Quality of Life in Patients With End Stage Renal Disease on Hemodialysis

8/10/2019 Quality of Life in Patients With End Stage Renal Disease on Hemodialysis

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Quality of Life in Patients with End-StageRenal Disease on Hemodialysis

Tondra Ivey & Briaca Lane

This paper was written for Dr. Sauter.

AbstractPatients with renal failure face many challenges due to their condition

which may leave them feeling fatigued and depressed. Most of these patientschoose to be placed on hemodialysis which can be debilitating and canthreaten body image, nances, relationships and independency. Studies havebeen conducted to identify the factors that contribute to the quality of life in

patients who are on dialysis to determine what strategies can be implementedto improve quality of life. The purpose of this study was to examine the qualityof life in patients with End-Stage Renal Disease (ESRD) on hemodialysis.Data collection took place at West Georgia Dialysis in LaGrange, Georgia.A convenience sample of 63 patients was used in the study. The meanage was 57 years, 57.1% were female and 74.6% were African American.Approximately 69.8 % had a high school diploma or higher education, 95.2%were unemployed, disabled or retired and 42.9% were married. Participants

completed Ferrans & Powers Quality of Life Index Dialysis Version III inwhich they were asked to rate satisfaction and importance of 68 items thatmeasure overall quality of life. Participants also completed a demographicsurvey which ascertained age, race/ ethnicity, education, employment, maritalstatus and number of chronic illnesses. Five scores were produced by Ferrans& Powers Quality of Life Index Dialysis Version III that measured quality of lifeoverall and quality of life in four domains: health and functioning, social andeconomic, psychological/ spiritual, and family. The possible range of scores

for each subscale was 0 to 30. Results showed a mean overall quality of lifescore of 23.2 (SD 4.0). Findings suggest that patients receiving hemodialysisas treatment for End Stage Renal Disease have a fair perception of theirquality of life. This study provides healthcare providers with ways to identifythe patients quality of life as well as to plan and implement strategies to helpenhance it.

IntroductionBefore dialysis was available, patients with renal disease faced imminent

death. However, since the development of treatment modalities such asdialysis and renal transplant, the life of renal patients have been improvedand prolonged. Hemodialysis is a treatment option available for patientsexperiencing renal insufciency, in which a machine is used to act out thefunction of the kidney such as ltering the blood and excretion of by-products.Considering the risks that may occur with the treatment options available,


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many choose to be placed on dialysis. However, hemodialysis treatment maybe debilitating. Patients with renal failure face many challenges due to theircondition which may leave them feeling fatigued and depressed. Body image

may be affected by stula or grafting for dialysis access. Finances may beaffected by the high cost of weekly treatments for dialysis and occasionaladmission to the emergency department due to complications. Relationshipsand independency are also threatened. Studies have been conducted toidentify the factors that contribute to the quality of life in patients who are ondialysis to determine what strategies can be implemented to improve qualityof life. The purpose of this study was to examine the quality of life in patientswith End-Stage Renal Disease (ESRD) on hemodialysis. Researchers want toincrease knowledge that will improve nursing practice, ultimately enhancingquality of life for these patients.

A literature review was commenced to identify the quality of life inpatients experiencing renal failure. The literature search was performedusing the Cumulative Index of Allied Health Literature (CINAHL), an electronicdatabase from 1995 through 2010. The search terms included: quantitativestudies, renal failure, quality of life, ferrans & powers, hemodialysis. Thetools used in the studies included the Jaloweic Coping Scale, ChronicKidney Disease (CKD) Stress Inventory (Harwood, Wilson, Locking-Cusolito,

Sontrop & Spittal, 2009), Ferrans and Powers Quality of Life Index DialysisVersion III (Greene, 2005), a Dialysis Demographic Form, Dialysis SymptomIndex, Hospital Anxiety and Depression Scale, Fatigue Visual Analog ScaleInventory of Functional Status- Dialysis, Palliative Performance Scale (Kring& Crane, 2009). Participants in these studies were mostly in large groupswho were patients at dialysis centers across the globe. Harwood et al (2009)measured stressors and identied coping methods used by 226 patients withchronic kidney disease who are not on dialysis. Greene (2005) explored the

perceptions of 98 African American patients with ESRD who were receivinghemodialysis and compared those perceptions by age. Kring & Crane (2009)performed a study using 73 patients with ESRD to describe the quality of lifeand examine the factors that inuence it.

In the Harwood et al (2009) study, 226 patients with chronic kidneydisease who were not on dialysis were evaluated using the Jaloweic CopingScale and the CKD Stress Inventory. The Jaloweic Coping Scale is a 60item questionnaire that is used to identify coping methods and their effect

on the specic situation. The items are classied into eight coping styles:confrontation, evasive, optimistic, fatalistic, emotive, palliative, supportant,and self- reliant. The CKD Stress Inventory was developed specically forthe purpose of this study to identify stressors and evaluate their intensity.The results indentied six stressors that had high intensity: fatigue, sleepproblems, peripheral neuropathy, muscle cramps, restless legs, and shortness


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of breath. The Jaloweic Coping Scale indentied that the optimistic copingstyles was the most likely used and effective coping strategy overall. Nextwere confrontive, supportant, self- reliant, palliative, evasive, fatalistic and

emotive, in that order.Data collection for the Kring and Crane (2009) study took place atan outpatient dialysis clinic. The study used a Dialysis DemographicForm which included age, gender, race, employment, time on dialysis,marital status, socioeconomic status as well as recent serum albumin andhemoglobin levels. The Dialysis Symptom Index was used to measure 30of the most common physical and emotional symptoms experienced bypatients on dialysis and the severity and frequency of those symptoms.Each patient was asked if the symptom had been experienced within thepast week. If yes, to what degree was the symptom bothersome on a5-point likert scale (1=not at all and 5=very much). The Hospital Anxietyand Depression Scale was developed to identify patients at risk for anxietyand depression on a 14-item questionnaire. The Fatigue Visual AnalogScale was used to measure fatigue. The Inventory of Functional Status-Dialysis was developed for patients to identify and evaluate the activitiespatients engage in. The participants were asked to rate the degree ofparticipation in a typical week in the past month on a 4-point scale. The

Palliative Performance Scale was used to measure the decline in functionthat is experienced by patients who are terminally ill. The patients classiedaccording to ambulation, activity/ evidence of disease, self-care, intake andlevel of consciousness. The General Perception of Health was measuredby asking the question How would you rate your health on a scale of 1 to10, with 1= poor and 10=excellent? The Ferrans & Powers Quality of LifeIndex Version III was also used in this study. The results of the study (Kring& Crane, 2009) suggest that persons with ESRD experience a relatively

comparable quality of life given their symptom burden and intensive therapy.Participants in the Greene (2005) study were drawn from a convenience

sample of African American patients on dialysis in Washington, DC. Thesample was sub grouped according to age into 4 categories: 26 to 45 years(n=23); 46 to 55 years (n=23); 56 to 65 years (n=28); and 66 and older (n=24).Participants were interviewed using Ferrans & Powers Quality of Life Indexof Dialysis Version III. Five quality of life subscales were analyzed usingage as the research variable: health and functioning, social and economic,

psychological and spiritual, family and total quality of life. Greene (2005)found that the quality of life of African Americans with ESRD increased asthey aged for all subscales except psychological and spiritual. The resultssuggested that younger patients with ESRD had a lower perception ofquality of life than the older individuals.

All studies suggested that determination of quality of life in


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renal failure patients can be used to measure the outcomes of therapy.Understanding the factors that inuence well being will allow nurses to focuson specic interventions for enhancing quality of life (Kring & Crane, 2009).

Knowledge gained from these studies can be applied to education andsupportive interventions for patients with chronic kidney disease (Harwood etal, 2009)

The conceptual framework that was used to guide this study wasthe revised version of Wilson and Clearys (1995) Model for Health-RelatedQuality of Life (Ferrans et al., 2005). This framework encompasses fourmain determinants to overall quality of life: biological function, symptoms,functional status and general health perceptions (Kring, 2008, p. 13). Thesedeterminants, as well as overall quality of life, are ultimately affected by thecharacteristics of the individual and the environment (Ferrans et al., 2005,Kring, 2008)

The revised model clearly indicates the association between thedeterminants (Figure 1.1). The rst determinant is the biological function,which is the cell functions supporting life. These are easily accessed throughlaboratory test, physical assessment and medical diagnoses. The seconddeterminant is symptoms, which refers to physical, emotional, and cognitivesymptoms that the patient expresses. The third determinant, functional

status, consists of physical, psychological, social, and role function. Thefourth determinant, general health perceptions, includes subjective ratings ofthe valued determinants. Overall quality of life is the concept of how satisedsomeone is with their life in general (Ferrans et al., 2005). Ferrans et al (2005)revised model focuses more on the effects of the decits in functioning andhow it impacts a persons daily life while continuing to measure the fourdomains of functioning (Kring, 2008). The arrows represent the relationships ofthese concepts and effect they have on one another that reects the patients

perception of their quality of life.Research Questions

1. What are hemodialysis patients perceptions of their quality of life?2. What factors do ESRD patients perceive as important with regards

to helping them cope with the life style changes and hardships caused byhemodialysis?

3. Does hemodialysis have a positive or negative impact on quality oflife?

Methods The study was reviewed and approved by the Lagrange CollegeInstitutional Review Board and Nursing Faculty prior to data collection. Inaddition, permission was granted from the director of West Georgia DialysisCenter. Patients were approached by a researcher to ascertain interest andreceive verbal and written explanation of the purpose, benets and risks


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associated with the study. Those who were interested in participating in thestudy were asked to review and sign the consent form. Each participantreceived a copy of the signed consent form for their records. Participation

in this study was voluntary. Subjects were fully informed of their rights todecline or withdraw from participation in the study if desired. Condentialitywas maintained on all data collection forms by using codes to identify eachparticipant. A master list of patients was kept separate from data collectionforms. All information was kept in a locked le cabinet and shredded after dataanalysis.

Participants A descriptive design was used to examine the quality of life in patients

with ESRD. Data collection took place at West Georgia Dialysis in Lagrange,Georgia. Participants were selected from a convenience sample. A total of 63patients were used in the study. Inclusion criteria of 18 years of age or older,able to read, write and speak English, and have the cognitive ability to answersurvey questions and give consent.

Materials and Procedure The instruments used for data collection included a general

demographic survey as well as Ferrans and Powers Quality of Life IndexDialysis Version III. The demographic survey, developed by researchers,

ascertained age, gender, ethnic origin (race), education, marital status,employment status, and any comorbidity.

Researchers received permission from Dr. Carol Estwing Ferrans forthe use of the Quality of Life Index (QLI) Dialysis Version III. This instrumentwas developed by Ferrans and Powers to measure quality of life in terms ofsatisfaction with life (1985). This instrument measures both satisfaction as wellas the importance of certain aspects of their life. Importance ratings are usedto weight the satisfaction responses, so that scores reect the respondents

satisfaction with the aspects of life they value. The items rated most importanthave a larger impact on the scores than those of less importance. Theinstrument contains two parts, each containing thirty-four items: the rstmeasuring satisfaction with certain aspects of life and the second measuringthe importance of those same aspects. There are four domains: healthand functioning (HFSUBa), psychological/ spiritual (PSPSUBc), social andeconomic (SOCSUBb) and family (FAMSUBd) as well as overall quality of lifeare scored (Ferrans, 1996; Ferrans &; Powers, 1985; Ferrans & Powers, 1992;

Ferrans, 1990; Warnecke, Ferrans, Johnson, &et al., 1996). The Quality of Life Index is a self-administered questionnairecontaining 68 questions that are answered on a scale of 1-6. 1 indicates verydissatised and 6 indicates very satised. This instrument has an internalconsistency reliability that ranges from .73 to .99, using the Cronbachs alpha,across 48 studies. The QLI was tested for sensitivity to change in ESRD and


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hemodialysis patients using Cronbachs alpha scoring between .88 to .93(Ferrans & Powers, 1992). Researchers set up appointments at West GeorgiaDialysis on two different weekly sessions. The participants were asked to

complete the demographic survey as well as the QLI questionnaire.Results Statistical analyses were performed using the Statistical Package for

the Social Science (SPSS) as well as Microsoft Excel 2010. Demographiccharacteristics of the sample are presented in Table 1.1. The mean agewas 57 years, 57.1% were female and 74.6% were African American.Approximately 69.8 % had a high school diploma or higher education, 95.2%were unemployed, disabled or retired and 42.9% were married. Five scoreswere produced by Ferrans & Powers Quality of Life Index Dialysis Version IIIthat measured quality of life overall and quality of life in four domains: healthand functioning, social and economic, psychological/ spiritual, and family. Thepossible range of scores for each subscale was 0 to 30.

The mean score for the overall quality of life was 23.2 (SD 4.0)(Table1.2). Scores in this category ranged from 4.16 to 28.50. Scores were highest inthe psychological/spiritual (PSPSUBc) subscale ranging from 1.71 to 30, witha mean score of 26.1 (SD 4.7). This subscale included items pertaining to faith,achieving personal goals, happiness, peace of mind, and satisfaction with life

in general. Considering ages by decade, there were no signicant differencesbetween QOL scores. However, when comparing male and female scoresin the health and functioning subscale (HFSUBa), a signicant differencewas noted (p=0.042) (Table 1.3). Males had a mean score of 23 and femaleshad a mean score of 20.5 (Table 1.4). The remaining subscales showed nosignicant differences.

Discussion The results of this study concluded that patients with end-stage renal

disease on hemodialysis generally have a fair perception of their quality oflife. This information may correlate with the length of time these patientshave been receiving dialysis treatments. The health and functioning subscaleincluded factors such as health, healthcare, fatigue, worries, ability to takecare of family responsibilities and changes made in life because of kidneyfailure. Men viewed their health and functioning substantially higher than thewomen. However, considering the age range of the patients who participatedin this study, many of the female patients may be experiencing menopause.

This factor may contribute to their perceptions of quality of life at this time. For future studies it will be essential for researchers to consider thelength of time that the patients have been receiving dialysis treatments. Thisvariable may greatly affect the quality of life in these individuals. In this attemptto examine the quality of life in patients with end stage renal disease onhemodialysis, we did not address the length of time these patients have been


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on dialysis. A larger and more diverse population can be utilized to generalizestudy ndings more appropriately.

Studying these phenomena can be benecial to both the patient

and the healthcare professional through the knowledge gained. This studyprovides healthcare providers with ways to identify the patients quality of lifeas well as to plan and implement strategies to help enhance it. It can also beeducating for the patient by increasing their awareness that may affect theirquality of life.

References

Burns, N., Grove, S. (2003). Understanding Nursing Research.Philadelphia: W.B. Sanders Co.

Ferrans, C., & Powers, M. (1985). Quality of Life Index: Development andpsychometric properties. Advances in Nursing Science, 8, 15-24.

Ferrans, C. E. (1990). Development of a quality of life index for patientswith cancer. Oncology Nursing Forum, 17(3), 15-19.

Ferrans, C., & Powers, M. (1992). Psychometric assessment of the Qualityof Life Index. Research in Nursing and Health, 15, 29-38.

Ferrans, C. (1996). Development of a conceptual model of quality of life.Scholarly Inquiry for Nursing Practice: An International Journal,10(3), 293-304.

Greene, R.A (2005). Using the Ferrans and Powers Quality of Life Indexof Dialysis: A Comparison of Quality of Life in Older and

Younger African Americans Receiving Hemodialysis. Topics inGeriatric Rehabilitation. Vol.21, No. 3,pp 230-232

Harwood, L., Wilson, B., Locking-Cusolito, H., Sontrop, J., & Spittal, J.

2009). Stressors and Coping in individuals with Chronic Kidnely Disease. Nephrology Nursing Journal , 265-275, 301.Jablonski, A. (2007). The Multidimensional Characteristics of symptoms

Reported by patients on Hemodialysis. Nephrology NursingJournal , 29-38.

Kring, D., (2008). Using the revised Wilson and Cleary model to explorefactors effecting quality of life in persons on hemodialysis.

Kring, D., & Crane, P. (2009). Factor affecting Quality of life In Persons on

Hemodialysis. Nephrology Nursing Journal , 15-24, 55.Warnecke, R., Ferrans, C., Johnson, T., et. al. (1996). Measuring qualityof life in culturally diverse populations. Journal of the NationalCancer Institute Monographs, 20, 29-38.


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Figure 1.1

Figure 1.1 Revised Wilson and Cleary model for health-related qualityof life. Adapted from Linking Clinical Variables with Health-Related Qualityof Life: A Conceptual Model of Patient Outcomes, by I.B. Wilson and P.D.Clearly, 1995.

Figure 1.2


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Table 1.1

Description of Sample

Age (Years) n %

2938 5 83948 12 19.2

4958 15 24

5968 18 28.6

>69 13 20.8

Gender

Male 27 42.9

Female 36 57.1

Ethnicity

African American 47 74.6

Caucasian 16 25.4

Other 0 0

Marital Status

Not Applicable 1 1.6

Married 27 42.9

Single 15 23.8

Divorced 14 22.2

Widowed 6 9.5

Education

Not Applicable 5 7.9


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Table 1.2

Ferrans & Powers Quality of Life Index Dialysis

N Mean

Std.

Deviation

Overall QOL 63 23.1902 3.97524

HFSUBa 63 21.5958 5.03400

SOCSUBb 63 22.0813 4.14805

PSPSUBc 63 26.0850 4.71605FAMSUBd 63 25.3762 4.93463

Table 1.3

ANOVA Summaries for Male Versus Female Quality of Life

Sum of

Squares df Mean Square F Sig.

Between Groups 21.266 1 21.266 1.353 .249

Within Groups 958.490 61 15.713

Overall

Quality of

Life Total 979.756 62

Between Groups 103.624 1 103.624 4.307 .042

Within Groups 1467.526 61 24.058

HFSUBa

Total 1571.150 62

Between Groups 25.465 1 25.465 1.492 .227

Within Groups 1041.329 61 17.071

SOCSUBb

Total 1066.794 62

Between Groups 4.910 1 4.910 .218 .642

Within Groups 1374.037 61 22.525

PSPSUBc

Total1378.948 62

Between Groups 61.258 1 61.258 2.580 .113

Within Groups 1448.476 61 23.746

FAMSUBd

Total 1509.734 62


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Table 1.4

Males

QLI HFSUBa SOCSUBb PSPSUBc FAMSUBd

N Valid 27 27 27 27 27

Mean 23.8611 23.0767 21.3472 26.4074 26.5148

Females

QLI HFSUBa SOCSUBb PSPSUBc FAMSUBd

N Valid 36 36 36 36 36

Mean 22.6871 20.4851 22.6319 25.8433 24.5222

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Quality of Life in Patients With End Stage Renal Disease on Hemodialysis