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Experiences of Hmong patients on hemodialysis and the nurses working with them.

Goal

To increase understanding of the experiences of Hmong patients on hemodialysis.

Objectives

1. Explain the traditional beliefs of the Hmong culture and how they are related to the health care of Hmong patients.

2. Discuss the experiences of Hmong patients on hemodialysis.

3. Describe nurses' experiences of working with Hmong patients on hemodialysis.

The United States has long been described as a "melting pot" due to its culturally diverse population. This trend continues today, with the Hmong immigrants adding to the diversity since the mid-1970s. The Hmong are some of the most recent immigrants to the U.S. Their homeland has been identified as Laos, Thailand, Vietnam, and Burma (Parker & Kiatoukaysy, 1999). It has been suggested that many Hmong were instrumental in aiding U.S. forces during the Vietnam War and that they were promised safety and shelter by the U.S. when the war ended (Mattison, Lo, & Scarseth, 1994). Many Hmong families fled to the jungles to escape the wrath of the communists (Duff), et al., 2004; Faderman, 1998; Fadiman, 1997; Mattison et al., 1994) and risked their lives attempting to reach refugee camps in Thailand. Living conditions in these camps were horrendous (Faderman, 1994; Mattison et al., 1994; Moore-Howard, 1982). Church groups and individual citizens sponsored Hmong immigrants and agreed to help their transition to American life (Mattison et al., 1994). In the 2000 census, there were 186,310 Hmong in the U.S., with the majority residing in California, Wisconsin, and Minnesota (Hmong National Development, Inc., 2004).

Most Hmong, like other immigrants to the U.S., have unique cultural beliefs and practices that they bring with them. These cultural norms affect their daily life in the U.S., in addition to their beliefs about health, illness, medicine, and healing. These customs may also impact the Hmong's utilization and understanding or acceptance of western healthcare services.

In their homeland, many Hmong experienced acute and chronic illnesses, such as tuberculosis, diarrhea, small pox, and infections. In the U.S., they also experience chronic diseases, such as diabetes, cardiovascular disease, and kidney disease. These disease processes and their accompanying treatments may be new to some Hmong, and it is essential that nurses gain an awareness of Hmong experiences with these conditions in order to provide quality nursing care. Unfortunately, there is a lack of research exploring Hmong experiences with these diseases and their treatment modalities. In particular, end stage renal disease (ESRD) and hemodialysis have not been studied in the Hmong population. Nor has there been an exploration of challenges nurses face while working with Hmong patients on hemodialysis. The purpose of this study was to explore Hmong experiences with hemodialysis as well as the experiences of nurses working with these Hmong patients.

Review of Literature

Traditional Hmong Belief System

According to traditional Hmong view, illness is experienced because of soul loss (Bliatout, 1986; Tapp, 1989; Westermeyer, 1988), natural hardships, environmental events, stress, or spirits that are angry (Westermeyer, 1988); spirits that are unhappy or offended (Reznik, Cooper, MacDonald, Benador & Lemire, 2001); or an accumulation of bad blood (Westermeyer, 1988). This bad blood needs to be removed cautiously because the Hmong believe the human body only has a finite amount of blood to last their lifetime.

The concept of a chronic illness that can be controlled but not cured is traditionally unfamiliar to the Hmong; thus, when the Hmong seek health care, they want their symptoms resolved, usually with medication (Waters, Rao, & Petracchi, 1992). When this does not occur, the Hmong are often noncompliant (Cha, 2003; Johnson, 2002). Traditional methods of healing or treating illness include rituals performed by particular diagnosticians, such as the egg reader, fortune teller, or basket spirit caller (Bliatout, 1991). Non-spiritual healers include the herbalist, massage therapist, and acupuncturist (Blaitout, 1991). Cupping and coining are used as treatment for illnesses that are not severe, but these are sometimes mistaken by western care providers as evidence of abuse (McInnis, 1991). The Hmong might also use special string or chains tied around the wrist or neck to prevent soul loss (Johnson, 2002; Westermeyer, 1988). The shaman is a spiritual healer who can be consulted to help treat some illnesses (Bliatout, 1991). The shaman is believed to be able to communicate with the spirits to assist in healing (Duffy et al., 2004). There is evidence that some Hmong utilize their traditional healing methods as well as current medical treatment available from healthcare providers (Cha, 2003; Culhane-Pera & Lee, 2006; Dhooper, 1991; Moua, 2003; Plotnikoff, Numrich, Wu, Yang, & Xiong, 2002).

Effects of Hemodialysis

There has been extensive research exploring the effects of hemodialysis. Hemodialysis has the potential to affect every aspect of an individual's life: physical, emotional, social, financial, and spiritual (Furr, 1998). Fatigue and emotional exhaustion occur frequently (Chang, Lee, Kim, & Kim, 2003; Hagren, Pettersen, Severinsson, Ltitzen, & Clyne, 2001; O'Brien, 1983). Sleep disturbances and insomnia occur as a result of the disease, treatment, and medications (Curtin, Bultman, Thomas-Hawkins, Waiters, & Schatell, 2002; Gurklis & Menke, 1988; Polaschek, 2003). The ability to perform daily activities is affected (Thomas-Hawkins, 2000) and may even vary with the dialysis cycle (Polaschek, 2003).

Physiological effects from dialysis may produce discomfort and include hypotension, nausea, vomiting, muscle cramps, headaches, loss of muscle tone, and change in skin color (Gurklis & Menke, 1995; Suet-Ching, 2001). Psychological effects include isolation, affecting relationships (O'Brien, 1983); disrupted marital and family life (Hagen et al., 2001); inability to fulfill roles and responsibilities (Gurklis & Menke, 1988); and a loss of control (Moua, 2003). Unemployment and frequent hospitalizations can affect the financial status of a patient on hemodialysis (Gurklis & Menke, 1988).

Methodology

Subject Selection and Description

Following approval from the Institutional Review Boards of the researcher's affiliated institution and hospitals, the entire population of Hmong patients on hemodialysis (N = 7) and registered nurses working in hemodialysis (N = 23) at two medium-sized hospitals (250 beds) in a midwestern city were invited to participate in the study.

Data Collection Procedure

To maximize participation in the study, a respected member of the Hmong community agreed to assist with explaining the study to the Hmong patients on hemodialysis (Polit, Beck, & Hungler, 2001; Shadick, 1993). The translator working with these patients at the hospitals agreed to assist with the interview process. All participants requested to be interviewed during their dialysis treatment. All interviews were tape recorded and field notes were taken. Clarification of misunderstandings or confusing responses was attempted during the interview process, although a structured format was used. Immediately following the interviews, the recordings were transcribed verbatim by the researcher. The field notes were referred to when clarification in the recording of the interview was required. No participant names or other identifying information was recorded.

Data were collected from the nurses working in the hemodialysis units using a questionnaire developed for the purpose of this study. Suggestions by Dillman (2000) were utilized to maximize participation. Three contacts with the nurses were made: initially a letter describing the study; the following week, the questionnaire and a self-addressed stamped envelope in which to return the questionnaire to the researcher; and one week later, a follow-up postcard to remind the nurse to complete the questionnaire and offer gratitude for her participation. Each contact was made using the nurse mailbox system at the unit of employment. All returned questionnaires were secured by the researcher and implied consent. No names or other specific identifying data were obtained.

Data Analysis

Once the interviews with the Hmong participants were transcribed, the responses were read thoroughly to identify initial themes. As each interview was added to the data set, the researcher read all the interviews again, looking for new insight. Categories were developed that described parts of the data. The researcher looked for themes across the categories and attempted to describe similarities, differences, and connections among the data. The data from the nurses' questionnaires are reported in frequencies and ranges. A correlation analysis was used for a section of the data. A summary of the results is provided.

Results

Because of the small sample size, the results need to be interpreted carefully. However, this study does provide some data for a newly explored area in nursing. The results will be separated into two main sections: nurses' experiences working with Hmong patients on hemodialysis, and experiences of Hmong patients on hemodialysis.

Nurses' Experiences of Working with Hmong Patients On Hemodialysis

Questionnaires were returned by 17 of the 23 nurses, yielding a response rate of 74%. All nurses were female. The sample characteristics are described in Table 1. The majority of nurses (70%) were over the age of 40. While the majority had extensive years of nursing practice, they had few years of experience in hemodialysis nursing.

The nurses varied greatly in their efforts to learn about Hmong culture. One respondent spent "minimal" time in discussion or other methods of learning. Four (24%) nurses admitted to 2 hours or less in total hours spent learning about Hmong culture, 6 (35%) indicated they spent 4 to 20 hours, 4 (24%) spent 30 to 50 hours, and one nurse each estimated a total of 73 and 170 hours learning about Hmong culture. The most frequently used method of learning was informal discussion with Hmong community members and/or family members of the patient (n = 14, 82%). The next most frequently used method was discussion with other healthcare providers (n = 11, 65%). Approximately half of the participants (n = 8, 47%) read journals or articles about Hmong culture, 5 read books, 3 took university courses, and 2 respondents attended a conference or seminar to learn more about Hmong culture. Only one nurse felt she was at risk from a legal standpoint, and none of the nurses felt their ethical standards were in jeopardy when working with Hmong patients. There was no correlation between total hours of time spent learning about Hmong culture and years working in hemodialysis (r = -0.23) or type of degree earned (r = 0.28). A mild inverse relationship was found between the total number of hours spent learning about Hmong culture and years of nursing experience (r = -0.423).

In comparison to other patients on hemodialysis, these nurses viewed their Hmong patients as being less compliant with medications (n = 13, 76%), diet and fluid restrictions (n = 11, 65%), and dialysis treatment schedule (n = 7, 41%). The majority of nurses (n = 10, 59%) felt their Hmong patients were less likely to participate in the multidisciplinary plan of care.

Challenges or barriers to care were explored by items on the questionnaire. Response options to these items were "very common," "sometimes a problem," and "not a problem." By combining the responses of "very common" and "sometimes a problem," 14 (82%) nurses indicated transportation was a problem for the Hmong patients on hemodialysis, 13 (76%) indicated finances were a problem, 12 (71%) thought family support was a problem, 15 (88%) indicated depression was a problem, and 13 (76%) indicated anxiety was a problem. Ten (59%) nurses thought there was a lack of trained interpreters, while 14 (82%) felt the interpreters were not available when needed; 12 (71%) felt there was inadequate time to spend with the patient, and all nurses agreed that there was a lack of training on Hmong culture.

Cultural challenges were also explored. The majority (n = 13, 76%) of the nurses felt Hmong fears about treatment, Hmong beliefs about illness (n = 14, 82%), and Hmong beliefs about treatment (n = 15, 88%) were problems encountered. All nurses believed communicating with their Hmong patients was a problem. When the nurses were uncertain of their Hmong patient's understanding of teaching or recommendations, a trained interpreter was "sometimes" used by 13 (76%) of the nurses and "always" used by 4 of the nurses. The respondents were almost evenly divided by the frequency of using an adult Hmong family member in these situations. Eight of the respondents chose "always" and 9 chose "sometimes" in response to this item. A minor family member was used "always" by 3 nurses, "sometimes" by 11 (65%) nurses, and "never" by 3 nurses.

Lastly, the nurses were asked to identify rewards they experienced while working with their Hmong patients on hemodialysis. The majority (n = 14, 82%) wrote comments. The rewards can be explained by three categories: learning the culture, being recognized for care provided, and getting to know the family. Several nurses indicated that being exposed to and learning about a new culture was rewarding. One nurse also added she has more respect for different cultures. Several nurses described their Hmong patients as loving and caring.

Experiences of Hmong Patients on Hemodialysis

There were 7 Hmong patients on hemodialysis who were invited to participate in the study. Three patients declined. One had just recently (within three months) started on dialysis. One was being treated for an acute illness during the data collection period, and the other patient had been recently diagnosed with cancer and was undergoing treatment for that as well. Although a response rate of 57% with such a small sample is not ideal, it is conceivable that these three patients could be experiencing an inordinate amount of stress, making their situations perhaps more unique than the other patients' experiences.

All participants were male. The lengths of time on dialysis were 8 months, 1 year, 2 years, and 4 years. The patients varied in their lengths of time living in the U.S. One patient was born in the U.S. His parents came from Laos, but he was not sure how long ago. The other participants have been in the U.S. for 3, 15, and 20 years. The participant who was born in the U.S. spoke English and did not require assistance of the interpreter during the interview. The interviews lasted from 20 to 31 minutes.

The interviews revealed Hmong patients on hemodialysis experience many of the same physical, emotional, and social effects as other patients on hemodialysis. Quotations from the Hmong participants are included to provide more depth and understanding of their personal turmoil. Overwhelming sadness was the most consistent theme. Sadness resulted from physical symptoms of weakness and fatigue, which caused an inability to participate in activities and perform roles and responsibilities; psychosocial symptoms of uncertainty, worthlessness, hopelessness, and fear; and the dialysis treatments themselves, as well as the dietary restrictions, added to the sadness these patients experienced. A typical example of the sadness is:
   I started on dialysis. I feel weak. I am
   unable to do anything. I am too tired.
   I can't babysit. I can't help my wife
   around the house. If they have work to
   do, I can't help. I'm very sad. I am
   unable to do any of these things. My
   appetite is not good so that leads to
   weakness ... I'm so sad that I'm weak
   and have to go through all of this.


Weakness and fatigue resulted in feelings of sadness because of an inability to participate in activities, both social and familial, as one participant described:
   Having kidney disease has stopped me
   going to family and joining in clan
   activities; whether they are having
   parties, feasts, festivals, even funerals,
   too, I can't do that any more ... I can't
   help out in the home doing chores ... I
   used to go squirrel hunting and like to
   go fishing. Now I can't do any of that
   as well, and it saddens me a lot that
   being a person and you are not able to
   help out your family at home, especially
   when you are a head of household,
   you're the father, and you can't do
   anything to help your family anymore.


Emotional feelings of worthlessness revolved around the inability to perform roles and responsibilities. There was hope that a kidney transplant would improve their conditions, but at the same time, a sense of hopelessness in realizing the transplant might never occur. Fear and uncertainty derived from watching others experience complications during treatments and not knowing how long they could live with their condition. One patient expressed his hopelessness regarding a transplant:
   People, doctors say that because I'm
   younger that I'll probably be towards
   the top of the list. There [are] so many
   people out there that need a transplant,
   too, so I don't really see myself
   getting one anytime soon. I don't really
   feel like I'm going to, don't really
   feel like I'm getting it ... The list
   doesn't mean very much.


Another patient felt the transplant was "the only thing that can make my life better." One patient described his feeling of worthlessness as a vacillating emotion:
   Sometimes I feel sad, and I feel that my
   life is worthless. That's usually at the
   times when I'm generally very sick,
   can't do anything to help out with family,
   and I feel that it's probably time for
   me to go. I'll leave it up to God to make
   the decision whether or not it is time to
   go or if I should live longer. And then
   on other days when I'm feeling much
   stronger, I feel that I feel stronger, I
   want to help out my family us much as
   I can. So I really look forward to that
   day and on those days I feel that I'm
   not worthless; that I have a family,
   have children, that I have to love them
   to the most that I can.


Feelings of uncertainty were common. One patient described this as:
   I feel pretty sad because everybody in
   this world--they just want to live,
   they don't want to die. They want to
   be healthy. They don't want to get
   sick. So I feel pretty sad that I'm sick.
   I don't know when I'm going to die so
   that worries me a lot. I don't know if,
   I know, I hope, I will still be alive
   today, but I don't know if I will be
   alive tomorrow.


Another patient stated, "I don't know how long my life is going to last, maybe months, maybe years, I don't know."

The dialysis treatments themselves also resulted in fears, sadness, and uncertainty. One patient complained specifically of boredom during the treatment, yet another was fearful:
   On dialysis, the medicine they put into
   the dialysis makes me feel weak,
   makes me feel sick, and sometimes I
   feel like I am going to die.


Another patient described the uncertainty of the treatment in helping the disease:
   The thing that bothers me is the medicine
   they give me to help me, but then
   I take them and they should make me
   feel better and have a better appetite,
   but I don't feel better, and I'm just sort
   of worried about that. And if the medicine
   that will help me doesn't help
   me, I don't want to take it anymore.


Coping methods utilized were very few and not detailed. Three of the patients really depended on the prescribed medication to help relieve their symptoms and help them feel better, but as noted in the above statement, this does not always happen. One patient stated he shares his concerns with his sisters, who are supportive and listen when he wants to talk about his feelings. Another patient stated he tries to exercise and spend time gardening or fishing so he can stay as healthy as possible. One patient used prayer and faith. Two patients felt more energetic and less symptomatic on non-dialysis days, so they tried to enjoy those days. The other two patients felt the same weakness and fatigue on dialysis and nondialysis days. All patients agreed that western medicine and treatments were appropriate and necessary, whereas there was not a role for the traditional Hmong healing methods. A typical explanation was provided:
   The traditional Hmong healing is not
   something for this situation. If it's
   something that is disease, health-related,
   or due to kidney, heart, lung, brain
   even, our traditional customs or rituals
   are not able to help with [these]
   sorts of situations. If it's spiritual,
   then there are methods, there are ways
   for helping that person. But in my situation,
   there's nothing that we can do
   to help with that.


Three participants described their relationships with the healthcare providers as good, believing that the nurses and doctors were helping the patient and the family. One participant was not as pleased, feeling there was not enough contact or concern displayed by the physicians. All participants felt the nurses were trying to be helpful.

Discussion

It can be challenging, stressful, and yet rewarding simultaneously when caring for patients from other cultures, especially those who do not speak English when that is the native language of the healthcare provider. Communicating with the Hmong patients was seen as a barrier to care by these nurses. While just over half (59%) of the nurses felt there was a lack of trained interpreters, 82% felt availability of interpreters was a problem. In 1998, Warner and Mochel claimed there was a lack of trained interpreters. This was supported by Cha (2003), who also suggested there is a need for formal training programs for the Hmong interpreters. The results of this study corroborate these suggestions. Cha (2003) also found that family members were frequently used to translate. The nurses in this study identified that the use of family members was also common. However, the use of minor family members poses concerns. Frye (1995), Osborn (1992), and Waters et al. (1992) suggested using minors would violate Hmong views on authority and be disrespectful and embarrassing for the elder.

Uba (1992) and Cha (2003) found transportation and finances can be barriers to care for Hmong patients. The nurses in this study agreed that these were challenges for their patients. None of the Hmong patients on hemodialysis in this study indicated that their beliefs about treatment or illness were challenges. These patients felt dialysis was the only appropriate treatment for them, aside from kidney transplant.

The majority of the nurses (76%) felt their Hmong patients on hemodialysis were less compliant in their medication regimen than their other patients. Almost two-thirds (65%) felt the Hmong patients were less compliant with dietary and fluid restrictions than the other patients on hemodialysis. These nurses did not indicate that the Hmong patients experience more complications; in fact, the responses on the questionnaire indicated they felt the Hmong patients experienced similar complication rates as other dialysis patients. This could be interpreted to mean other factors not included in this study contribute to complications, non-compliance was not severe enough to result in complications, or the Hmong patients may be more resilient and able to handle non-compliance better. These conclusions would be speculations only, and further research is required to determine the relationship between compliance and complications in the Hmong patient. One might surmise that rates of compliance in reality are the same for the Hmong as non-Hmong patients on hemodialysis, which is why complication rates are similar.

Another component of care for patients on hemodialysis is the multidisciplinary approach. Despite the fact that one agency includes a Hmong interpreter at all care conferences, the majority of these nurses still felt their Hmong patients did not participate in the multidisciplinary plan of care as much as the non-Hmong patients. While no explanations for this were provided, a variety of reasons for this may exist. One nurse did provide an example of the difficulty in communicating with the Hmong patients and not knowing for sure if they understand because they tend to agree to what is recommended and ask no questions. Some of the Hmong participants also alluded to their belief that what the doctors recommended was what was best, and they would go along with this. Barnes, Davis, Moran, Portillo, and Koenig (1998) suggested this passivity may be a cultural value. It is possible that these patients listen in care conferences but offer little to no comments or questions, whereas non-Hmong patients might be more active participants. However, one Hmong patient did state that there is a mutual respect between the doctor and the patient, and that the doctor listens to him just as he listens to the doctor. There could also be concern that the use of the interpreter in care conferences is not the same as the patient participating. There has been concern by researchers that interpreters could distort messages or instructions (Cha, 2003; Hartog & Hartog, 1983).

There has been ample evidence in the research describing the emotional impact of dialysis on the patient and family. Depression and anxiety are two such manifestations that patients frequently experience (Furr, 1998; Siegal, Calsyn, & Cuddihee, 1987). The nurses in this study felt their Hmong patients experienced depression and anxiety as well. This was also supported in the interviews with the Hmong patients in this study. It was interesting that the majority of nurses felt family support was a problem for these patients, considering the wives of the married patients were always present during dialysis treatments. This researcher observed several loving gestures the wives displayed, such as gentle touch, covering the patient with blankets, rubbing the hand or the head, and sitting close by their husbands.

The nurses did not feel they had adequate time to spend with their patients, and they did not have adequate knowledge of Hmong culture. Despite their admittance of a lack of knowledge, communication barriers, and concerns about compliance, these nurses did not feel their ethical standards were being violated, nor did they feel they were in legal jeopardy. A concern that could be brought forward is that of informed consent. Autonomy, the right to make decisions, is inherent in informed consent, as are adequate knowledge and understanding. Informed consent has been described as an "ethical obligation" and "when the health care provider and the patient do not share the same first language, there is an immediate barrier to informing the patient of his or her clinical situation and the available choices" (Barnes et al., 1998, pp. 412, 416). These nurses indicated a need for more information about their Hmong patients. They identified several barriers to care as well as concerns about compliance with treatment. These nurses also described rewards they experienced in caring for Hmong patients on hemodialysis.

Review of Experiences of Hmong Patients on Hemodial sis

The most prevalent themes were feelings of sadness, weakness, and uncertainty. All participants described feeling sad that they had kidney failure, were on dialysis, were weak, missed out on family and clan activities, and could not fulfill their roles and responsibilities. Weakness was a major contributor to each of these issues. Uncertainty about their future, complications they might experience, and the potential for a transplant were discussed. Studies by Siegal et al. (1987) and Furr (1998) included descriptions of depression resulting from being a patient on hemodialysis. It is unclear in the results of this study if sadness in these patients could be equated as depression. While it seemed that weakness and fatigue contributed most to the other issues these patients experienced, it is possible that sadness could also be a component.

Weakness and fatigue were common in these patients. The literature is replete with evidence of these effects from dialysis as major stressors for the patient on dialysis (Chang et al., 2003; Curtin et al., 2002; Hagren et al., 2001; Lok, 1996; Moua, 2003; O'Brien, 1983; Polaschek, 2003). Feelings of weakness and fatigue often contributed to the inability to participate in activities. Previous research (Baldree, Murphy, & Powers, 1982; Gurklis & Menke, 1988; Welch & Austin, 1999), as well as the results of this study, indicate these are problems for patients on dialysis, both Hmong and non-Hmong. Mattison et al. (1994) found in their research that something Hmong immigrants looked forward to was sightseeing. Being able to see the United States was important, but not achievable, by one participant in this study.

Further similarities in the Hmong patients' experiences to previous research include other health problems, such as sleep disturbances, fluctuating feelings of well being, physical discomforts during dialysis, and the inability to find meaningful employment. One patient in this study also described his fistula causing weakness and pain in his arm and hand, which limited his participation in recreational activities. Welch and Austin (1999) found this to be a stressor as well.

Support from both family and nursing staff have been shown to be effective and important coping mechanisms (Bordelon, 2001; Furr, 1998; Gurklis & Menke,1995; Mok, Lai, & Zhang, 2004; Siegal et al., 1987). One patient in this study expressed support he received from family members. However, while he did not find the nursing staff particularly supportive or those in whom he would confide, he did feel the nurses had an understanding of what he was going through, and at times, they did try to talk with him to help him pass the time while he was on dialysis. The other participants in this study did feel supported and cared about by the nursing and medical staff. In contrast, the nursing staff felt the Hmong patients lacked family support.

Previous research in coping with dialysis has shown that hoping for a kidney transplant was a strategy used by Korean hemodialysis patients (Chang et al., 2003). Two patients in this study expressed a desire to receive a transplant, but neither felt it would happen anytime soon. Both thought a transplant would make their lives better.

The use of prayer and faith in God has been shown in some studies to be coping mechanisms of patients on hemodialysis (Baldree et al., 1982; Gurklis & Menke, 1995), but other researchers found religion did not contribute to coping (Siegal et al., 1987). Only one patient in this study expressed that faith was a means of dealing with his illness. He and many of his friends and family members prayed for his health.

Trying to stay as active as possible was one way a patient in this study coped with dialysis. Previous research has shown this to be a coping mechanism of patients on dialysis (Chang et al., 2003; Gurklis & Menke, 1995). A study by Culhane-Pera and Lee (2006) of Hmong patients with kidney stones revealed "patients and healers said it was important to exercise in order to keep the kidney, body, and bodily fluids strong, as breathing heavily and sweating keeps the body fluids moving, and keeps the organs working, including the kidney" (p. 10).

Giles (2003) found that the large, open ward atmosphere could be frightening for patients on hemodialysis. There were two patients in this study who described similar feelings. Watching other patients experience complications left them fearful. They wanted more nurses and doctors available, especially for these times. One participant in particular stated he could not communicate his concerns to the nurses. This could contribute to further fear of the unknown. Interestingly, three of the four Hmong patients expressed gratitude for the opportunity to share their experiences and feelings regarding their condition by participating in this study. They hoped their participation would be helpful to nurses and other patients on hemodialysis.

The patients in this study also expressed feelings of uncertainty and fear related to life, death, dialysis, the future, and kidney transplant. These types of concerns have been previously identified as sources of stress for family members of patients on hemodialysis (O'Brien, 1983; Pelletier-Hibbert & Sohi, 2001; Starzomkski & Hilton, 2000; Ziegert & Fridlund, 2001).

In summary, this study found that the Hmong patients on hemodialysis experience many of the same stressors described in the literature. Sadness, weakness, inability to perform roles, inability to participate in activities, and feelings of uncertainty and fear were all described. The Hmong patients used compliance with medications, support from family members, faith in God, and trying to stay active as their main methods of coping. They felt their nurses and doctors were trying to help them, but they also felt more staff were needed, particularly to prevent complications or to deal with these complications promptly.

Limitations

The most obvious limitation to this research is the small sample size. Only one city was used for data collection, and 4 Hmong patients on hemodialysis and 17 nurses working in hemodialysis participated. The results cannot be generalized to other populations, but this study does provide the reader with a beginning understanding of what these patients are experiencing and what their needs may be. There has been no previous research on the experiences of Hmong patients on hemodialysis. The results also help us to understand the experiences of these nurses and what their needs are as well.

Whenever an interpreter is used, there is a potential for meanings to be distorted, messages to be lost, or words to be misunderstood. It is important that participants trust the interpreter in order for them to disclose their true feelings. The interpreter used for this research has been working with the Hmong patients for many months and attends care conferences with them. It was hoped that there was a trusting relationship developed prior to this data collection.

Another limitation is that it is unclear how the experiences of these participants would compare to those nurses and Hmong patients who declined participation. Lastly, the questionnaire distributed to the nurses lacks long established reliability.

Recommendations

Based on the findings from this research, recommendations can be made to nurses working in hemodialysis. The data indicated that nurses have not been self-motivated to learn about the Hmong culture. Although this study did not explore the reasons for this, some potential reasons could be time constraints, lack of resources, lack of finances to attend learning activities, or other learning needs of higher priority.

The data also indicated the Hmong patients on hemodialysis would like prompt attention following completion of the dialysis treatment and a variety of distraction techniques during dialysis treatment. Although the majority of the experiences described by the Hmong participants are similar to those in the research of non-Hmong patients on hemodialysis, the nurses in this study identified barriers to care and treatment not identified by the Hmong participants. Further exploration of these differences is needed.

Furthermore, all nurses expressed that barriers to communication existed between themselves and their Hmong patients. This was also identified by the Hmong participants as a concern. Although translators are available, they might not be readily accessible when the nurses need them. Further training or other innovative methods of communication are needed to overcome this barrier to care. Nurses could also assist the Hmong patients on hemodialysis to explore current coping mechanisms and support systems, implement nursing interventions to enhance these coping mechanisms, and collaborate with other professionals to enhance these coping mechanisms and support systems.

Administrators can also use the results of this research to respond to the needs of nurses and patients. Nurses working with the Hmong patients on hemodialysis indicated more time is needed to spend with the patient and more knowledge is needed on Hmong culture. The Hmong patients also noted that more staff are needed for patient support and to promptly handle complications. The workforce is aging, and this will create staffing challenges in the future for hemodialysis units. Administrators should promote lifelong learning in nursing by encouraging and financially supporting attendance at conferences on multicultural nursing. Staff meetings could incorporate information on Hmong culture, or a speaker from the Hmong community could be available for questions during a time when staff are most readily available. Recent research and general articles regarding Hmong culture should be made readily available for staff as well.

There are also some recommendations for future research based on the results of this study. More research is needed on the experiences of Hmong patients on hemodialysis, particularly in terms of coping methods and barriers to treatment. Research is needed to explore what would be helpful to the Hmong patients in coping with their illness. This study did not examine the impact on the family, and this is an area that could be explored. Although a qualitative method was used to collect data from the Hmong patients, there are numerous tools available to measure the concepts identified in this study. Research is needed to explore the applicability of these tools to the Hmong population.

This offering for 1.2 contact hours is being provided by the American Nephrology Nurses' Association (ANNA).

ANNA is accredited as a provided of continuing nursing education (CNE) by the American Nurses Credentialing Center's Commision on Accreditation.

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

This CNE article meets the Nephrology Nursing certification Commisions (NNCC's) continuing nursing education requirements for certification and recertification.

Sources of Support: The author would like to thank the Southeast Asian Studies Center at the UW-Madison for their support in funding the literature review.

Acknowledgments: The author would like to thank Dr. Bruce Pamperin for his support and guidance, as well as for sharing his passion for the Hmong people.

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

Nursing Journal Editorial Board Statements of Disclosure

In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below.

Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of Clinical Trials for Roche.

Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the recipient of unrestricted educational grants from OrthoBiotech and Roche.

Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc.

Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers' Bureau for Watson Pharma, Inc.

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Linda Krueger, EdS, MSN, RN, is a Nursing Instructor, Chippewa Valley Technical College, Eau Claire, WI, and was a Staff Nurse, Luther Hospital, Eau Claire, WI, at the time this article was written.
Table 1 RN Participant Demographic Information

Demographic
                                 N    %
Age
20 to 30                         2   12
31 to 40                         3   18
41 to 50                         6   35
51 to 60                         6   35

Years in Nursing
1 to 10                          6   35
11 to 20                         1    6
21 to 30                         6   35
31 to 40                         4   24

Years in Hemodialysis Nursing
1 to 5                          11   65
6 to 10                          2   12
11 to 15                         2   12
16 to 20                         1    6
21 to 25                         1    6

Degree Earned
ADN                              8   47
BSN                              8   47
MSN                              1    6
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Date:Jul 1, 2009
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