Adherence to Treatment: the Nurse's Role in Promoting Wellness in Patients Undergoing Treatment for End-Stage Kidney Disease

With more than 400,000 Americans currently on some form of dialysis, dialysis nurses who know how to provide good patient care and promote positive patient outcomes have become more important than ever (Johns Hopkins Medicine, 2005). One of the biggest obstacles these nurses face in providing quality care is non-adherence by their patients (Kammerer, Garry, Hartigan, Carter, & Erlich, 2007).
However, nurses can provide better quality care with improved outcomes by approaching dialysis care in a holistic manner. This includes giving patients a sense of control over their treatment, using positive reinforcement to help modify behavior, and incorporating spirituality into patient care.

According to White (2004), most American people already have trouble adhering to a healthy lifestyle and complying with prescribed medical treatments. Many diabetic patients do not exercise or control their weight or diet properly, and patients diagnosed with a bacterial infection and prescribed a ten-day course of antibiotics often do not finish out the course. So it is even more challenging for patients who are diagnosed with End-Stage-Renal-Disease (ESRD) because suddenly they are told they must follow a highly restrictive diet, limit their fluid intake, and follow a specific medical regimen which includes many medications and undergoing dialysis treatments at least two times a week. If they do not follow their treatment plans closely, serious complications often develop. Such a lifestyle change is a huge undertaking, and many dialysis patients can feel entirely overwhelmed. Therefore, it is no surprise that one of the biggest challenges dialysis nurses face is getting their patients to adhere to treatment regimens.

Many patients placed on dialysis believe they no longer have control over their lives. Some of these people may try to regain control in a negative way by deciding to shorten their treatment or not taking prescribed medications. Kammerer (2007) notes that some might feel such a loss of control that they develop a “sense of futility” and just give up, discontinuing all treatment (p. 481). Nurses can help combat these feelings of helplessness by involving the patient as much as possible in their healthcare decisions, informing them of all treatment options, and by placing an emphasis on self-care. Landreneau’s (2006) study found that the patients interviewed were not aware that they had any choices concerning treatment; in fact, they did not even know what the available options were. It was discovered that most patients do indeed want to be involved in making decisions regarding their treatment, and that more desirable outcomes occur as a result (Landreneau, 2006). In addition, nurses can give patients a sense of control by teaching them to perform as much self-care as possible. This can include preparing the dialysis machine, performing self-monitoring during hemodialysis, and choosing their own interventions based on signs and symptoms they have self-assessed. This type of self-care has recently been suggested as a strategy to improve adherence (Richard, 2006).

Just possessing the knowledge about their choices and treatment, though, is not necessarily enough to keep patients compliant. Studies have shown that patients must not only be made aware of available resources, but they must also have the motivation to follow a treatment plan (as cited in Kammerer, 2007). A method that has been met with some success by nephrology nurses is cognitive behavioral modification. This works on the premise that patients will not adhere to a treatment plan unless they feel it is “personally worthwhile” and stresses the importance of positive interactions and relationships between nurses and patients (White, 2004). Nurses must be sensitive to the needs and feelings of their patients, and leave them feeling that their opinions are important. Instead of lecturing patients about not maintaining their blood pressures, a nurse using the behavioral modification approach might ask his or her patients if they notice a difference in their appearance or in the way they feel on days when their blood pressure is high. By using this approach, nurses help patients become aware of the way their treatment works and how non-adherence can affect them personally.

Another way nurses can improve adherence while helping patients retain a sense of purpose is by incorporating spirituality into their care. Walton’s study in 2002 found that a patient’s spirituality, which includes faith, prayer-life, and “meaningful relationships,” provides a strong support system that can help the patient through the difficulty of dialysis treatment (as cited in Tanyi, 2006 ). As a result, Tanyi (2006) conducted a study to examine the role of the dialysis nurse in regards to spirituality. It was found that the level of care a nurse is perceived to have provided was directly affected by the nurse’s level of spirituality, their own as well as their patients’. The respondents stated that nurses could incorporate spirituality into their care not just by addressing religious issues, but also by displaying caring behaviors such as showing genuine concern for their patients’ well-being, active listening, and using therapeutic touch (Tanyi, 2006).

Because adherence to treatment is such a problem for dialysis patients, it is important for nurses to incorporate different strategies for adherence into their dialysis care plans. Giving patients more of a sense of control over their treatment, teaching them how the treatment affects them personally, and including spirituality as a part of care are some ways that dialysis nurses can combat non-adherence. When patients have a sense that they are in control of what happens to them, the outcomes are generally better (White, 2004). All three of these nursing approaches have patient empowerment as a common theme. As more of these methods are researched and utilized, dialysis patients will have much better success at consistently following their treatment plans.

Intervention #1
Nurses can use cognitive behavioral modification to promote adherence.
Disadvantage #1
It is important for patients with Chronic Kidney Disease (CKD) and End Stage Kidney Disease (ESRD) to monitor and maintain strict control of their blood pressures, reduce proteinuria in order to slow down the progression of the disease, and to take all medications as prescribed (Costantini, 2008). This requires a patient’s active involvement in his or her treatment and frequent self-assessment of symptoms. However, many of these patients have no apparent symptoms, and therefore find it difficult to take seriously the need for adhering to a treatment plan. It is very difficult for some patients to grasp the severity of their disease, since many experience no adverse effects until the disease has progressed towards the end-stages. As one patient remarked about his disease, “There’s no way it could be that bad, you feel good... (Costantini, 2008).”

Disadvantage #2
In order for cognitive behavioral modification to work, the patient must have a certain level of cognition and ability to learn. Research has suggested that people who have kidney disease can have some cognitive impairment as a result of their disease, and those with End-Stage Renal Disease (ESRD) are much more likely to be cognitively impaired than those in earlier stages of the disease (Hain, 2008). This can be a vicious cycle because pathologies that exist with kidney disease can be exacerbated by non-adherence to treatment and can cause worsening cognitive impairment. Older dialysis patients have many risk factors for vascular dementia which include older age, hypertension, and diabetes. With the number of people who are 65 and older and undergoing dialysis steadily rising, and 16% of the dialysis population 75 or older, cognitive impairment is a big factor in adherence. This is because cognitive impairment can impact decision-making, medication compliance, ability to learn, and the ability of patients to perform self-assessments, all of which are key components of cognitive behavioral modification. Nurses working with these populations will have to learn to recognize when a patient is non-adherent due to cognitive impairment and adopt different approaches to teaching those patients.

Intervention #2
Nurses can improve adherence by incorporating spirituality into their patients’ care.

Disadvantage #1
Heavy patient loads leave little time for addressing spiritual issues, and dialysis nurses tend to have extremely heavy workloads. A dialysis nurse typically oversees the treatment of between 25-30 patients in a 12 hour shift, which can mean administering 200 injections in that time (MacReady, 2008). With this kind of patient load, it can be very difficult to find the time to do things that are usually considered “extras,” such as discussing patients' faith with them, and still practice safe nursing care.

Disadvantage #2
Losing empathy for their patients can be another barrier to incorporating spirituality into patient care. Studies have shown a direct link between nurse burnout and loss of empathy (Bodin, 2008). Because of their heavy patient loads, nurse burnout is a big problem with nurses who work in dialysis units (MacReady, 2008). Burnout can cause job dissatisfaction, which in turn leads to high turnover rates among dialysis nurses, and, as a result, heavier patient loads. It is a problem that continues to perpetuate itself. In a recent survey, twenty percent of the dialysis nurses that were interviewed planned to leave their jobs (MacReady, 2008). It is very difficult for people to be caring and compassionate when they are exhausted, and don’t feel a sense of satisfaction in the work they do.






Health in Dialysis: the Nurse’s Role in Promoting Wellness in Patients Undergoing Treatment for End-Stage Kidney Disease
Julia Morris
Nursing 131
Rachelle Ligrano








With more than 400,000 Americans currently on some form of dialysis, dialysis nurses who know how to provide good patient care and promote positive patient outcomes have become more important than ever (Johns Hopkins Medicine, 2005). One of the biggest obstacles these nurses face in providing quality care is non-adherence by their patients (Kammerer, Garry, Hartigan, Carter, & Erlich, 2007). However, nurses can provide better quality care with improved outcomes by approaching dialysis care in a holistic manner. This includes giving patients a sense of control over their treatment, using positive reinforcement to help modify behavior, and incorporating spirituality into patient care.
According to White (2004), most American people already have trouble adhering to a healthy lifestyle and complying with prescribed medical treatments. Many diabetic patients do not exercise or control their weight or diet properly, and patients diagnosed with a bacterial infection and prescribed a ten-day course of antibiotics often do not finish out the course. So it is even more challenging for patients who are diagnosed with End-Stage-Renal-Disease (ESRD) because suddenly they are told they must follow a highly restrictive diet, limit their fluid intake, and follow a specific medical regimen which includes many medications and undergoing dialysis treatments at least two times a week. If they do not follow their treatment plans closely, serious complications often develop. Such a lifestyle change is a huge undertaking, and many dialysis patients can feel entirely overwhelmed. Therefore, it is no surprise that one of the biggest challenges dialysis nurses face is getting their patients to adhere to treatment regimens.
Many patients placed on dialysis believe they no longer have control over their lives. Some of these people may try to regain control in a negative way by deciding to shorten their treatment or not taking prescribed medications. Kammerer (2007) notes that some might feel such a loss of control that they develop a “sense of futility” and just give up, discontinuing all treatment (p. 481). Nurses can help combat these feelings of helplessness by involving the patient as much as possible in their healthcare decisions, informing them of all treatment options, and by placing an emphasis on self-care. Landreneau’s (2006) study found that the patients interviewed were not aware that they had any choices concerning treatment; in fact, they did not even know what the available options were. It was discovered that most patients do indeed want to be involved in making decisions regarding their treatment, and that more desirable outcomes occur as a result (Landreneau, 2006). In addition, nurses can give patients a sense of control by teaching them to perform as much self-care as possible. This can include preparing the dialysis machine, performing self-monitoring during hemodialysis, and choosing their own interventions based on signs and symptoms they have self-assessed. This type of self-care has recently been suggested as a strategy to improve adherence (Richard, 2006).
Just possessing the knowledge about their choices and treatment, though, is not necessarily enough to keep patients compliant. Studies have shown that patients must not only be made aware of available resources, but they must also have the motivation to follow a treatment plan (as cited in Kammerer, 2007). A method that has been met with some success by nephrology nurses is cognitive behavioral modification. This works on the premise that patients will not adhere to a treatment plan unless they feel it is “personally worthwhile” and stresses the importance of positive interactions and relationships between nurses and patients (White, 2004). Nurses must be sensitive to the needs and feelings of their patients, and leave them feeling that their opinions are important. Instead of lecturing patients about not maintaining their blood pressures, a nurse using the behavioral modification approach might ask his or her patients if they notice a difference in their appearance or in the way they feel on days when their blood pressure is high. By using this approach, nurses help patients become aware of the way their treatment works and how non-adherence can affect them personally.
Another way nurses can improve adherence while helping patients retain a sense of purpose is by incorporating spirituality into their care. Walton’s study in 2002 found that a patient’s spirituality, which includes faith, prayer-life, and “meaningful relationships,” provides a strong support system that can help the patient through the difficulty of dialysis treatment (as cited in Tanyi, 2006 ). As a result, Tanyi (2006) conducted a study to examine the role of the dialysis nurse in regards to spirituality. It was found that the level of care a nurse is perceived to have provided was directly affected by the nurse’s level of spirituality, their own as well as their patients’. The respondents stated that nurses could incorporate spirituality into their care not just by addressing religious issues, but also by displaying caring behaviors such as showing genuine concern for their patients’ well-being, active listening, and using therapeutic touch (Tanyi, 2006).
Because adherence to treatment is such a problem for dialysis patients, it is important for nurses to incorporate different strategies for adherence into their dialysis care plans. Giving patients more of a sense of control over their treatment, teaching them how the treatment affects them personally, and including spirituality as a part of care are some ways that dialysis nurses can combat non-adherence. When patients have a sense that they are in control of what happens to them, the outcomes are generally better (White, 2004). All three of these nursing approaches have patient empowerment as a common theme. As more of these methods are researched and utilized, dialysis patients will have much better success at consistently following their treatment plans.




References

Bodin, S. (Mar/Apr 2008). Keeping individuals with kidney disease safe: raising awareness of the effects of nurse fatigue. Nephrology Nursing Journal, 35, 115-116. Retrieved May 8, 2008, from ProQuest database.

Costantini, L., Beanlands, H., McCay, E., & Cattran, D. (Mar/Apr 2008). The self-management experience of people with mild to moderate chronic kidney disease. Nephrology Nursing Journal, 35, 147-154. Retrieved May 8, 2008, from ProQuest database.

Hain, D. (Jan/Feb 2008). Cognitive function and adherence of older adults undergoing hemodialysis. Nephrology Nursing Journal, 35, 23-29. Retrieved May 8, 2008, from ProQuest database.

Johns Hopkins Medicine (2005, August 1). Dialysis treatment choice affects risk of death in patients with end-stage kidney disease. Retrieved January 14, 2008, from http://www.hopkinsmedicine.org/Press_releases/2005/08_01_05.html

Kammerer, J., Garry, G., Hartigan, M., Carter, B., & Erlich, L. (Sep/Oct 2007). Adherence in patients on dialysis: strategies for success. Nephrology Nursing Journal, 34, 479-486. Retrieved January 16, 2008, from ProQuest database.

Landreneau, K., & Ward-Smith, P. (Jul/Aug 2006). Patients’ perceptions concerning choice among renal replacement therapies: A pilot study. Nephrology Nursing Journal, 33, 397-402. Retrieved April 10, 2007, from ProQuest database.

MacReady, N. (April 2008). System Overload. Dialysis & Transplantation, 118-122.
Richard, C. (Jul/Aug 2006). Self-care management in adults undergoing hemodialysis. Nephrology Nursing Journal, 33, 387-394. Retrieved January 16, 2008, from ProQuest database.

Tanyi, R., Werner, J., Recine, A., Sperstad, R. (Sep/Oct 2006). Perceptions of incorporating spirituality into their care: A phenomenological study of female patients on hemodialysis. Nephrology Nursing Journal, 33, 532-538. Retrieved October 14,2007, from ProQuest database.

White, R. (Jul/Aug 2004). Adherence to the dialysis prescription: Partnering with patients for improved outcomes. Nephrology Nursing Journal, 31, 432-435. Retrieved January 16, 2008, form ProQuest database.