Dialysis Patients and Self-Care: Intervention Approaches that Work - Essay Example

?Table of Contents ………………………………………………………………………..2 Introduction………………………………………………………………………3 Problem Identification…………………………………………………………….4 Solution Description………………………………………………………………5 Research Support………………………………………………………………….5 Implementation Plan……………………………………………………………….9 Evaluation Plan…………………………………………………………………….11 Decision Making……………………………………………………………………12 Conclusion………………………………………………………………………..13 Sources Used………………………………………………………………………15 Appendix…………………………………………………………………………….18 Dialysis Patients and Self-Care: Intervention Approaches that Work Abstract When patients have certain diseases, such as hypertension or diabetes, they often suffer from a secondary concern which is known as End stage renal disease (ESRD) or End stage renal failure (ESRF) (Sonnier, 2000, p. 5). ESRD and ESRF is diagnosed when the patient loses 85% to 90% of kidney function, which necessitates dialysis, because kidneys can no longer remove toxins from the blood. Dialysis circulates blood on one side of a semipermeable membrane, while the other side circulates dialysis fluid. (Answers.com). Patients on dialysis have to spend four hours, three times a week, which makes dialysis treatment very demanding for the patient (Sonnier, 2000, p. 5). Dialysis patients must adhere to fluid and dietary restrictions, and, if patients do not comply with fluid and dietary restriction protocol, then there is a greater chance of death for that patient. There have been various measures which have been used to try to address this problem, and this project will address three of them - information reinforcement, behavior modification and cognitive behavioral therapy. The solution is a combination of information reinforcement techniques, cognitive behavioral therapy and behavioral modification techniques. Information reinforcement techniques worked in the Barnett (2007) study - after 26 weeks, this group reduced their average IDWG from 2.64 kg to 2.21 kg, and the rate of fluid adherence increased from 47% to 71.5% (Barnett et al. pp. 304-305). Cognitive behavioral therapy has proven effective in the research – for instance, a study conducted by Christensen et al. (2002). In this study the intervention group received a protocol of 9 steps. In this protocol, the patients were taught about self-monitoring, setting goals, coping, reinforcement, and evaluation (Christensen et al., 2002, p. 393).  Their study proved to be effective after 8 weeks – the control group gained around 3.3 pounds, while the intervention group lost around 3 pounds (Christensen, et al., 2002, p. 396).   Behavioural modification is another model that has been studied with regards to dialysis patients and compliance with protocols and regimens. For instance, a study by Hegel et al. (1992) found that the reinforcement produced the greatest drop in IDWG, and that this drop in IDWG was persistent over time – the IDWG continued to be lowered two months after the intervention, even though, during this period of time, the patients only received information about graphing and monitoring (Hegel et al., 1992, p. 326). It is feasible to implement into a work setting, as there is not a need for special equipment. There is a need for special training, but the methods are easy to learn and implement. Because of this, it would be consistent with community culture and resources, because it would not be overly taxing for resources. Introduction When patients have certain diseases, such as hypertension or diabetes, they often suffer from a secondary concern which is known as End stage renal disease (ESRD) or End stage renal failure (ESRF) (Sonnier, 2000, p. 5). ESRD and ESRF is diagnosed when the patient loses 85% to 90% of kidney function, which necessitates dialysis, because kidneys can no longer remove toxins from the blood. Dialysis circulates blood on one side of a semipermeable membrane, while the other side circulates dialysis fluid. (Answers.com). Patients on dialysis have to spend four hours, three times a week, which makes dialysis treatment very demanding for the patient (Sonnier, 2000, p. 5). Dialysis patients must adhere to fluid and dietary restrictions, and, if patients do not comply with fluid and dietary restriction protocol, then there is a greater chance of death for that patient. Problem Identification Self-care is important for patients on dialysis, and they must adhere to a strict regimen that is prescribed to them before their initial dialysis treatment. Patients often do not self-care correctly or comply with their prescribed regiments. Therefore, there is a need for solutions to this problem. Such solutions might include education – patients may learn why self-care is necessary, and may be given the tools for proper self-care. Patients may also go through behavior modification (Ricka, et al., 2002, p. 329). Compliance is similar to self-care, only compliance focuses upon the correlation between compliance with the prescribed regimen and outcomes (Ricka, et al., 2002, p. 331). Patients must comply with a variety of dietary issues when they are on dialysis – they must regulate their protein intake, as well as limit their electrolytes (such as potassium and sodium). They must also take vitamins, and lower their fluid intake (Finn & Alcorn, 1986, p. 67). Because fluid compliance causes stress, because the patient must change his or her behavior so drastically, this is considered one of the most difficult compliance measures for a patient (Sonnier, 2000, p. 6). If a patient experiences fluid overload, this is very serious for the patient because the body cannot produce urine. In the short term, the patient may experience nausea, muscle cramping, dizziness, hypertension and shortness of breath. In the long-term, the patient may experience edema, congestive heart failure, disease process that are accelerated and may even die (Sonnier, 2000, p. 6). A patient’s non-compliance is detected physiologically by the fact that the patient might show a catabolic rate that is impaired, may gain weight, and may have impaired serum potassium levels (Finn & Alcorn, 1986, p. 69). Alternatively, their blood urea nitrogen and serum phosphorous levels may be elevated (Takaki, et al. 2003, p. 525). Solution Description The solution is a combination of information reinforcement techniques, cognitive behavioral therapy and behavioral modification techniques. Information reinforcement techniques worked in the Barnett (2007) study - after 26 weeks, this group reduced their average IDWG from 2.64 kg to 2.21 kg, and the rate of fluid adherence increased from 47% to 71.5% (Barnett et al. pp. 304-305). Cognitive behavioral therapy has proven effective in the research – for instance, a study conducted by Christensen et al. (2002). In this study the intervention group received a protocol of 9 steps. In this protocol, the patients were taught about self-monitoring, setting goals, coping, reinforcement, and evaluation (Christensen et al., 2002, p. 393).  Their study proved to be effective after 8 weeks – the control group gained around 3.3 pounds, while the intervention group lost around 3 pounds (Christensen, et al., 2002, p. 396).   Behavioural modification is another model that has been studied with regards to dialysis patients and compliance with protocols and regimens. For instance, a study by Hegel et al. (1992) found that the reinforcement produced the greatest drop in IDWG, and that this drop in IDWG was persistent over time – the IDWG continued to be lowered two months after the intervention, even though, during this period of time, the patients only received information about graphing and monitoring (Hegel et al., 1992, p. 326). It is feasible to implement into a work setting, as there is not a need for special equipment. There is a need for special training, but the methods are easy to learn and implement. Because of this, it would be consistent with community culture and resources, because it would not be overly taxing for resources. Research Support Impact of information reinforcement           Information reinforcement was the first kind of intervention that will be discussed. The Transtheoretical Model is one such type of information reinforcement. In TTM, the patient changes gradually, in five different stages. First is precontemplation – this is where the patient develops the mindset that provides the patient with the ability to make a long-term change. In contemplation, the patient is given information that raises that patient’s consciousness about the task at hand. It is during this period that the patient is given education about dietary fluid sources, and what interdialytic weight gain is. Preparation is the next step, and this is where the patient prepares to make a change. This might mean that the patient strategizes about to decrease fluid intake, writing down concrete ways that the goals of decreasing fluid intake and IDWG. Action is the next step, and this is where the patient takes all the tools and strategies and implements them into his or her own life. Maintenance is the fifth and final step, and this is where the patient continues to use the skills and knowledge to maintain proper IDWG and fluid intake (Molaison & Yadrick, 2001, p. 5).  Their study found that the adherence rate to IDWG was not increased, in line with previous studies, such one by Meichenbaum and Turk (1987) (Molaison & Yadrick, 2001, p. 10). Casey et al. (2002) also studied information reinforcement for dialysis patients, studying three blocks over six weeks. Each of the patients studied went through the first block, which is where they received standard advice regarding compliance. In their second block, each of the patients saw a dietician, and the dietician provided for the patients information regarding fluid intake and overall information regarding healthy habits. In the patients’ third block, the patients received information that was tailored for them (Casey et al.  p. 44).   The results of this intervention, as with the previous intervention regarding information reinforcement, was discouraging – the patients gained 2.6 kg in the first block, 2.3 kg in the second block, and 2.4 kg in the third (Casey et al. p. 44).   Effect of Active Learning and Cognitive Behavioural Treatment           The studies listed above show that giving patients information does little to affect how much their behavior might change, except with long-term dialysis patients. Therefore, more and different intervention treatments must be studied, and one such intervention strategy was cognitive behavioural treatment coupled with active learning. Patients who are actual participants in learning, as opposed to being passive learners, might have better outcomes than those that are simply provided information. Tsay and Hung (2003) conducted one such study on the issue of active learning and compliance. In their study, the patients were empowered by developing skills and an awareness on how to set goals and solve problems. They were also taught about stress management and the importance of social support, and how to develop this social support. Further, they were made aware of how they could increase their motivation to change. This intervention recognized that compliance, or lack thereof, has social roots, as well as psychological ones, so it set to address these social issues. The researchers found in this instance that the patients were able to overcome psychosocial barriers to change, so they became more ready to change. This helped them achieve their goals, and decreased overall dissatisfaction with the process of (Tsay & Hung, 2003, p. 63).  The patients in the intervention group were also significantly less depressed than those in the control group, and there was more effective self-care in the intervention group than in the control group as well. The patients were more able to handle stress and became more positive that they could change their own behavior. Because the patients were more likely to believe that they could change, they were also more likely to change and were more likely to comply with their self-care regimen (Tsay & Hung, 2003, p. 63).           Another study by Ekers and Kingdon (2003) featured five subjects who received six sessions of CBT. tested cognitive behavioural therapy (CBT) on five subjects who were offered six session of CBT. The plan included education, problem solving and coping strategies, self-monitoring and relapse prevention. Two of the subjects improved in their IWG, and this improvement was persistent through follow-up. One subject improved, then relapsed by the time of follow up. A fourth subject never improved and had to have a kidney transplant. Also, overall, the patients’ work and social lives did not improve (Ekers & Kingdon, 2003, p. 17). Behavioural Modification Methods           Behavioural modification is another model that has been studied with regards to dialysis patients and compliance with protocols and regimens. One such study was conducted by Sonnier (2000). In this study, the patients were either monitored or given monetary rewards in the first four weeks of the study. During the second four weeks, the patients were given both monetary rewards and monitoring. In the third four weeks, they were given either monetary rewards or monitoring, and in the fourth four weeks they were given both. The patients were given money according to how little weight they gained between dialysis sessions – the less weight gained, the more the monetary reward, although all the rewards were small, ranging from fifty cents to three dollars (Sonnier, 2000, p. 22).  Sonnier found that only one patient met the treatment goal (Sonnier, 2000, pp. 23-24).            Another study that centered around cognitive behavioural intervention strategies is that conducted by Hegel et al. (1992). Two groups were studied – one group received traditional behavioural modification and another group received rewards that included the ability to watch private videos and private television while they underwent dialysis, and were also given the chance to earn lottery tickets. Moreover, the patients in this group signed a contract regarding their behavior. The researchers also reinforced behavior management for those in the second group who did not meet the criteria by giving that person behavior management facts. They found that the reinforcement added to the second group’s protocol produced the greatest drop in IDWG, and that this drop in IDWG was persistent over time – the IDWG continued to be lowered two months after the intervention, even though, during this period of time, the patients only received information about graphing and monitoring (Hegel et al., 1992, p. 326).  Implementation Plan The best course of action is combining CBT with BM, and education for the family. This would help to empower patients and change his or her belief system, and it also be a way for the family to be involved and to know how to help the patient. The family has to know what behaviours might be sabotaging to the patient, and how to help the patient monitor his or her IDWG and fluid intake.          The implementation strategy will therefore involve CBT, and will be six weeks long. The patient will have to begin by logging fluid and diet for two months before implementation. This should be a detailed diary that would spell out when the patient was non-compliant and why. A sample diary might be provided to the patient, so that the patient will know how to fill it out. The patient might write something like he or she was not compliant on Day X because their relatives were in from out of town, and everybody wanted to go out for pizza and beer. Or that they were non-compliant because they went to a birthday party and had chips, cake and soda. Emotions might be logged in – the person might be stress eating and drinking, and this would be pinpointed in the diary as well. People have triggers, and the best way to pinpoint a trigger is to keep a diary. Then, these triggers might be worked on through CBT by providing the person with specific strategies for how to cope with each situation that might cause the patient to be non-compliant. Along with specific strategies for handling certain social and emotional situations, the patient might also learn general strategies for coping and complying. Information may be provided to the patient, that would go along with working on the specific triggers. Knowledge about self-care and the importance of self-care might be reinforced each week. Also, in the diary, there might be a space where the patient can detail any negative beliefs that may be barriers to compliance. A patient might believe that he or she does not have to comply because dialysis will mitigate the damage that they might do through their actions. If this is a belief, then CBT may be used to target this belief so that the belief is fundamentally changed. The patient will be given information about dialysis, and how dialysis is limited and isn’t going to filter toxins with as much efficiency as a working kidney, and it is dangerous to not comply with treatment protocols. The information reinforcement will emphasize this and be combined with CBT to fundamentally change the patients’ thoughts and beliefs.          Rewards is also going to be a part of the therapy for the patients. The patients can get tokens that would go towards getting certain rewards, such as having his or her name in a raffle to win a position in a private room during dialysis, during which time the patient can watch a movie of his or her choice, or a television program that he or she chooses. The tokens may be earned for properly filling out the journal entries regarding IDWG, fluid compliance and dietary compliance. If the log is filled out, the patient earns a single token. If the patient is compliant, according to the journal, the patient will earn two tokens. If the patient is shown to be compliant through physiological measures - catabolic rate, serum and potassium levels and IDWG, then this earns the patient two more tokens. If the patient does not care about the movies and television, then the patient may choose other prizes from a list. The list might include lottery tickets or other items that are low-cost but provide high psychological reward.          Family counseling is another important component of the treatment protocol. The family must be involved every step of the way, so that the family also knows the dangers of non-compliance and how to help the patient comply. The family might have the same false beliefs that the patient does – that the dialysis machine will do the work of a kidney, therefore it would not be detrimental to serve the patient junk food and alcohol. The family must have information reinforcement, and, if necessary, CBT to change their fundamental beliefs. They also must know how to help the patient cope with certain circumstances, and how to help the patient manage his or her emotions so that the emotions do not result in non-compliance. Just like with the patient, the family needs to complete a journal, so that any kind of detrimental behaviours or beliefs can be targeted for information and CBT. Evaluation Plan In evaluating the plan, an interdisciplinary team should be assembled. This interdisciplinary team may consist of organizational leaders, bedside clinicians and other stakeholders who might have an interest in the solution. This team may review the outcomes of the patients who are involved in the intervention, and, if the outcomes are not in line with where they should be, this team may examine the discrepancies and attempt to implement a new solution (Newhouse et al., 2007). Outcome Measures The outcome measure will be based upon the SF-36 health survey questionnaire (Appendix), which is a 36 item questionnaire that takes about five minutes to complete (Brazier et al., 1992). This outcome measure is reliable and valid, as the internal consistency was ruled acceptable by Brazier et al., (1992), and, for all dimensions of the survey, 91-98% of the cases were within the 95% confidence interval for a normal distribution. Moreover, the researchers also found that the distribution of the scores for the measure was what was expected, which provided evidence of construct validity, and that the expected relations for convergent and discriminant validity were also satisfied (Brazier et al, 1992). The SF-36 is a general health care questionnaire, but it would be relevant to the patient population, because the measures that are a part of the SF-36 would measure the patient’s overall sense of well-being, which would be a reflection on how well they are feeling in general. Evaluation Data Collection The data will be collected from all the patients who take part in the intervention. The resources necessary for this data collection would be the questionnaires that go out to the patients, as well as proctors who can collate the questionnaires and ensure that these questionnaires are filled out in a timely and proper manner. The feasibility of the plan is high, as the questionnaires are short, which means that the patients are likely to fill them out, therefore the only obstacle will be in collecting them and ensuring that they are forwarded to the researchers on the project. Decision Making The methods that will be used to decide the future of the solution is that the patients who are prescribed each of the intervention methods will be followed over a period of one year. At the end of the one year, the outcome measures will be examined, and the outcomes that show the most promise will be implemented. After this outcome is implemented on a permanent basis, it will be maintained by implementing it in different hospitals and doctors offices who agree to participate in this solution, and the healthcare interdisciplinary team that was involved in evaluating the measures initially will be in charge of evaluating the solutions as time goes on. If the outcome measure needs to be revised, then this same interdisciplinary team will look at the data that is available and work together on a solution on tweaking the measure. If the measure needs to be terminated, this interdisciplinary team will communicate this to the participating doctors and hospitals through a letter and e-mail. Moreover, throughout the project, the researcher will solicit feedback by sending the doctors and hospitals questionnaires for them to fill out which would detail how they feel that the project is working, and why. The questions will be open and closed-ended, so that the health care professionals can elaborate on what aspect that they think is working best, and why. Conclusion A dialysis patient must comply with self-care if the patient is going to maintain a reasonable degree of health while he or she is waiting for a new kidney. They have to maintain their weight, and they have to monitor their fluid intake. They also must abide by certain dietary restrictions. This is difficult for patients to do. They’re human, and, as such, they face temptations every day, and they also might be faced with the fact that they have no social support for their struggle. The patient must not only know why compliance is necessary, and have this information reinforced on a regular basis, but also must know how to comply and they also must have their overall belief system changed. The best way to do this is by combining CBT and BM, along with information intervention and family intervention. This is a holistic approach that would work the best with kidney dialysis patients, according to the research provided. Sources Used Barnett, T., Yoong, T., Pinikahana, J., Si-Yen, T. (2007) Fluid compliance among patients having haemodialysis: can an educational programme make a difference?” Jan Original Research, pp. 300-306. Brazier, J., Harper, R., Jones, N., O’Cathain, A., Thomas, K., Usherwood, T. & Westlake, L. (1992) Validating the SF-36 health survey questionnaire: New outcome measure for primary care. British Medical Journal, 305, pp. 160-164. Casey, J., Johnson, V., McClelland, P. (2007) Impact of stepped verbal and written reinforcement of fluid balance advice within an outpatient haemodialysis unit: A pilot study. Journal of Human Nutrition and Dietetics 12.2, pp. 43-47. Christensen, A., Moran, P., Wiebe, J., Ehlers, S., Lawton, W. (2002) Effect of a behavioral self-regulation intervention on patient adherence in hemodialysis. Health Psychology, 21.4, 393-397. Ekers, D., Kingdon, D. (2003) Can cognitive behavioural psychotherapy assist adherence to fluid restriction with dialysis patients: A case series. Clinical Effectiveness in Nursing, 7.1, 15-17. Finn, P., Alcorn, J. (1986) Noncompliance to hemodialysis dietary regimens: Literature review and treatment recommendations. Rehabilitation Psychology, 31.2, 67-78. Hegel, M., Ayllon, T., Oulton, G. (1992) Improving adherence to fluid restrictions in male hemodialysis patients: A comparison of cognitive and behavioral approaches. Health Psychology, 11.5, 324-330. Molaison, E., Yadrick, M. (2003) Stages of change of fluid intake in dialysis patients. Patient Education and Counseling, 49, 5-12. Ricka, R., Vanrenterghem, Y., Evers, G.(2002) Adequate self-care of dialysed patients: A review of the literature. International Journal of Nursing Studies, 39, 329-339. Sonnier, B. (2000) Effects of self-monitoring and monetary reward on fluid adherence among adult hemodialysis patients. Dissertation prepared for the Degree of Doctor of Philosophy, University of North Texas (December), 1-69. Tsay, S. (2003) Self-efficacy training for patients with end-stage renal disease. Issues and Innovations in Nursing Practice, 370-375. Tsay, S., Hung, L. (2004) Empowerment of Patients with End-Stage Renal Disease – a Randomized Controlled Trial. International Journal of Nursing Studies, 41, 59-65. Appendix RAND 36-Item Health Survey 1.0 Questionnaire Items Unformatted version 1. In general, would you say your health is: Excellent 1 Very good 2 Good 3 Fair 4 Poor 5 2. Compared to one year ago, how would your rate your health in general now? Much better now than one year ago 1 Somewhat better now than one year ago 2 About the same 3 Somewhat worse now than one year ago 4 Much worse now than one year ago 5 The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line) Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports [1] [2] [3] 4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [1] [2] [3] 5. Lifting or carrying groceries [1] [2] [3] 6. Climbing several flights of stairs [1] [2] [3] 7. Climbing one flight of stairs [1] [2] [3] 8. Bending, kneeling, or stooping [1] [2] [3] 9. Walking more than a mile [1] [2] [3] 10. Walking several blocks [1] [2] [3] 11. Walking one block [1] [2] [3] 12. Bathing or dressing yourself [1] [2] [3] During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Circle One Number on Each Line) Yes No 13. Cut down the amount of time you spent on work or other activities 1 2 14. Accomplished less than you would like 1 2 15. Were limited in the kind of work or other activities 1 2 16. Had difficulty performing the work or other activities (for example, it took extra effort) 1 2 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Circle One Number on Each Line) Yes No 17. Cut down the amount of time you spent on work or other activities 1 2 18. Accomplished less than you would like 1 2 19. Didn't do work or other activities as carefully as usual 1 2 20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (Circle One Number) Not at all 1 Slightly 2 Moderately 3 Quite a bit 4 Extremely 5 21. How much bodily pain have you had during the past 4 weeks? (Circle One Number) None 1 Very mild 2 Mild 3 Moderate 4 Severe 5 Very severe 6 22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (Circle One Number) Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks . . . (Circle One Number on Each Line) All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time 23. Did you feel full of pep? 1 2 3 4 5 6 24. Have you been a very nervous person? 1 2 3 4 5 6 25. Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 6 26. Have you felt calm and peaceful? 1 2 3 4 5 6 27. Did you have a lot of energy? 1 2 3 4 5 6 28. Have you felt downhearted and blue? 1 2 3 4 5 6 29. Did you feel worn out? 1 2 3 4 5 6 30. Have you been a happy person? 1 2 3 4 5 6 31. Did you feel tired? 1 2 3 4 5 6 32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? (Circle One Number) All of the time 1 Most of the time 2 Some of the time 3 A little of the time 4 None of the time 5 How TRUE or FALSE is each of the following statements for you. (Circle One Number on Each Line) Definitely True Mostly True Don't Know Mostly False Definitely False 33. I seem to get sick a little easier than other people 1 2 3 4 5 34. I am as healthy as anybody I know 1 2 3 4 5 35. I expect my health to get worse 1 2 3 4 5 36. My health is excellent 1 2 3 4 5   Read More