questionnaires.

Conclusions

The results of this study show that interventions to improve the quality of care have had a significant impact on the empowerment of persons with CKD regarding support of individuality, personal life situation, and decisional control. The results give an impetus to facilitating improvements in quality care and the interactive research approach to promote sustainable implementation of strategies that empower persons with disease. Further research is needed to evaluate intervention studies of empowerment and to conduct longitudinal evaluations. Moreover, the nurse's leadership and significance as facilitator for improved health care in short- and in long-term must be explored in future studies.

[ILLUSTRATION OMITTED]

This offering for 1.4 contact hours is provided by the American Nephrology Nurses' Association (ANNA).

American Nephrology Nurses' Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Comission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.

This ONE article meets the Nephrotogy Nursing Certification Commission's (NNCO's) continuing nursing education requirements for certification and recertification.

Acknowledgments: The authors gratefully acknowledge the financial support of Vinnvard, administrated by School of Health Sciences, Jonkoping, Sweden, and Jonkoping County Council, Sweden.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

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Annette Nygardh, RN, is a Doctoral Student, Jonkoping University, School of Health Sciences, Jonkoping, Sweden. The author may be contacted directly via e-mail at annette.nygardh@hhj.hj.se

Dan Malm, PkD, RN, is a Senior Lecturer, Jonkoping University, School of Health Sciences, Jonkoping, Sweden.

Kerstin Wikby, PkD, RN, is a Senior Lecturer, Linneus University, Vaxjo, Sweden.

Gerd Ahlstrom, PhD, R,N, is Professor, and Director, Swedish Institute for Health Sciences, Department of Health Sciences, Lund University, Lund, Sweden.
Table 1
Participant Characteristics in the Two Study Groups (n = 46)

                           Intervention Group (n = 25)

Variables                  Baseline      Follow Up            P
                           n (%,)         n (%)               (Within
                                                              Group)
Gender
  Male                     19 (76)
  Female                   6 (24)
Age
  65 years or younger      10 (40)       9 (36)
  Over 65 years            15 (60)       16 (64)
Marital Status
  Married/living with      16 (64)       16 (64)
  someone
  Living alone             9 (36)        8 (32)
                                         ([dagger])
Education
  Compulsory school        9 (36)
  Upper secondary school   7 (28)
  University               9 (36)
Duration of CKD
  2 years or less          8 (32)
  More than 2 years        17 (68)

Employment
  Full or part-time        8 (32)        4 (16)
  Sick leave               1 (4)
  Student, seeking work    1 (4)         3 (12)
EQ-5D
Mobility
  No problems              15 (60)       13 (52)
  Some problems            10 (40)       11 (44)
                                         ([dagger])
  Confined to bed
Self-Care
  No problems              24 (96)       22 (88)
  Some problems            1 (4)         2 (8)
                                         ([dagger])
  Usual Activities
No problems                24 (96)       10 (40)
  Some problems                          13 (52)              0.000
  Unable to perform        1 (4)         1 (4)
  usual activities                       ([dagger])
Pain/Discomfort
  None                     12 (48)       8 (32)
  Moderate                 13 (52)       14 (56)
  Extreme                                2 (8)                0.025
                                         ([dagger])
Anxiety/Depression
  None                     18 (72)       17 (68)
  Moderate                 7 (28)        7(28)
                                         ([dagger])
EQ-5DVAS Mean (SD)         72.7 (19.6)   62.8 (18.1)
                                         ([dagger, dagger])
EQ-5D Index Mean (SD)      0.82 (0.19)   0.71 (0.23)          0.038
                                         ([dagger])

                           Comparison Group (n = 21)

Variables                  Baseline      Follow Up    P
                           n (%)         n (%)        (Within
                                                      Group)
Gender
  Male                     14 (67)
  Female                   7 (33)
Age
  65 years or younger      12 (57)       7 (33)
  Over 65 years            9 (43)        14 (67)
Marital Status
  Married/living with      19 (90)       19 (90)
  someone
  Living alone             2 (10)        2 (10)

Education
  Compulsory school        10 (48)
  Upper secondary school   7 (33)
  University               4 (19)
Duration of CKD
  2 years or less          2 (10)
  More than 2 years        18 (86)
                           ([dagger])
Employment
  Full or part-time        6 (29)        3 (14)
  Sick leave               2 (9)         2 (9)
  Student, seeking work    1 (5)         1 (5)
EQ-5D
Mobility
  No problems              15 (71)       11 (52)
  Some problems            6 (29)        9 (43)

  Confined to bed                        1 (5)
Self-Care
  No problems              21 (100)      21 (100)
  Some problems

  Usual Activities
No problems                16 (76)       13 (62)
  Some problems            4 (19)        8 (38)
  Unable to perform        1 (5)
  usual activities
Pain/Discomfort
  None                     9 (43)        10 (48)
  Moderate                 11 (52)       10 (48)
  Extreme                  1 (5)         1 (4)

Anxiety/Depression
  None                     13 (62)       16 (76)
  Moderate                 8 (38)        5 (24)

EQ-5DVAS Mean (SD)         71.4 (217)    70 (19.2)
                           ([dagger])    ([dagger])
EQ-5D Index Mean (SD)      0.79 (0.21)   0.77 (23)

Variables                  P
                           (Between
                           Groups)
Gender
  Male
  Female
Age
  65 years or younger
  Over 65 years
Marital Status
  Married/living with
  someone
  Living alone             0.045

Education
  Compulsory school
  Upper secondary school
  University
Duration of CKD
  2 years or less
  More than 2 years

Employment
  Full or part-time
  Sick leave
  Student, seeking work
EQ-5D
Mobility
  No problems
  Some problems

  Confined to bed
Self-Care
  No problems
  Some problems

  Usual Activities
No problems                0.048
  Some problems
  Unable to perform
  usual activities
Pain/Discomfort
  None
  Moderate
  Extreme

Anxiety/Depression
  None
  Moderate

EQ-5DVAS Mean (SD)

EQ-5D Index Mean (SD)

([dagger]) One missing value.

([dagger, dagger]) Two missing values.

Table 2
Significant Differences in Baseline and Follow-Up Scores of WCO-S,
ICS-A, and ICS-B Subscales

                                   Intervention Group (n = 25)
Sub-Scales                         n    Mean (SD)

WCQ-S (Scale 0 to 3)
Escape-Avoidance
  Baseline                         22   0.56 ([+ or -] 0.41)
  Follow up                        21   0.82 ([+ or -] 0.47)
ICS (Scale 1 to 5)
ICS-A
Support of individuality (ICS-A)
  Baseline                         23   3.53 ([+ or -] 0.75)
  Follow up                        20   3.98 ([+ or -] 0.60)
Personal life situation
  Baseline                         22   2.85 ([+ or -] 0.96)
  Follow up                        20   3.82 ([+ or -] 0.89)
Decisional control
  Baseline                         23   3.45 ([+ or -] 0.75)
  Follow up                        21   3.92 ([+ or -] 0.84)
ICS-8
Personal life situation
  Baseline                         20   3.58 ([+ or -] 1.00)
  Follow up                        20   3.93 ([+ or -] 1.01)

                                              Comparison
                                              Group (n = 21)
Sub-Scales                            p       n
                                   (Within
                                    Group)
WCQ-S (Scale 0 to 3)
Escape-Avoidance
  Baseline                                    18
  Follow up                         0.011     17
ICS (Scale 1 to 5)
ICS-A
Support of individuality (ICS-A)
  Baseline                                    19
  Follow up                         0.013     15
Personal life situation
  Baseline                                    19
  Follow up                         0.001     15
Decisional control
  Baseline                                    19
  Follow up                         0.019     15
ICS-8
Personal life situation
  Baseline                                    18
  Follow up                         0.030     13

                                   Comparison Group (n = 21)
Sub-Scales                         Mean (SD)                p
                                                            (Within
                                                            Group)
WCQ-S (Scale 0 to 3)
Escape-Avoidance
  Baseline                         0.77 ([+ or -] 0.61)
  Follow up                        0.80 ([+ or -] 0.65)
ICS (Scale 1 to 5)
ICS-A
Support of individuality (ICS-A)
  Baseline                         3.30 ([+ or -] 1.14)
  Follow up                        3.43 ([+ or -] 1.04)
Personal life situation
  Baseline                         2.95 ([+ or -] 1.10)
  Follow up                        3.04 ([+ or -] 1.15)
Decisional control
  Baseline                         3.21 ([+ or -] 1.11)
  Follow up                        3.43 ([+ or -] 1.14)
ICS-8
Personal life situation
  Baseline                         3.37 ([+ or -] 0.97)
  Follow up                        1 4.04 ([+ or -] 0.76)

                                   p
Sub-Scales                         (Between
                                   Groups)

WCQ-S (Scale 0 to 3)
Escape-Avoidance
  Baseline
  Follow up
ICS (Scale 1 to 5)
ICS-A
Support of individuality (ICS-A)
  Baseline
  Follow up
Personal life situation
  Baseline
  Follow up                        0.044
Decisional control
  Baseline
  Follow up
ICS-8
Personal life situation
  Baseline
  Follow up

Table 3
Significant Differences between Baseline and Follow Up at Item Level

Group of       Instrument/Index       Baseline/Follow Up
Participants   Item                   Mean (SD)

Intervention   SWE-DES-S/Goal         3.75 (1.13)/4.05 (0.84)
Group          Achievement (Scale 1
               to 5)
               In general, I can
               consider if it is
               worth the effort to
               change the way I
               take care of my
               disease.

               WCQ-S/Confrontive
               Coping (Scale 0        1_0.14(0.47)/0.62 (1.02)
               to 3)
               I direct my anger
               towards the person/
               persons who have
               caused the problem.

               WCQ-S/
               Escape-Avoidance *
               (Scale 0 to 3)

               I sleep unusually      0.73 (1.03)/1.24 (1.04)
               much.

               I mostly avoid         0.27 (0.63)/0.52 (0.68)
               associating with
               other people.

               WCQ-S/Seeking Social
               Support (Scale 0 to
               3)

               I talk to other        0.59 (1.05)/1.00 (1.08)
               people in order to
               find out more about
               the situation.

               WCQ-S/
               Self-Controlling
               (Scale 0 to 3)

               I try to make sure     1.18 (1.18)/1.57 (1.17)
               that the feelings
               caused by the
               problem do not have
               an impact on
               anything else,
               the problem must
               not take over.

               ICS-A/Personal Life
               Situation * (Scale 1
               to 5)

               Staff members have     2.50 (1.14)/3.84 (1.28)
               asked me about my
               earlier experiences
               in care.

               Staff members have     2.57 (1.50)/3.86 (0.96)
               asked me about my
               everyday habits.

               Staff members have     2.48 (1.38)/3.37 (1.54)
               asked me if I wish
               to involve family
               members in my care.

               ICS-A/Decisional
               Control over Care *
               (Scale 1 to 5)
               Staff members have     1.74 (1.10)/2.75 (1.52)
               asked me what time I
               would prefer to
               wash.

               ICS-B/Personal Life
               Situation * (Scale 1
               to)

               My earlier             3.10 (1.41)/4.10 (1.02)
               experiences have
               been respected in
               care.

               My everyday habits     3.62 (1.43)/4.00 (1.45)
               have been taken into
               account in care.

               ICS-B/Decisional
               Control over Care
               (Scale 1 to 5)

               I have followed the    4.68 (0.57)/4.30 (1.08)
               instructions
               received in care.

Comparison     WCQ-S/Positive
Group          Reappraisal (Scale 0
               to 3)

               I had ad another,      1.17 (1.00)/2.00 (1.12)
               deeper sense of what
               is important in
               life.

               I change myself in     1.22 (0.94)/0.76 (0.90)
               some ways

               WCQ-S/Accepting
               Responsibility
               (Scale 0 to 3)

               I criticize or         0.17 (0.38)/0.81 (1.11)
               lecture myself.

               ICS-A/Decisional
               Control over Care
               (Scaled to 5)

               Staff members have     2.11 (1.24)/2.73 (1.34)
               asked me what time I
               would prefer to
               wash.

               ICS-B/Personal Life
               Situation (Scale 1
               to 5)

               My earlier             3.11 (1.37)/4.14 (1.03)
               experiences have
               been respected in
               care.

Group of       Instrument/Index
Participants   Item                   p-Value

Intervention   SWE-DES-S/Goal         0.046
Group          Achievement (Scale 1
               to 5)
               In general, I can
               consider if it is
               worth the effort to
               change the way I
               take care of my
               disease.

               WCQ-S/Confrontive
               Coping (Scale 0        0.026
               to 3)
               I direct my anger
               towards the person/
               persons who have
               caused the problem.

               WCQ-S/
               Escape-Avoidance *
               (Scale 0 to 3)

               I sleep unusually      0.021
               much.

               I mostly avoid         0.023
               associating with
               other people.

               WCQ-S/Seeking Social
               Support (Scale 0 to
               3)

               I talk to other        0.040
               people in order to
               find out more about
               the situation.

               WCQ-S/
               Self-Controlling
               (Scale 0 to 3)

               I try to make sure     0.047
               that the feelings
               caused by the
               problem do not have
               an impact on
               anything else,
               the problem must
               not take over.

               ICS-A/Personal Life
               Situation * (Scale 1
               to 5)

               Staff members have     0.000
               asked me about my
               earlier experiences
               in care.

               Staff members have     0.002
               asked me about my
               everyday habits.

               Staff members have     0.012
               asked me if I wish
               to involve family
               members in my care.

               ICS-A/Decisional
               Control over Care *
               (Scale 1 to 5)
               Staff members have     0.006
               asked me what time I
               would prefer to
               wash.

               ICS-B/Personal Life
               Situation * (Scale 1
               to)

               My earlier             0.005
               experiences have
               been respected in
               care.

               My everyday habits     0.009
               have been taken into
               account in care.

               ICS-B/Decisional
               Control over Care
               (Scale 1 to 5)

               I have followed the    0.025
               instructions
               received in care.

Comparison     WCQ-S/Positive
Group          Reappraisal (Scale 0
               to 3)

               I had ad another,      0.046
               deeper sense of what
               is important in
               life.

               I change myself in     0.033
               some ways

               WCQ-S/Accepting
               Responsibility
               (Scale 0 to 3)

               I criticize or         0.034
               lecture myself.

               ICS-A/Decisional
               Control over Care
               (Scaled to 5)

               Staff members have     0.042
               asked me what time I
               would prefer to
               wash.

               ICS-B/Personal Life
               Situation (Scale 1
               to 5)

               My earlier             0.027
               experiences have
               been respected in
               care.

* Significant on index level.
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Article Details
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Title Annotation:CNE: Continuing Nursing Education
Author:Nygardh, Annette; Malm, Dan; Wikby, Kerstin; Ahlstrom, Gerd
Publication:Nephrology Nursing Journal
Article Type:Report
Geographic Code:4EUSW
Date:Jul 1, 2012
Words:6990
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