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Self-management of hemodialysis for End Stage Renal Disease.

Recommendations

The following interventions should be implemented to assist patients with End Stage Renal Disease (ESRD) undergoing hemodialysis to improve self-management of their condition:

* A structured, individualized self--efficacy training program conducted by trained nephrology nurse specialists. (Level B)

* Group cognitive behavioral therapy intervention using techniques such as relaxation and self-monitoring skills. (Level B)

* An empowerment program focusing on assisting patients to develop skillsand self-awareness in goal setting. (Level B)

* Structured weekly telephone contact and a behavioral contract with a family member or friend. (Level B)

* Hemodialysis education and support program (a specific education program that includes support from nurses) for a period of three months with weekly teaching and support sessions. (Level B)

Information Source

This Best Practice Information Sheet has been derived from a systematic review published in 2011 in the JBI Library of Systematic Reviews. The full text of the systematic review report (2) is available from the Joanna Briggs Institute

(www.joannabriggs.org).

Background

End Stage Renal Disease (ESRD) is an irreversible loss of kidney function to the point that the kidneys fail to support life. (2) When this occurs, Renal Replacement Therapy (RRT), also called kidney dialysis, or transplantation is required. Currently 1.4 million patients are reported to be receiving RRT globally with the incidence of ESRD growing at approximately 8% annually. (2) The burden of costs to meet the rising incidence and prevalence of ESRD is expected to increase substantially.

A large investment is therefore required to promote effective management and care interventions such as self-care for people with ESRD.

Exploring self-management in ESRD is extremely important for patients as they encounter several challenges including ongoing symptoms, complex treatments and restrictions, uncertainty about life and a dependency on technology, all impacting upon their autonomy particularly after commencement of hemodialysis. (2)

An important issue supporting self-management interventions for people with ESRD is the concept of compliance or adherence to their treatment regime and it has been reported that 33% to 50% of people are non-compliant or non-adherent to their treatment.

Objectives

The purpose of this Best Practice Information Sheet is to summarise the effects of nursing interventions on self-management of hemodialysis by patients with End Stage Renal Disease.

Types of Intervention

The interventions assessed included: a self-efficacy intervention based on Bandura's self-efficacy theory (a structured, individualized training program created by the investigator); an empowerment programme consisting of individualized consulting sessions based upon guidelines for facilitating a patient empowerment program; group psychosocial education intervention based on cognitive behavioural therapy and self-efficacy theory; a teaching and support program emphasising the physical and psychosocial aspects of care for hemodialysis patients based on Orem's theoretical framework; behavioural contracting alone and behavioural contracting with involvement of a family member or friend and weekly telephone contacts with patients. Interventions were compared to usual care in all of the included studies.

Quality of the research

The five included studies were randomized controlled trials that reported the inclusion of a psychosocial intervention. Only one study did not report including an education intervention. Three of the included studies were from outpatient dialysis centres in Taiwan and two studies were conducted in outpatient dialysis centres in the United States.

Results

Self-efficacy training program

One study aimed to develop self-management skills in people with ESRD undergoing hemodialysis. A total of 62 people participated (31 each in the intervention and control groups). The intervention included a structured, individualized self-efficacy training program consisting of twelve one-hour sessions conducted three times per week by two trained nurse specialists whilst patients received dialysis. Mean weight gains were used as measures of adherence to fluid intake for dialysis patients. There were no differences between the intervention and control groups except for baseline body weight change, which were accounted for in the repeated measures analysis. Results showed there was a statistically significant difference between the two groups and that the fluid intake compliance program was effective in reducing fluid weight gains for up to six months after the intervention was implemented. Clinical significance of the improvement from the intervention was not stated.

Empowerment program

An empowerment program developed for ESRD patients concentrated on assisting the participants develop skills and self-awareness in goal setting, problem solving, stress management, coping, social support and motivation. The Empowerment Scale was used to measure empowerment as the main outcome. Other measures in this study included self-care self-efficacy as measured by the Strategies Used by People to Promote Health (SUPPH) and depression as measured by Beck Depression Inventory. The participants in the experimental group received an information package with individual consulting sessions three times per week for four weeks. The consulting sessions were delivered by the nephrology clinical nurse specialist. The control group received the information package only. The empowerment program was shown to increase levels of empowerment, decrease levels of depression and improve self-care self-efficacy.

Cognitive Behavioural Therapy

There were four components to the therapy: (i) CBT aimed at self-management and coping strategies for stress and depression; (ii) restructuring thought patterns and beliefs; (iii) stress management; and (iv) health education focused on psychosocial skill of self-care strategies. The post test for this study was conducted one month after the intervention. The effectiveness of the group therapy was measured by self-care self-efficacy (SUPPH), depression (Beck Depression Inventory) and quality of life (Medical Outcomes Study, SF36). The results showed improved self-efficacy for the intervention group and a decline in self-efficacy for the control group. There was a statistically significant improvement in perceived self-care self-efficacy, depression and the physical component of quality of life indices for the participants who received the group psychosocial therapy in this study. Clinical significance was not reported.

Education intervention

The effectiveness of a hemodialysis educational and support program (HESP) upon the physical and psychosocial adaptation to ESRD was examined in a study with a total of 135 participants. The participants in the experimental group received 12 consecutive educational support weekly sessions for one hour at the beginning of dialysis treatment by trained nurse facilitators. The HESP investigated patients' self-care, activities of daily living, social activities, interactions with significant others, hemodialysis regimen compliance and perceived alienation. A series of three interviews was conducted at the end of the program at three months, six months and one year to evaluate the short and long term effects of the program. The post-test only group was measured at one year. The participants in the pre-test/post-test control group and the post-test only control group received routine hemodialysis treatment only three times per week. At one year, the experimental group showed statistically significant improvements in physical and psychosocial adaptation as measured by Sickness Impact Profile, Exercise of Self-Care Agency, Inventory of Social Functioning and the Dean Alienation Scale. However there were no statistically significant differences found between the groups in adherence with hemodialysis treatment (Hemodialysis Regimen Compliance Scale). It is not reported whether this translated into a clinically significant difference.

Behavioural contracting and weekly telephone contact intervention

These strategies included behavioural contracting alone, behavioural contracting with the participation of a family member or friend who was expected to modify the patient's behaviour, and weekly telephone contact only with patients designed to modify the patients' health beliefs and therefore improve adherence. The study group comprised of 120 participants in total who were interviewed prior to commencement of the interventions; at six weeks following the interventions; and at three months after completion of the interventions. The control group received standard care.

After explaining the contract process and working out the tentative contract, the nurse and the patient further negotiated a timetable noting when specified behaviours would be achieved, how they would be evaluated and at what time the patient would be rewarded. The rewards, state lottery tickets, were then scheduled so patients would have short and long term goals to work towards.

The telephone contacts were conducted by nurses from the dialysis clinics. Patients were contacted once a week for six weeks with each phone call lasting approximately eleven minutes and tailored to the patients' needs and medical experiences. Diet adherence was measured by mean serum potassium levels and fluid adherence was measured by mean weight gain between dialysis treatments. Changes in health beliefs were measured using a questionnaire (seven-point Likert scale). The questionnaire measured perceived susceptibility to sequelae of non-adherence, perceived severity of sequelae associated with non-adherence and beliefs about the likely benefits of the diet. Barriers to diet and fluid intake adherence questions were also measured using 'yes' or 'no' responses.

Serum potassium levels

Six weeks post-intervention, serum potassium levels were lower showing improved levels in the three intervention groups compared to the control group with statistically significant differences found in the weekly telephone contact group and the behavioural contract only group. However, this difference was not maintained in any of the intervention groups at three months after completion of the interventions.

Fluid limit compliance

Mean weight gain measured between dialysis treatments were used as the measure of adherence to the regimen limiting fluid intake. Weight gains were calculated by subtracting the pre-dialysis weight of each participant from the post-dialysis weight at the last treatment. Weight gains were lower and therefore were improved for the three intervention groups at six weeks post-intervention. The patients in the behavioural contract with a family member or friend showed statistically significantly lower weight gains than the control group. No significant differences in weight gains were found at three months post-intervention among any of the intervention groups. Those participants in the two behavioural contract groups showed average weight gains of 13% less than those in the control group and 9% lower than those participants in the weekly telephone contact group. Clinical significance of these differences was not stated.

Health beliefs and adherence

Health beliefs in relation to adherence with diet and fluid intake and the perceived relationship with illness were assessed at the three time points (pre-intervention, six weeks and three months). Correlations between belief measures and adherence levels (diet and fluid limit) showed that the number of barriers interfering with adherence to either diet or fluid limits was found to be significantly correlated to compliance.

Experimental therapies and health beliefs

There were no statistically significant differences at six weeks or three months between the experimental groups, however patients in the weekly telephone contact group tended to report higher levels of perceived susceptibility and perceived severity of non-adherence compared to the other experimental groups.

It was concluded that all three interventions had an effect upon adherence to therapy. However, health beliefs were not predictive and showed little impact upon adherence, i.e., there was little effect from the interventions in changing the participants beliefs about their diet and/or fluid limit.

Conclusions

Psychosocial interventions such as self-efficacy interventions (e.g., structured, individualized training programs) are effective in controlling mean body weight gains; participation in a patient empowerment program can be effective at improving perceived levels of empowerment, self-care self-efficacy, and for decreasing levels of depression; group psychosocial therapy can be an effective method of increasing confidence in self-care; an educational and support program was shown to be effective in improving psychosocial skills and performance of activities of daily living; a behavioural contract and a behavioural contract with a family member or friend resulted in lowered weight gains (compliance to treatment); and a weekly telephone contact intervention also improved compliance to treatment. However, none of the interventions in this last study changed the participants' health beliefs.

Successful interventions in four of the included studies involved one-on-one contact over several weeks using a number of theory-based methods to develop coping and decision-making skills. The studies also showed that such interventions can be effective by using both an individual and group format.

Acknowledgments

This Best Practice information sheet was developed by the Joanna Briggs Institute.

Grades of Recommendation

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (1)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Definitions

For the purposes of this information sheet the following definitions were used:

Home hemodialysis (HHD) is hemodialysis carried out at home and requires self management. It is attended to predominantly by the patient or their support person. HHD is regarded as being physiologically better for the patient, as the patient is able to dialyse longer or more frequently; there is better psychosocial support and it offers patients more control over their lives, thus improving their health related quality of life.

Satellite hemodialysis (SHD) is hemodialysis carried out in specialized dialysis centres usually located away from the parent hospital and involves some self management by the patients.

Evidence-based Practice evidence, context, client preference judgement

This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilise this evidence with consideration of their context, their client's preference and their clinical judgement. (3)

References

(1.) The Joanna Briggs Institute. Levels of evidence and Grades of Recommendations. http://www.joannabriggs.edu.au/About%20Us/JBI%20Approach

(2.) Reid C, Hall J, Boys J, Lewis S, Chang A, Self management of haemodialysis for End Stage Renal Disease: a systematic review. The Joanna Briggs Library of Systematic Reviews 2011;9(3):69-103

(3.) Pearson A, Wiechula R, Court A, Lockwood C. The JBI model of evidence-based healthcare. Int J of Evid Based Healthc 2005; 3(8):207-215.
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Publication:Best Practice
Date:Jun 1, 2011
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