Abstract
Educational interventions for chronic kidney disease patients requiring dialysis treatments can result in a multitude of positive outcomes. This literature review has evaluated an existing body of evidence on the effect of educational intervention that influence the quality of life of dialysis patients. Many studies show that, patients have benefited from educational intervention in physical and psychological aspects of wellbeing.
The information identified is important for nurses to provide appropriate steps to improve patients’ knowledge and information in view of promoting patient’s treatment accordingly as well as encouraging them to cope and adapt to their long-term treatment options such as haemodialysis. This review highlights the provision of adequate information to dialysis patients to support with their needs such as diet and fluid control, adherence to treatment and psychological wellbeing. All these aspects are considered an integral part of healthcare provision to enhance the health related quality of life of dialysis patients in many western countries including in the United Kingdom.
Introduction
This literature review is an evaluation of the effect of educational intervention on the quality of life of haemodialysis patients (Griva et al., 2014). The review considered western literature to evaluate the effectiveness of education and information for dialysis patients in several aspects of their treatment. The literature search covered published nursing articles since 2004 to 2014 to have an up-to-date analysis of the evidence of best practice in educational interventions in dialysis patients in view of improving the health related quality of life for this particular group of patients.
The study will evaluate the literature in terms of its methodologies and analyse the common themes in the literature. Furthermore, the review will aim to identify the best practice in clinical setting as well as explore the gaps in the evidence. Finally this literature review aims to make recommendations about the future developments in educational interventions and the role of nurses as well as the multidisciplinary team in providing education to dialysis patients in clinical setting to improve the patient’s treatment and wellbeing.
Literature Review Proposal
Individuals with chronic kidney disease (CKD) face a lifetime of complicated treatments such as dialysis, complex medication schedules, dietary and fluid restrictions. Quality of life for this group of patients refers to the measure of a patients functioning, wellbeing and general health perception in physical, psychological and social domains (Mason et al., 2008). Ali et al. (2011) states that along with survival and all the positive treatment outcomes, patient quality of life is an important marker of the effectiveness of the treatment and medical care they receive.
Therefore, adherence to medical treatment and especially dialysis concordance is essential for improving optimum health related quality of life of a CKD patient. Poor adherence is associated with poor clinical outcomes and increased mortality rate. For example, according to Kim and Evangelista (2010), missing one or more dialysis sessions per month can put the patient at increased mortality rate (25-30%), increased intra dialylatic weight gain, increased serum phosphate and potassium severely affecting heart function and leading to further health issues and complications.
According to the National Institute of Health and Clinical Excellence (NICE) (NICE, 2011) kidney disease is affecting one in ten of the population and progress to Chronic Kidney Failure (CRF) requiring life saving treatments such as renal transplantation, dialysis or renal replacement therapies. Furthermore, the incident of CRF is steadily increasing worldwide and patients with CRF have conditions that are associated with renal failure such as bone disease, anaemia, nutritional inadequacy and fluid and electrolyte imbalance as well as psychological issues (Thomas, 2008).
Since dialysis patients and their families or carers require lifetime commitment to their renal replacement therapy and medication relating to other co-morbidities, they should receive sufficient information and education regarding the nature of their illness and treatment options, which may allow them to make an informed decision about the management of their CRF.
Recent development in technology and advances in dialysis treatment have greatly contributed to improved survival of patients with established renal failure (ERF), however studies shows that health related quality of life (HRQOL) is much lower for those patients for the general population (Ali et al., 2011). In an attempt to improve quality of life of dialysis patients, clinical practice guidelines such as Kidney Dialysis Outcome Quality Initiative (KDOQI) were established to provide recommended ranges for parameters associated with management of ERF patients. A successful implementation of these guidelines not only the responsibility of the dialysis team but also greatly depend on dialysis patients, who can also greatly contribute to this process by understanding to the practices through education and active participation.
Many studies identified the importance and various methods of patient education programme. These research studies concluded that, there were improvements in control of blood pressure, calcium levels, phosphate management, and anaemia as well as fluid control after implementation of patient education in CKD management. Known that knowledge is a precondition for change; if a patients’ knowledge about the importance of renal diet, medication and treatment adherence are absent, they have little motivation to change their behaviour (Mason et al., 2008).
Providing education to dialysis patients about their disease and treatment may positively impact on enhanced psychological and social functioning as well as empower patients positively in modification of their treatment and concordance with treatment choice. Patient education is a crucial part of nursing care and is essential to individuals who are on dialysis treatment. CKD patients are facing challenges that are also correlated with complications and co-morbidities generated by dialysis treatment. Many of the co-morbidities that increase mortality rate and reduce the quality of life of dialysis patients are modifiable through patient education and providing information (Lingerfelt & Thornton, 2011).
The majority of studies look at the choice of dialysis mode and mainly focusing on predialysis education programmes (Wells, 2011). However, patients who began dialysis are instantaneously subjected to a host of medicines, procedures and dietary and lifestyle modifications. Therefore, patients require an expanded knowledge and information to internalise behavioural changes to successfully adapt to the new situation (Kugler et al., 2005).
This may explain why nurses are at the central role of education and teaching as patients spend a large amount of time in dialysis units getting treatment with many opportunities for planned and spontaneous teaching (Loos-ayav et al., 2008).
For many CKD patients diagnosing with kidney failure is already a traumatic event which can lead to stress and depression with emotions that prevent or miss the opportunity to maintain their health and wellbeing or prevent them from regularly attending life saving treatment such as dialysis. This can set the phase for a worst case scenario where the patient’s overall health may deteriorate and can also leaving them with limited dialysis therapy and need for acute interventions or hospitalisation. The importance of patient education and improving patient’s health literacy need to be emphasised as educational programmes are aimed at improving patients understanding of the disease and the best way to manage it.
Patients who were selected to participate in pre-dialysis educational programmes have showed improved psychosocial outcomes, adherence to dialysis therapy, shorter hospital admissions and improved mood (Ong, Jassal, Porter, Logan & Miller, 2013). Structured health education is adapted in relation to promote a better health. This is regarded both in short and long terms perceived benefits to the patients. Education helps patients to have full responsibility and understanding for the day-to-day control of their condition, including management of their lifestyle. For example, having balanced diet and physical exercises (National Institute for Clinical Excellence.
Health education is to improve their knowledge and skills, enabling them to take control and integrate self-management of their daily lives. The NSF supports this by proposing a ‘supported self care service model’ to promote healthy living through education. Evidence has shown that by increasing knowledge about the patients illness and treatment has either reduced or early detection of complications and patients may have improved self-management and have better health.
The nurse’s aim is to promote health and this can be at the same time very difficult to achieve due to some barriers, as some patients do not comply with the treatment. The patients have the right to make an inform choice about their health behaviour and may not be persuaded or motivated by the change as many newly diagnosed patients do not bring changes. Also factors like poverty, family preferences and unemployment may be barriers to influence health behaviour. Therefore, no action will be taken by these patients.
This study will assess and examine the educational intervention and information given to dialysis patients and how this impact on their quality of life and self care motivation. Data will be accessed from various studies and publications over the last 15 or more years. They will be chosen according to their type, professional role and focus on the area of education and the effect on various factors affecting the quality of life of patients requiring haemodialysis.
Literature which does not give a clear relation between education and quality of life in patients with renal disease requiring dialysis will not be included in the study. Furthermore, evidence based practice uses best available research to support the clinical decision making. Following the identification of the research objective the study has now developed the research question using PICO analysis (See Appendix: C). Once a structured process is used in developing the research question there is less chance of missing out the stages of thinking. Moreover, this aids the researcher to keep focused on the research question. Therefore, the research question was structured using PICO analysis and the question will be:
- What is the effect of education in determining the quality of life and self care motivation in haemodialysis patients?
- How education can promote independence and promote self-care in haemodialysis patients.
The importance of the relationship between the health related quality of life and patient education indicates a significant need for nurses to focus on this aspect of care. Effective ways to provide patient education is to provide not only information on disease process itself but also the effective way to manage the symptoms and complications that arise due to intensive dialysis treatment. Although renal disease progress slowly, patients comes into interaction with healthcare professionals very closely when they start dialysis (Danguilan et al., 2013).
Therefore providing a holistic approach to patient education with patient participation is crucial for successfully conveying the message for a better health related quality of life for the dialysis patients. This project will consider continuous effort of providing information and education to dialysis patients. The importance and the role of nurses in providing education and information for patients with chronic kidney disease although emphasised in literature, is rarely evaluated to show weather improvements are maintained overtime. Furthermore, several limitations such nurse’s lack of knowledge, busy work schedule and lack of resources or language barrier may make it difficult to achieve the desired outcome (Sondrup, Copland, Black & Trask. 2011).
Personalised interactive educational interventions which are relevant to the patient could improve the overall health related quality of life of dialysis patients. Nurses are have a central role to ensure and prioritise the best evidence based care for dialysis patients. The findings from this research will play a significant part in highlighting the areas that need added research and developing the best practice in providing education and evaluating the effects of interventions. Moreover, this will have significant impact on the quality of life that can be attained by dialysis patients and therefore have both economical and health implications on the entire society (Nygårdh, Malm Wikby & Ahlström, 2012).
Methodology and Results
The integrity of the research largely depends on the methodology of obtaining accurate information through research approach which is also used in obtaining the research objective (Chisholm, et al., 2007). Therefore, to obtain an answer rose for the research question, one has to consider the effectiveness of the research approach and the presentation as well as the subject relevance to the objectives of the study conducted. All of the above factors are all important in ensuring the research process as well as focused on the research objective. The presentation in this chapter is discussing the literature review methodology and exploring the development of much greater understanding of the accuracy and integrity of the research question.
Providing high quality health care and management of healthcare are very diverse areas of study which deals with a large number of issues. Furthermore, the issues are greatly related to the level of efficiency following interventions such as patient education that is determining the patient’s quality of life. Majority of these diverse areas involves the actual nursing practice or multidisciplinary intervention and there is a possibility of development of different advances to practice and improved patient satisfaction (Curtis & Julie, 2007). This admiration is crucial in developing awareness to an approach that can be employed in developing a more robust and evidence based research strategies and hence literature review.
According to D’Adamo & Whitney (2005) variables and approaches being used have to be considered when evaluating an assessment or research study. Therefore use of literature review is an approach to research which ensures not only the presentation of critical analysis of the views of the factors but also the factors that determine the efficacy of the assessment. Moreover, literature review aims to develop an understanding of the variable approaches which is appropriate to the goal or research objective.
The electronic libraries and search engines came in sensible sources of finding the resources for the literature review. Google scholar and iBoogie were both easily accessible utilities in searching and scheming through relevant articles and electronic copy of relevant books. These search engines played a crucial part in quest of wide range of supporting literature to the research subject. Google scholar and iBoogie produced a number of results when the question were searched in full and was looked at materials from year 1995 onwards.
The materials along with references from the studies helped to provide a broader context of recent and relevant information. In addition, web sites for the relevant government bodies such as NICE and Department of Health documents such as national service frame works and consultation documents that provided further insight into the chosen subject area.
TRIP data base and EBSCO were found useful in the search and selection of resources that can be reviewed in the literature review. The smart search utilities found in NHS evidence database made it possible to find relevant literature by typing in key search words. Accuracy of the resources and relevance to the objectives are determined by the title of the objectives as well as scheming through the article content (Sandra & Bredow, 2008). Therefore careful selections of title keywords were used in performing searching for research articles specific to the subject in electronic database search engines. This is also important due to the widespread use of articles specially journal articles that are driving at the research objectives (Oh, Park & Seo, 2013). (The key words used are listed in appendix: A).
One of the most important factors that establish the level of efficacy in literature review is the search criteria considering the nature of research and subject of study. The articles will determine the level of accuracy that can be attained due to the research approach (Cattinelli et al., 2012). Journal articles of primary research and empirical literature review articles were specified as criteria of inclusion to diminish the bias that would otherwise been acquired in using other articles. Moreover, recent published articles were selected by defining an inclusion criteria of journals published after 1995 to make the study relevant to current nursing practice.
The electronic search engines and databases are capable of providing up-to-date articles on the chosen subject. NHS evidence database was used in the research which provides extensive search utility that it allowed multiple databases with single search. The key search words, patient education, dialysis patient, quality of life, wellbeing, self-care management and renal failure were included in the search. (A full list is provided in appendix: A).
The search produced over 667 articles of which 29 were primary or extended primary research and empirical review were included in the primary list. EBSCO, TRIP and British Nursing Index (BNI) database also produced over a 297 articles relevant to the topic. It is significant to note that inclusion criteria relating to publication date was set to journals published after year 1995, and the relevance of the research was the only discriminative factor left. Journal abstract was looked at carefully to determine firstly, if they were engaged in primary or extended primary research or empirical review paper and secondly, how relevant they were to dialysis patient education and providing information to manage their care in a better way to improve the overall quality of life Jansen et al., 2013).
Although there were many studies relating to patient education, only few studies were found matching the exact predefined criteria for the selection of articles. Many studies were conducted and measured benefits of either diet or fluid restriction or clinical, behavioural, or knowledge outcomes only, which limited the effectiveness of an extensive source of information for the literature review. However, six articles published mostly related to nursing publications were reviewed and made through the meticulous search process. (A table of search criteria and the results are listed in appendix: A). (Refer to appendix: D for tabulated summary of critically appraised articles, including main findings and limitations of the articles chosen for the literature review).
Primary research articles or extended primary research articles were preferred to include in the study to minimise author bias. Articles which were not relevant to the subject were left out. The reliably, trustworthiness and validity of the published studies are determined by critical appraisal tool and using an existing framework. Moreover, peer reviewed articles must be of high quality as the studies are reviewed by a panel of experts, such as researchers specialists who focuses on upholding standard and improving quality. They can easily determine the follies in the hypothesis as well as strategies used in research. Research articles that used statistical approaches or a sample of more than 20 participants as well as a confidence level of 95% also guarantee that the results discussed are significant to the study group.
Most articles found in the search on effect of educational intervention in dialysis patients were used qualitative approach. This has led to the assumption that educational intervention and improved quality of life as a key issue in adherence to treatment and time to dialysis in chronic kidney disease treatment. It is evident from the relevant studies discussed in the review. Moreover, these issues are not only evident in Established Renal Failure treatment areas but also in other areas of health such as diabetics and heart failure. This knowledge was crucial in building up an understanding of different approaches and the level of accuracy in interpreting the research approach.
This research review has been developed with an objective that seeks to develop an understanding of a professional approach and come up with recommendations for best practice in the clinical setting. Therefore the relevance to the findings is important in determining the level of accuracy that the research will attain. Bryce et al., (2007) states that recommendations for best practice should be based on recent research studies, for instance enclosure of studies from the last millennium in research review is likely to lead an approach that is blemished or flawed and may be unsafe for recommending nursing practice based these studies.
Furthermore, research is a tool that is considered as the foundation in structuring clinical practice and further studies and also to develop an understanding of gaps in research. The research integrity is ensured by providing literatures from widely available sources and relevant materials. This has also helped to establish research gap which ascertain further research for the best evidence based practice in clinical settings (Painter & Marcus, 2013).
The literature review has highlighted the current practice and approaches that are considered reflective of best evidence based practice in haemodialysis patients. The breakdown and weakness of the current approaches in improving the quality of life of haemodialysis patients has formed to develop a basis for an action plan on improvement plans and implement patient education programmes in haemodialysis patients in accordance with the research findings.
The research information has collected from a large pool of resources and they are mostly of qualitative approach and empirical reviews of educational interventions relating to dialysis patients. There is a possibility that materials used in the study exhibits some degree of bias that would be evident in the review. However the research approach has a greater degree of advantage as well as increased span of research as the search has collected data from a large pool of sources. A checklist (Refer to appendix: B) was developed to reduce bias and inaccuracies in selecting articles.
The study has been developed to appreciate the objectives as well as evaluated the accuracy of the findings. Therefore, the findings from the research could make a difference to the future evidence based practice in relation to patient education. A key trend developed in the research methodology is the degree of research that has been made on the impact of patient education not only on the quality of life of dialysis patients but also in other chronic illnesses. Methodology of presentation is crucial in understanding the recommendations which is central to the research and has formed a basis for the following chapter.
Overview of Literature Review Findings
Lingerfelt and Thornton (2011) managed to utilise research studies with qualitative approach and come up with findings that largely in line with those developed by other researchers. These research findings show that a majority of patient education aimed at providing information on diet and fluid control in ERF patients requiring dialysis treatment. These research findings also show that there is a close and complex relationship between patient’s perception of their disease and treatment outcome as well as concordance to prescribed treatment.
Patients and their families found to be suffering from depression, anger, hopelessness while adjusting to a life on dialysis, especially when they were not given adequate information on treatment options and disease management (Iles-Smith, 2005). The studies aim to highlight the existing information on patient education and alongside it influences the factors that exploring dialysis patient’s information needs. Moreover, this is a reflective factor that may cause more complication in studying the effect of education in improving the quality of life of dialysis patients. These are supported in the research done by Wells (2011).
Mollicone, Pulliam and Lacson (2013) sought to examine information topics by addressing the educational intervention that is integral to haemodialysis patients. The study has looked at few research works that has been seeking out appropriate information to deal with and adjust to their treatment and the professionals who can provide the specific information for this particular group of patients. This shows the use of explanatory and cross-sectional survey on influencing factors of quality of life of patients and plays a crucial part in developing the levels of reliability and trustworthiness to the research (Cueto-Manzano, Martínez-Ramírez & Cortés-Sanabria, 2013).
A distinguishing factor in the chosen articles are that, they all utilizes multiple approaches to the study and target the various resources that can make an effect on the quality of life that can be achieved through active patient education and information seeking. Furthermore, a complex relationship is evident between disease specific knowledge and functional and emotional wellbeing (Wingard et al., 2007). Although the research establishes an apparent picture of the existence of the association between these factors, there is a lack of linkage between these factors discussed above. Another key involvement to the existing literature is about influencing behavioural activity and motivation to adhere to treatment protocol (Wells, 2011).
It is worth to appreciate the complexity of motivation to change behaviour but in contrast it suggest that, individual’s behaviour therapy works better in group intervention than when done individually. Moreover, in many patients cognitive behavioural therapy improves outcome only temporally therefore they should be assisted with education and explore the effects periodically (Chaboyer et al., 2005). This emphasises the role of nurses who are in constant contact with patients in dialysis units.
This study is unique in the sense that, it aims to establish added knowledge to many common aspects of dialysis patient education such as treatment adherence, fluid control or diet restrictions and psychological wellbeing through primary research (Gonzalez-perez, Vale, Stearns & Wordsworth, 2005). Moreover, this research paper seeks to address a clear picture of the association between the variables mentioned as being influential on the manifestation of education intervention in haemodialysis patient. Based on these findings, this review has identified three important aspects of patient education for patients on haemodialysis. The following three chapters will explore this in detail.
Literature Review Themes
Evaluation of Educational Interventions on Fluid and Diet Restriction for Haemodialysis Patients
A fundamental thesis in many studies was the need for fluid and diet restrictions. Diet and fluid restrictions are a crucial part of dialysis treatment and considerably impacts on the quality of life of haemodialysis patients. It is important to observe that there has been considerable development in education programmes in the field of ERF with regards to diet and fluid control (Barnett et al., 2008). The interventions to promote the prevention of complications due to uncontrolled fluid and diet restrictions are determined by the level of psycho-educational and behavioural interventions and increase patients knowledge of the possible complications (Devins et al., 2005).
The result of two studies suggests that the provision of written educational programmes and group intervention regarding pathophysiology of renal failure complications and stress management had better fluid and diet adherence (Wells, 2011). Despite these interventions this area of treatment management remains a challenging area for many patients. For instance, patient’s educational intervention alone may not help them to adhere to prescribed medication regime or understand the importance of necessary restrictions. A successful education programme must also hold factors such as motivation and constant support from nursing professionals (Peng et al., 2011).
Renal failure is associated with reduced urine output and thus retaining all the fluids in the body leading to excess fluid in the lungs, heart and ankles (Thomas, 2008). Lingerfelt and Thornton (2011) explain and list the resources for nurses to effectively provide education for haemodialysis patients with emphasis on fluid and diet control. They recommend a comprehensive educational programme to eliminate the possibility of patients facing multiple co-morbidities and increased mortality rate due to lack of disease and treatment specific knowledge.
Face to face individual session which allowed participants to ask questions and advocated to use an ESRD chart in special areas of diet and medication and treatment adherence are mentioned in the study (Williams, Manias, Walker & Gorelik, 2012). Nurses’ role in improving patients outcomes have been cited in four different studies (Lingerfelt & Thornton, 2011; Wells, 2011). Multidisciplinary approaches together with patient’s active participation in most cases have a resulted in decreased anxiety for both patients and their family and enhanced self-care strategies. This evidence shows a clear need for nurses to communicate with patients and their family to provide reassurance to enhance treatment outcome and thereby improve health and wellbeing.
Benefits of dietary restriction in renal failure patients are well documented. Adhering to strict control of reduced sodium, potassium, protein and phosphate intake has a significant impact on survival and health maintenance for haemodialysis patients (Thomas, 2008). The results of a number of studies have demonstrated weak to moderate positive and significant association between diet and non-adherence to treatment leading to poor results of serum potassium, phosphate and serum albumin levels.
Mason et al, (2008) in the empirical review reports of more than four studies, where research group conducted single session interventions to educate patients and improve motivation with regards to diet restriction have results of significant improvements. However, there are many other studies in the review that talk about different interventions such as structured dietary education with monthly review and behavioural control resulted in some significant improvement in fluid and diet control (Mason et al, 2008). Therefore a combination of one-off sessions to structured educational interventions can make a difference that is favourable to improve patient’s health and wellbeing.
It is not only the patients who are new to renal replacement therapy benefit from educational intervention, but also patients already established on dialysis reinforce the importance of gaining knowledge regarding self-management skills and specifically improve knowledge regarding diet control to reduce the adverse effect of raised minerals in the blood (Mason et al., 2008; Idier et al., 2011). Patient education programmes alone may not be sufficient to maintain diet control specific for renal failure and attain higher level of wellbeing unless education programmes are ongoing and evaluated by clinical staff (Schaefer & Wühl, 2012).
The dialysis team consisting of nurses, dietician and clinicians can meet the challenge of educating patient regarding their fluid and diet control through the development of formal education is cited by Lingerfelt & Thornton (2011). Wells, Lingerfelt & Thornton (2011) identified nephrology nurses are in constant contact with dialysis patients and are in a better position to continue and evaluate educational interventions. This could suggest that nurses and other multidisciplinary team encouraging patients have shown improved fluid control. Despite this best clinical practice, fluid and diet restriction remains a challenging subject for the nurses and multidisciplinary team as well as clinician’s point of view and suggests more study input.
Outcome of Treatment Adherence Following Educational Interventions in Haemodialysis Patients
Dialysis treatment is considered as the most frequent technique of treatment option for established renal failure patients consisting of 4-5 hour sessions three times a week and non-adherence to treatment is commonly observed in haemodialysis group of patients (Idier et al., 2011). Patients understanding of their disease, treatment options and developing self-care skills play an important part in improving adherence to treatment (Idier et al., 2011).
Patient involvement and concordance to treatment is cited in all studies reviewed, and it is an important factor determining the quality of life that can be attained in ERF. Empowering patients to become active participants in their own care through education and making informed treatment decisions allow them to well manage their illness and adhere more closely with their treatment.
The study conducted by Wells (2011) reports that, the effect of patient education and adherence to treatment shows significant increase in patients’ knowledge regarding haemodialysis but no significant increase in perceived medical concordance. It is important to note that the failure of adherence due to patients’ behavioural activity or perceived medical concordance needs further study as there is little evidence of research in this area.
Many studies support positive self management behaviour that can extensively influence treatment outcomes. According to self-determination theory, motivation such as pressure from another person or fear of consequences as well as internal factors like feeling of achievement or both can drive people’s behaviour. Although the treatment of ERF can be complex, adherence to medical regimes have positive outcomes (Wells, 2011). There is evidence of patients seeking information on topics such as clear advantages and disadvantages of different treatment options, and how certain functions of the normal kidneys are replaced with dialysis.
These patients offered with such comprehensive information were turned out to be placed in a better position to take informed choice of treatment and were prepared for adherence to selected treatment with significant positive outcomes. However, many studies lacked thorough evaluation and study design on the effect of educational interventions to improve behaviour and concordance in dialysis treatment.
Idier et al., (2011) suggests in the empirical review that results into adherence to treatment should be taken with caution as different studies assess adherence in different ways. Improving the knowledge of dialysis patients through education not always improve adherence or may not be sufficient to change their behaviour (Kaptein et al., 2010 & Sun et al., 2008). According to the World Health Organisation, adherence to treatment has been defined as the extent to which patient’s behaviour in strictly following the physician’s instructions or recommendation to restricting or following a strict diet control, taking prescribed medication and adapting to life style changes due to the illness.
The study by Wells (2011) where eighty-five participants were studied shows the relationship between knowledge and medical adherence and significant improvement in treatment adherence following educational intervention. However patient’s motivation such as constant encouragement in addition to knowledge scores is indicating and emphasising improvement in adherence to the prescribed treatment protocol.
The primary outcomes in many studies involved clinical and biological indicators of adequacy of treatment such as URR (Urea Reduction Ratio) and improved or normal potassium and phosphorous levels in the blood (Idier et al., 2011). It is worth noting that adequacy of dialysis is not entirely the result of adhering to treatment and strictly following medical recommendations, but also the mode of treatment as well as the components of treatments to the extent that is possible (Devins et al., 2005). Although the treatment modality and clinical factors influencing the treatment adequacy were not discussed in the study, there was a clear picture of educational interventions with a complete overview that placed patients in a better position to stick to the recommended treatment regime.
Lingerfelt & Thornton (2011) explain that patients face a life time of complications and co-morbidities generated by haemodialysis and increased mortality rate where patients are not given information regarding the importance of treatment adherence. The researcher emphasises the role of nurses and other multidisciplinary team members in promoting patients involvement in self-management behaviours as well as treatment adherence. Nephrology nurses are central to innovative approach to involve patients in their care to make positive outcomes (Costantini, 2006).
Evaluation of Educational Programmes on Psychological Outcomes and Motivation
Physical as well as psychological impact of chronic kidney disease and different treatments can be devastating for the patients and their family. ERF patients are often required to make decisions about their choice of treatment without having any information or experience about such therapies.
Additionally, educational interventions are given when patients are in an anxious and emotional state that may hinder ability to understand and ask questions to the nurses and other multidciplinary team involved in their health education and care (Katz et al., 2006). Patients’ demand for information regarding how to cope with treatments such as dialysis and everyday life has been cited in most of the research studies and empirical review articles reviewed (Lingerfelt & Thornton, 2011; Idier et al., 2011; & Wells, 2011).
Patients who participated in educational programmes showed improved mood, less sense of loneliness, and also reduced anxiety and improved emotional wellbeing. According to Mason et al., (2008) in addition to educational sessions counselling sessions and self-directed audio tapes was involved aiming for motivational mechanism as goal setting to achieve empowerment in treatment. This has been successful in improving the psychological factors associated with coping skills and adaptation to dialysis treatment. However some patients found to be reluctant to change their behaviour or adapt to change despite the information or educational interventions while others used it positively to make changes and therefore have improved health related quality of life (García-Llana et al., 2014).
Idier et al., (2011) in the empirical review, states that although physiological outcomes are predominant in assessing the effect of educational intervention in dialysis patients, psychosocial outcomes also play a vital role in improving the understanding the effects of patient education. The research result of the review article demonstrates the evidence of reduced stress of the disease and treatment as well as improvement in self-efficacy.
Wells (2011) in the study conducted on haemodialysis patients’ knowledge and adherence study reveals that behavioural activity or behavioural intent does not always change by educational interventions alone. Lingerfelt & Thornton (2011) also agree with this statement and suggests additional longitudinal studies behavioural changes which significantly affecting mortality and morbidity rates.
ERF patients’ perceived functioning and psychological wellbeing are basically subjective feeling and may be influenced by diverse factors like environmental and personal circumstances. Thus, there are other contributing factors causing anxiety, mood change and sense of loneliness in ERF patients. There are a number of environmental and individual circumstances causing psychological well being. For instance, educational interventions have an effect on the psychological wellbeing of these patients. The patients had the opportunity to discuss their concerns with the multidisciplinary team together with participation of relatives in the programme.
The reports shows that there were positive effect on the education programme especially when the patients were with the support of their relatives as they had joint discussions and emotional reactions to the illness and treatment choice. However, patients sense of coherence and psychological wellbeing are related each other. The patients with stronger sense of coherence had better health and wellbeing compared to patients with weaker sense of coherence. According to Nilsson et al., (2010) sense of coherence is determining the coping capacity of a person in stressful satiations and found to have improvement with increase in age and sex differences.
Mason et al., (2008) find that the primary outcome of many studies shows improvement in clinical parameters and only few studies were looked at psychological parameters of quality of life such as reduced anxiety or stress and less functional disabilities. However, there is a clear evidence of link between psychological motivation and improvement in concordance with dialysis treatment and fluid and diet control. According Mason et al., (2008), there is a clear evidence of decreased stress and depression in patients who were offered with peer mentoring or counselling that led to advanced directives and group adaptation training and these patients had a better adherence to treatment and improved quality of life.
Furthermore, younger dialysis patients were reported to have higher level of anxiety and more functional disabilities compared to older patients. This can be argued that young patients were less capable of coping with aggressive treatment such as dialysis. However, the purpose of all of these studies shows that educational interventions are aimed at improving both psychological and physical parameters of improved health and well being.
Discussion and Recommendations for Practice
Established renal failure affects patients’ everyday life and renal replacement therapies. For example, dialysis only corrects some of the functions of the kidney which require them to make substantial life style changes. This review has helped to identify the term quality of life for ERF patients that refer to the measures to the patient’s general well being in all aspects of physical and psychological domains. The availability of the research and information has significantly supported to develop the knowledge of how educational interventions could help improve the quality of life of dialysis patients.
This literature review is relevant to the objectives and has led to a number of findings that affect both clinical practice and further research (Chretien, 2011). This review has highlighted the need for educational interventions to improve knowledge and disease specific information to enhance the treatment outcomes in haemodialysis patients. According to Curtis et al. (2009) the common aspect of chronic illness such as renal failure is the apparent lack of control over the illness especially when the disease progresses to uncertainty or it leads to treatments such as dialysis to maintain life.
Quinan (2007) states that, ERF patients often find themselves in situation where they do not have complete control over their illness, whereas, control may be considered as a coping approach in times of uncontrollable situations (Brown, 2010). It is evident that educational interventions regarding the treatment such as dialysis and disease progress can be empowering patients and achieving motivation to self-care.
A plethora of research findings shows that adherence to renal replacement treatments have become an increasing problem without adequate information and increased knowledge levels related to their illness (Barnett et al., 2008). This review can help explain certain aspects of educational interventions such as adherence to treatment, fluid and diet control and behavioural motivation to follow their treatment plans and thrive, while in contrast there is evidence of aspects of treatment that is showing no improvement such as medication adherence and anaemia management through education alone.
Moreover, there appears to be a lack of exploration in this area of behavioural interventions among haemodialysis patients. On the other hand several studies shows that patient’s ability to understand the information or lack of trust in healthcare professionals plays a role in the failure of educational interventions aiming for a positive change. This could suggest the role of nurses and other multidisciplinary team in seeking out and listening to patients prospective, and encouraging an open discussion as well as supporting them in decision making process of treatment.
According to Harwood et al. (2005), many patients thought they would have done better in life if they had the proper information and knowledge with regards to their kidney disease and treatment such as dialysis. In this review, nurse’s role in providing education and guidance to dialysis patients is specified in all of the research studies as well as empirical articles.
Moreover, the literature review also suggests the degree of congruence between patients’ treatment and disease specific knowledge for self-care management and it is an important determinant of treatment adherence. Changes in nurse’s role as an educator not only benefit patients but also the entire healthcare work force delivering high quality care to dialysis patients both economically and significant improvement in treatment outcome in dialysis unit.
The research findings shows that though there has been some research on educational interventions to improve treatment adherence, the findings are not enough to determine the effect of patient education and quality of life of dialysis patients. More research ought to be conducted on the strategies as well as the appropriate referral time for education (Miaofen, Jeng-Jong & Hsiu-Lan, 2008). This important factor will aid the nurses and other health care team to develop more effective and robust strategies for patient education.
It is believed that providing education to dialysis patients within the six months of initiation of dialysis would have a positive effect on self-management and adherence to treatment (Lingerfelt & Thornton, 2011). However, according to Finkelstein et al. (2008), there are only limited published studies providing guidelines as to how and when to provide education to ERF patients. In addition, nurses or practitioners who provide education needs to consider the patients’ knowledge and understanding so that they can serve them in the most effective manner (Kauric-Klein, 2012).
Although the picture emerging from this study is reliable about the evidence that influence education in dialysis patient’s health outcome measurements, there is little evidence of positive changes in the attitudes and perceptions of family members and relatives who are actively participating in the care of dialysis patients (MacDougall-Rivers & Phillips, 2011). In addition, it is difficult to disentangle from the available study, which components of educational intervention in carers are likely to make positive changes in attitudes and behaviour. Family members can feel susceptible and insecure as the disease progresses.
Therefore, it is highly recommended for healthcare practitioners to assist family members who may be going through difficult time with dialysis patients. Additional study would be beneficial to understand the importance of providing information and recognising the family members’ role in psychological support for managing health issues during chronic illnesses. Clinical support centres should be opened and made easily accessible for dialysis patients (Behar-Horenstein, Guin, Gamble, Hurlock & Al, 2005).
Conclusion
This literature review was developed to evaluate the effect of patient education in different aspects of dialysis patient’s everyday life and wellbeing (Lopes et al., 2007). The primary finding of the literature review shows that ERF patients requiring dialysis treatment are facing numerous challenges of lifestyle changes such as diet and fluid restrictions and strict medication regimes to replace some of the lost kidney functions (MacDougall-Rivers & Phillips, 2011).
The review findings shows that educational interventions are necessary to underpin a patient centred care which ensures a much better health outcome and improved quality of life for dialysis patients and their families. Although there are no evidence of high quality studies that specifically measuring every aspects of the relation between patient education and quality of life of dialysis patients, the existing evidence suggests there is better health related quality of life for those patients who were given the opportunity to get answer to their questions relating to their disease and treatment through structured patient education.
The methodology of literature search was extensive that, it used the main sources of electronic database and web search engines to find published nursing articles to build a firm basis for the study. A growing number of literatures were identified relating to dialysis patient education and wellbeing but many of them did not meet the pre specified criteria of inclusion of studies for the review. This has limited the information to fully represent all aspects of the benefits of haemodialysis patient education and improved quality of life.
This has however, facilitated the researcher to identify gaps in research as well as develop recommendations for better nursing practice based on current evidence. Moreover, this is a key point in formulating further recommendations for best evidence based practice in clinical setting with regards to improving haemodialysis patients care (Harwood, Wilson, Sontrop & Clark, 2012).
This review has identified three main themes in the studies and has demonstrated an analytical approach to understand these findings. Although the aims and outcomes of the studies reviewed were varied, many measures were used to assess the effect of educational interventions in main themes of the study such as diet control, fluid restriction, psychological impact and adherence of treatment in haemodialysis patients.
The study has therefore, facilitated nurses to understand the measures to evaluate the effect of education to haemodialysis patients which included both clinical and positive behavioural outcomes to treatment regimes. Moreover, this is can be used by nurses and other clinical team as an evidence base for structuring more effective future educational programmes were also discussed in the study (Khalil & Abdalrahim, 2014).
Finally, this literature review aims to understand the definitive challenges and approaches in providing education among haemodialysis patients with an aim of making positive changes in patient’s wellbeing. The areas that have been discussed widely managed by nurses and therefore the information found in this review is crucial for the nursing team to prepare and highlight the best practice with respect to improving the quality of life of dialysis patients through proper educational interventions (Goldstein, 2006).
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Appendices
Appendix A
Flow diagram of selection of articles for the literature review
Appendix B
Check list
The following criteria must be met by the articles reviewed in the study:
- The article must be published in the current century and after 1995
- Of original research or original empirical review
- Only journal articles with nursing background
- The study should be specific to haemodialysis patients’ educational intervention
- Availability of all referencing information.
- All articles written in English
- Results focused on dialysis patient’s outcomes
Appendix C
PICO analysis (strategy for research question)
Patient Intervention Comparison Outcome