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Fielding C, Bramley L, Stalker C, Brand S, Toft S, Buchanan H. Patients' experiences of cannulation of arteriovenous access for haemodialysis: A qualitative systematic review. J Vasc Access 2023; 24:1121-1133. [PMID: 35034481 PMCID: PMC10631276 DOI: 10.1177/11297298211067630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/27/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cannulation is an essential part of haemodialysis with arteriovenous access. Patients' experiences of cannulation for haemodialysis are problematic but poorly understood. This review aims to synthesise findings related to patients' experiences of cannulation for haemodialysis from qualitative studies, providing a fuller description of this phenomenon. METHODS Eligibility criteria defined the inclusion of studies with a population of patients with end-stage kidney disease on haemodialysis. The phenomena of interest was findings related to patients' experiences of cannulation for haemodialysis and the context was both in-centre and home haemodialysis. MedLine, CINAHL, EMBASE, EMCARE, BNI, PsycInfo and PubMed were last searched between 20/05/2019 and 23/05/2019. The quality of studies was assessed using the using Joanna Briggs Critical Appraisal Checklist for Qualitative Research. Meta-aggregation was used to synthesise findings and CERQual to assess the strength of accumulated findings. RESULTS This review included 26 studies. The subject of included studies covered cannulation, pain, experiences of vascular access, experiences of haemodialysis and a research priority setting exercise. From these studies, three themes were meta-aggregated: (1) Cannulation for haemodialysis is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability and dependency. (2) The necessity of cannulation for haemodialysis emphasises the unpleasantness of the procedure. Success had multiple meanings for patients and patients worry about whether the needle insertion will be successful. (3) Patients survive unpleasant, necessary and repetitive cannulation by learning to tolerate cannulation and exerting control over the procedure. Feeling safe can help them tolerate cannulation better and the cannulator can invoke feeling safe. However, some patients still avoid cannulation, due to its unpleasantness. CONCLUSIONS Cannulation is a pervasive procedure that impacts on patients' experiences of haemodialysis. This review illuminates further patients' experiences of cannulation for haemodialysis, indicating how improvements can be made to cannulation. REGISTRATION PROSPERO (CRD42019134583).
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Affiliation(s)
- Catherine Fielding
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Louise Bramley
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Sarah Brand
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Suzanne Toft
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Weitkamp K, Feger F, Landolt SA, Roth M, Bodenmann G. Dyadic Coping in Couples Facing Chronic Physical Illness: A Systematic Review. Front Psychol 2021; 12:722740. [PMID: 34759866 PMCID: PMC8573212 DOI: 10.3389/fpsyg.2021.722740] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/27/2021] [Indexed: 01/09/2023] Open
Abstract
Objective: Chronic physical illness affects not only patients but also their partners. Dyadic coping (DC)-the ways couples cope in dealing with a stressor such as chronic illness-has received increased attention over the last three decades. The aim of the current study was to summarize the state of research on DC in couples with chronic physical illnesses. Methods: We conducted a systematic review of qualitative, quantitative, and mixed-methods studies published between 1990 and 2020, assessing DC in couples affected by severe physical illnesses. We used DC and related search terms for the literature search in Psycinfo, Psyndex, and Medline. Five thousand three hundred thirty studies were identified in three electronic databases and 49 of these were included in the review (5,440 individuals reported on 2,820 dyads). We excluded studies on cancer, cardiovascular disease, and multiple sclerosis because of existing reviews in the respective fields. Half of the studies included were on diabetes. Other studies were on arthritis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, human immunodeficiency virus (HIV), Huntington's disease, lupus erythematosus, Parkinson's disease, renal diseases, stroke, and endometriosis. Two raters extracted data using a predefined protocol, including study quality. Results were collated in a narrative synthesis organized by illness and DC operationalization. Results: Overall, DC was associated with beneficial outcomes in physical health, well-being, and relationship satisfaction. Differential effects became apparent for certain chronic conditions potentially depending on certain disease characteristics, such as early-onset, sudden-onset, or life-threatening conditions. Conclusion: Facing challenges together as a couple seemed indispensable for adapting to a diverse range of demands related to chronic illnesses with some specific demands of particular chronic diseases. There is a need for the development of truly dyadic interventions with an eye on the specific challenges of the various chronic conditions.
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Affiliation(s)
- Katharina Weitkamp
- Clinical Psychology Children/Adolescents and Couples/Families, University of Zurich, Zurich, Switzerland
| | - Fabienne Feger
- ZHAW Zurich University of Applied Science, Zurich, Switzerland
| | - Selina A Landolt
- Clinical Psychology Children/Adolescents and Couples/Families, University of Zurich, Zurich, Switzerland
| | - Michelle Roth
- Clinical Psychology Children/Adolescents and Couples/Families, University of Zurich, Zurich, Switzerland
| | - Guy Bodenmann
- Clinical Psychology Children/Adolescents and Couples/Families, University of Zurich, Zurich, Switzerland
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Khan I, Pintelon L, Martin H, Khan RA. Exploring stakeholders and their requirements in the process of home hemodialysis: A literature review. Semin Dial 2021; 35:15-24. [PMID: 34505311 DOI: 10.1111/sdi.13019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 06/16/2021] [Accepted: 07/26/2021] [Indexed: 11/27/2022]
Abstract
Providing home hemodialysis (HHD) therapy is a complex process that not only requires the use of a complex technology but also involves a diverse group of stakeholders, and each stakeholder has their requirements and may not share a common interest. Bringing them together will require the alignment of their interests. A process management perspective can help to accomplish the alignment of their interests. To align their interests, it is crucial to identify interest groups and understand their interests. The main objective of this paper is to identify the stakeholders and represents their interests as a list of requirements in the HHD process. An extensive literature review has been carried out and PubMed was used for literature extraction. In total, 1848 articles were retrieved of which 80 have fulfilled the inclusion criteria. A large array of actors is identified and their interests/requirements at different stages of the HHD process are represented in the form of a list. They have both common and conflicting requirements in the HHD process. If these requirements are aligned and balanced, a stakeholder's driven treatment process will be developed and a real improvement will be achieved in the treatment process.
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Affiliation(s)
- Ilyas Khan
- Center for Industrial Management, KU Leuven, Leuven, Belgium
| | | | - Harry Martin
- Faculty of Management, Sciences & Technology, Dutch Open University, Heerlen, The Netherlands
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Sousa H, Ribeiro O, Figueiredo D. End-stage renal disease is not yours, is not mine, is OURS: Exploring couples lived experiences through dyadic interviews. Hemodial Int 2021; 25:361-371. [PMID: 33763973 DOI: 10.1111/hdi.12929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION As a psychosocial dyad, couples are greatly challenged by end-stage renal disease (ESRD). Renal replacement therapies are highly demanding and involve lifelong restrictions and readjustments that sometimes translate into profound changes in couples' routines. However, little is known about the experiences of these couples with this condition. This study examined the experiences of couples living with ESRD. METHODS A qualitative exploratory study was conducted with a purposive sample. Semistructured dyadic interviews were conducted with 12 patients (65.1 ± 12.8 years old; eight males) undergoing in-center hemodialysis for 18.6 (±13.3) months and their spouses (60.3 ± 11.2 years old; seven females). The interviews were digitally audio-recorded, transcribed verbatim, and submitted to thematic analysis by two independent researchers. FINDINGS The findings from the dyadic perspective were conceptualized into two major themes: negative impacts (emotional distress, constraints on leisure and daily activities, impacts on couples' dynamics, and difficulties in meal planning) and unmet needs (educational, relational, financial, instrumental, and supportive needs). DISCUSSION The findings suggested that ESRD has several negative impacts that are related to the reported unmet needs, which might difficult couples' psychosocial adjustment to the condition. Both partners may benefit from educational and supportive interventions that address their needs, targeting the couple as a unit. Recognizing ESRD as a family condition is crucial for the development of innovative family-based interventions that can promote couples' healthy adjustment to the disease.
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Affiliation(s)
- Helena Sousa
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
| | - Oscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
| | - Daniela Figueiredo
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
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5
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Fielding CA, Hadfield A, White K, Waters D, James C, Buchanan H, Fluck RJ, Selby NM. A narrative systematic review of randomised controlled trials that compare cannulation techniques for haemodialysis. J Vasc Access 2021; 23:212-224. [PMID: 33427013 DOI: 10.1177/1129729820983174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cannulation of arteriovenous access for haemodialysis affects longevity of the access, associates with complications and affects patients' experiences of haemodialysis. Buttonhole and rope ladder techniques were developed to reduce complications. However, studies that compare these two techniques report disparate results. This systematic review performs an in-depth exploration of RCTs, with a specific focus on cannulation as a complex intervention. METHODS A PICO question and protocol was developed as per PRISMA-P guidance and registered on PROSPERO (CRD42018094656 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=112895). The systematic review included any RCT performed on adult patients with end-stage kidney disease undergoing cannulation of arteriovenous fistulae or grafts for in-centre haemodialysis, as performed by healthcare staff. Assessment of quality of RCTs and data extraction were performed by two co-authors independently. Data were extracted on the study design, intervention and comparator and outcomes, including patency, infection and patients' experiences. RESULTS The literature search identified 241 records. Ten records met inclusion criteria, which described five different RCTs that compared buttonhole to either rope ladder or usual practice. Results were disparate, with patency and infection results varying. Pain Visual Analogue scores were the only measure used to capture patients' experiences and results were inconclusive. All RCTs had differences and limitations in study design that could explain the disparity in results. CONCLUSION Current evidence does not allow definitive conclusions as to whether buttonhole or rope ladder needling technique is superior. Future RCTs should describe interventions and comparators with adequate detail, embed process evaluation, use standardised outcome measures and build on feasibility studies to produce definitive results.
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Affiliation(s)
- Catherine A Fielding
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,UK Renal Registry, Bristol, UK
| | - Amanda Hadfield
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Kelly White
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Dan Waters
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Cathryn James
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Richard J Fluck
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nicholas M Selby
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,University of Nottingham, Nottingham, UK
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Frontini R, Sousa H, Ribeiro Ó, Figueiredo D. "What do we fear the most?": Exploring fears and concerns of patients, family members and dyads in end-stage renal disease. Scand J Caring Sci 2020; 35:1216-1225. [PMID: 33615525 DOI: 10.1111/scs.12940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION End-stage renal disease (ESRD) and the need for haemodialysis (HD) treatment are increasing. The course of the disease and all the life readjustments needed may generate a multitude of fears in patients and families. AIM This study aimed to explore the main fears and concerns of patients with ESRD undergoing HD and their family members. STUDY DESIGN A qualitative study was performed. METHODS Individual semi-structured interviews were conducted with three groups: 20 patients, 14 family caregivers and 15 patient-family dyads. Interviews were audiotaped, transcribed verbatim and submitted to thematic analysis. FINDINGS Five major themes emerged: (i) fear of death (fear of earlier death, fear of a sudden death and fear of dying); (ii) fear of problems during HD (fears related to the vascular access, and fear of complications during HD); (iii) concerns related to the disease (fear of loss of autonomy, fears of getting worse, fears related to renal transplantation and concerns about dietary restrictions); (iv) fear about the future; and (v) absence of fears and concerns. DISCUSSION Patients with ESRD undergoing HD and their family members expressed different fears related to the disease and the treatments required. Renal care staff must acknowledge and understand such concerns and help patients and families to cope. This is important to improving people's quality of life (QoL), the dialogue between health professionals, patients, and family members, and the care offered by the dialysis care settings. Moreover, this study highlights the impact this disease has at a familial level. Future family-based interventions should acknowledge possible fears and concerns of this population and integrate them into their programs.
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Affiliation(s)
- Roberta Frontini
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
| | - Helena Sousa
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
| | - Óscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS.UA), Department of Education and Psychology, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
| | - Daniela Figueiredo
- Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro (Campus Universitário de Santiago), Aveiro, Portugal
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Moore C, Wearden A, Carter LA, Mitra S, Skevington SM. Development of a measure for patients preparing to start dialysis and their partners: The Starting Dialysis Questionnaire (SDQ). Health Qual Life Outcomes 2020; 18:358. [PMID: 33160381 PMCID: PMC7648298 DOI: 10.1186/s12955-020-01610-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/23/2020] [Indexed: 01/24/2023] Open
Abstract
Background The transition onto dialysis is a stressful time that affects both patients and their partners. Research suggests that psychological and interpersonal characteristics within the couple are related to how well they adapt to dialysis. The aim of this multi-phase, mixed methods study was to develop a measure, the Starting Dialysis Questionnaire (SDQ), that is applicable to both patients and their partners and assesses their own thoughts and feelings about these constructs. Methods Data from semi-structured interviews with patients and their partners (n = 22 couples) were analysed using theoretical thematic analysis to identify and define constructs related to quality of life (QOL). Next, items addressing these constructs were derived from the interviews. Then, cognitive interviews were conducted with patients with chronic kidney disease and their partners (n = 5 couples) to assess the face validity and comprehensibility of the items. Lastly, preliminary psychometric properties were evaluated in a sample of patients preparing to start dialysis and their partners (n = 83 couples). Results Three themes related to QOL were identified, namely dialysis expectations, accepting dialysis and dyadic relationship characteristics. The cognitive interviews refined the SDQ and established its face validity. Psychometric assessments indicated that overall the items performed well and did not show significant floor or ceiling effects. Good internal consistency was found within the three domains, and items correlated within the domains. Conclusions The SDQ is a measure (34 items) that assesses key psychological and interpersonal factors in patients and their partners as they start dialysis. It shows good preliminary psychometric properties; however, a large-scale field trial is needed to establish its validity. Once validated, it could offer a clinically useful tool to assist clinicians in preparing patients and partners for dialysis.
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Affiliation(s)
- Currie Moore
- School of Health Sciences, Division of Psychological Sciences and Mental Health, Manchester Centre for Health Psychology, Coupland Building I, University of Manchester, Oxford Road, Manchester, M13 9PL, UK. .,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Alison Wearden
- School of Health Sciences, Division of Psychological Sciences and Mental Health, Manchester Centre for Health Psychology, Coupland Building I, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Lesley-Anne Carter
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Sandip Mitra
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK.,NIHR Devices for Dignity, MedTech Cooperative, Sheffield, UK
| | - Suzanne M Skevington
- School of Health Sciences, Division of Psychological Sciences and Mental Health, Manchester Centre for Health Psychology, Coupland Building I, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Walker RC, Tong A, Howard K, Darby N, Palmer SC. Patients’ and caregivers’ expectations and experiences of remote monitoring for peritoneal dialysis: A qualitative interview study. Perit Dial Int 2020; 40:540-547. [DOI: 10.1177/0896860820927528] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Peritoneal dialysis (PD) can offer more flexibility and independence compared with hemodialysis, yet uptake of PD remains low. Barriers to PD include the fear of dialyzing without medical assistance and uncertainty about recognizing and managing complications. There is increasing use of remote monitoring in automated peritoneal dialysis (APD), but little is known about its acceptability by patients and caregivers. We aimed to describe patients’ and caregivers’ expectations and experiences of remote monitoring for APD. Methods: Qualitative study design, using semi-structured face-to-face interviews of patients who either receiving PD or were considered eligible for PD, and their caregivers. Transcripts were analyzed using thematic analysis. Results: Of the 34 participants, 27 were patients and the remainder caregivers. Four themes (with subthemes) were identified reducing patient burden (seeking reassurance and shared responsibility, convenience and accuracy); strengthening partnerships in care (empowering knowledge and understanding, increased accountability to dialysis team); improving access to treatment (saving time and money, providing timely care and avoiding hospital); and preserving quality patient–provider interactions (enhancing face-to-face contact, clarifying expectations of access and use of data). Conclusions: Remote monitoring may increase patient knowledge about their kidney disease and its treatment, encourage accountability to the clinical team, enhance partnerships with clinicians, and improve access to treatment and timely care. It is also important to ensure that remote monitoring does not replace face-to-face clinical contact with clinicians.
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Affiliation(s)
| | - Allison Tong
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Natasha Darby
- Department of Nephrology, Hawke’s Bay District Health Board, Hastings, New Zealand
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
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Moore C, Skevington S, Wearden A, Mitra S. Impact of Dialysis on the Dyadic Relationship Between Male Patients and Their Female Partners. QUALITATIVE HEALTH RESEARCH 2020; 30:380-390. [PMID: 31478450 DOI: 10.1177/1049732319869908] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The objective of this study was to explore the impact of three early phases of renal dialysis, namely pre-dialysis, starting dialysis, and establishing dialysis, on dyadic relationships. Twenty UK-based dyads (20 male patients and their female partners) participated in semi-structured interviews and discussed the effects of dialysis on themselves and their relationship. Dyadic thematic analysis, facilitated by dyadic-level charting, integrated participants' experiences and enabled identification of patterns across dyads. We found that dialysis had positive and negative influences on identity, social relationships, and mental health, forming the themes: Prioritizing the Patient, Carrying the Burden, and Changing Identities. The final theme, Managing the Relationship, described how dyads prevented dialysis from negatively impacting their relationship. Dyadic-level charting provided a systematic examination of individual and dyadic experiences. These findings indicate that access to informational and support services for dyads as they prepare to start dialysis may minimize negative effects on their relationship.
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Affiliation(s)
- Currie Moore
- School of Health Sciences and Manchester Centre for Health Psychology, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, United Kingdom
| | - Suzanne Skevington
- School of Health Sciences and Manchester Centre for Health Psychology, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, United Kingdom
| | - Alison Wearden
- School of Health Sciences and Manchester Centre for Health Psychology, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, United Kingdom
| | - Sandip Mitra
- Manchester Academic Health Science Centre, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Acquati C, Kayser K. Dyadic Coping Across the Lifespan: A Comparison Between Younger and Middle-Aged Couples With Breast Cancer. Front Psychol 2019; 10:404. [PMID: 30941068 PMCID: PMC6433932 DOI: 10.3389/fpsyg.2019.00404] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/11/2019] [Indexed: 11/28/2022] Open
Abstract
The association between dyadic coping and adjustment to cancer has been well-established. However, a significant gap in the literature is the understanding of how the life stage of couples may influence their dyadic coping and the accompanying quality of life. Although younger couples have been identified at higher risk for poor coping because of less collaborative behaviors and higher vulnerability to stress, only a limited number of studies have addressed younger women's coping with breast cancer in the context of close relationships. The present study addressed the differential impact of the illness on the quality of life and dyadic coping behaviors of younger and middle-aged dyads and the influence of relational mutuality on couples' coping in the two groups. A sample of 86 couples participated in a cross-sectional study; 35 younger couples were compared to 51 middle-aged dyads. Patients and partners completed measures of quality of life, dyadic coping, and mutuality. Independent-samples t-tests were used to examine differences in the two groups, while the Actor-Partner Interdependence Model (APIM) identified actor and partner effects of relational mutuality on dyadic coping. Younger women and their partners reported statistically significant worse quality of life and dyadic coping scores than the middle-age group. For younger couples, positive and negative coping styles were the result of both actor and partner effects of mutuality. The study highlighted the more negative impact of breast cancer on the quality of life of younger patients and partners. It also revealed a stronger influence of each partner's relational mutuality compared to the middle-age group in predicting both adaptive and maladaptive coping behavior. Future studies should continue to examine the developmental trajectory of dyadic coping across the lifespan in order to develop psychosocial interventions to promote younger dyads' coping efforts.
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Affiliation(s)
- Chiara Acquati
- Graduate College of Social Work, University of Houston, Houston, TX, United States
| | - Karen Kayser
- Renato LaRocca Chair of Oncology Social Work, Kent School of Social Work, University of Louisville, Louisville, KY, United States
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Seshasai RK, Wong T, Glickman JD, Shea JA, Dember LM. The home hemodialysis patient experience: A qualitative assessment of modality use and discontinuation. Hemodial Int 2019; 23:139-150. [DOI: 10.1111/hdi.12713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/19/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Rebecca Kurnik Seshasai
- Department of Medicine, Renal, Electrolyte and Hypertension DivisionPerelman School of Medicine Philadelphia Pennsylvania USA
| | - Tiffany Wong
- Department of Medicine, Renal, Electrolyte and Hypertension DivisionPerelman School of Medicine Philadelphia Pennsylvania USA
| | - Joel D. Glickman
- Department of Medicine, Renal, Electrolyte and Hypertension DivisionPerelman School of Medicine Philadelphia Pennsylvania USA
| | - Judy A. Shea
- Department of Medicine, Division of General Internal MedicinePerelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Laura M. Dember
- Department of Medicine, Renal, Electrolyte and Hypertension DivisionPerelman School of Medicine Philadelphia Pennsylvania USA
- Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and BiostatisticsPerelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
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12
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Roberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, Cicora F, Alonso JP, May CR. Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies. BMJ Open 2018; 8:e023507. [PMID: 30181188 PMCID: PMC6129107 DOI: 10.1136/bmjopen-2018-023507] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/28/2018] [Accepted: 08/08/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT). METHODS Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories. RESULTS Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem. CONCLUSIONS Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD. PROSPERO REGISTRATION NUMBER CRD42014014547.
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Affiliation(s)
- Javier Roberti
- FINAER, Foundation for Research and Assistance of Kidney Disease, Buenos Aires, Argentina
| | - Amanda Cummings
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Michelle Myall
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Jonathan Harvey
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Kate Lippiett
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Katherine Hunt
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Federico Cicora
- FINAER, Foundation for Research and Assistance of Kidney Disease, Buenos Aires, Argentina
| | - Juan Pedro Alonso
- Faculty of Social Sciences, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Carl R May
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
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Moore C, Majeed-Ariss R, Jayanti A, Mitra S, Skevington S, Wearden A. How an ordeal becomes the norm: A qualitative exploration of experiences of self-cannulation in male home haemodialysis patients. Br J Health Psychol 2018; 23:544-560. [PMID: 29508505 DOI: 10.1111/bjhp.12303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 01/08/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite home haemodialysis (HHD) being associated with significant health and psychosocial benefits, it remains an under-utilized dialysis modality for people with chronic kidney disease. Self-cannulation, where patients insert their own needles for dialysis, is a key component of HHD. Recent research suggests that the prospect of self-cannulation is a barrier for patients, but there is little research which examines why this is the case. The aim of this study was to explore male HHD patients' experiences and attitudes towards self-cannulation. DESIGN Qualitative methods were adopted to gather in-depth views from experienced HHD patients from a UK renal centre. METHODS Semi-structured interviews were conducted with eight male HHD patients (HHD duration: 12-55 months). During the interview, the researcher elicited participants' lived experience of self-cannulation. Topics included the decision to self-cannulate and the impact of self-cannulation on the patient. The data collected were analysed using interpretative phenomenological analysis. RESULTS The findings from this study elucidate the process of how self-cannulation changed from an ordeal to the norm in these participants' lives. The central theme from these interviews is that 'becoming a person who self-cannulates is a process'. Three super-ordinate themes were discussed that relate to this central theme: 'gaining control', 'building confidence', and 'becoming the norm'. CONCLUSIONS The findings from this study suggest that some patients' initial fears of self-cannulation can be overcome. These findings offer health care professionals and patients alike a greater understanding of how patients who self-cannulate conceptualize it and its role in their mental and physical health. Statement of contribution What is already known on this subject? Home haemodialysis is a cost-effective form of renal replacement therapy which is under-utilized in the United Kingdom. Home haemodialysis is associated with positive health outcomes. Self-cannulation is noted as a barrier to home haemodialysis. What does this study add? Describes the process by which male dialysis patients became proficient in self-cannulation. Highlights psychological mechanisms which may facilitate and maintain self-cannulation. Suggests practical techniques which can be incorporated into renal clinics and care plans.
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Affiliation(s)
- Currie Moore
- School of Health Sciences and Manchester Centre for Health Psychology, University of Manchester, UK.,Manchester Academic Health Science Centre, UK
| | | | | | - Sandip Mitra
- Manchester Academic Health Science Centre, UK.,Manchester University NHS Foundation Trust, UK.,NIHR Devices for Dignity, Health Technology Cooperative, Sheffield, UK
| | - Suzanne Skevington
- School of Health Sciences and Manchester Centre for Health Psychology, University of Manchester, UK.,Manchester Academic Health Science Centre, UK
| | - Alison Wearden
- School of Health Sciences and Manchester Centre for Health Psychology, University of Manchester, UK.,Manchester Academic Health Science Centre, UK
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Staff HR, Didymus FF, Backhouse SH. The antecedents and outcomes of dyadic coping in close personal relationships: a systematic review and narrative synthesis. ANXIETY STRESS AND COPING 2017; 30:498-520. [PMID: 28513191 DOI: 10.1080/10615806.2017.1329931] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Theories of dyadic coping and empirical literature have intermittently and inconsistently highlighted antecedents and outcomes of dyadic coping. The purpose of this review was to systematically identify the antecedents and outcomes of dyadic coping in close personal relationships. DESIGN A PRISMA-guided systematic review and narrative synthesis. METHODS Literature searches were conducted using CINAHL, PubMed, PsycINFO, and citation pearl growing to identify studies that were relevant to the aim of the review. The search strategy and exclusion criteria led to a final sample of 46 studies that each highlighted antecedents and outcomes of dyadic coping among married couples. Each study was critically appraised and analyzed using narrative synthesis. RESULTS The narrative synthesis highlighted five antecedents (learning, gender, relationship characteristics, relationship role, and cultural influences) and two outcomes (relationship functioning and personal health) of dyadic coping. CONCLUSION The review exposes inconsistencies in the conceptualization of dyadic coping, highlights a range of antecedents that influence dyadic coping, and suggests that dyadic coping can have positive benefits for relationship functioning and personal health. The findings have implications for future research and practice (e.g. when working with couples to improve relationship functioning).
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Affiliation(s)
- Helen R Staff
- a Carnegie Research Institute , Leeds Beckett University , Leeds , UK
| | - Faye F Didymus
- a Carnegie Research Institute , Leeds Beckett University , Leeds , UK
| | - Susan H Backhouse
- a Carnegie Research Institute , Leeds Beckett University , Leeds , UK
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15
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Care partner: A concept analysis. Nurs Outlook 2017; 65:184-194. [DOI: 10.1016/j.outlook.2016.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/11/2016] [Accepted: 11/13/2016] [Indexed: 11/17/2022]
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16
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Wilcox SB, Carver M, Yau M, Sneeringer P, Prichard S, Alvarez L, Chertow GM. Results of human factors testing in a novel Hemodialysis system designed for ease of patient use. Hemodial Int 2016; 20:643-649. [DOI: 10.1111/hdi.12430] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - May Yau
- Outset Medical, Inc; San Jose California 95112 USA
| | | | | | - Luis Alvarez
- Division of Nephrology; Department of Medicine; Palo Alto Medical Foundation; Palo Alto California USA
| | - Glenn M. Chertow
- Division of Nephrology; Department of Medicine; Stanford University School of Medicine; Stanford California USA
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17
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Nadeau-Fredette AC, Hawley C, Pascoe E, Chan CT, Leblanc M, Clayton PA, Polkinghorne KR, Boudville N, Johnson DW. Predictors of Transfer to Home Hemodialysis after Peritoneal Dialysis Completion. Perit Dial Int 2015; 36:547-54. [PMID: 26526050 DOI: 10.3747/pdi.2015.00121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/09/2015] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND The aim of the present study was to evaluate the predictors of transfer to home hemodialysis (HHD) after peritoneal dialysis (PD) completion. ♦ METHODS All Australian and New Zealand patients treated with PD on day 90 after initiation of renal replacement therapy between 2000 and 2012 were included. Completion of PD was defined by death, transplantation, or hemodialysis (HD) for 180 days or more. Patients were categorized as "transferred to HHD" if they initiated HHD fewer than 180 days after PD had ended. Multivariable logistic regression was used to evaluate predictors of transfer to HHD in a restricted cohort experiencing PD technique failure; a competing-risks analysis was used in the unrestricted cohort. ♦ RESULTS Of 10 710 incident PD patients, 3752 died, 1549 underwent transplantation, and 2915 transferred to HD, among whom 156 (5.4%) started HHD. The positive predictors of transfer to HHD in the restricted cohort were male sex [odds ratio (OR): 2.81], obesity (OR: 2.20), and PD therapy duration (OR: 1.10 per year). Negative predictors included age (OR: 0.95 per year), infectious cause of technique failure (OR: 0.48), underweight (OR: 0.50), kidney disease resulting from hypertension (OR: 0.38) or diabetes (OR: 0.32), race being Maori (OR: 0.65) or Aboriginal and Torres Strait Islander (OR: 0.30). Comparable results were obtained with a competing-risks model. ♦ CONCLUSIONS Transfer to HHD after completion of PD is rare and predicted by patient characteristics at baseline and at the time of PD end. Transition to HHD should be considered more often in patients using PD, especially when they fulfill the identified characteristics.
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Affiliation(s)
- Annie-Claire Nadeau-Fredette
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Université de Montreal, Montreal, Quebec, Canada
| | - Carmel Hawley
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, University of Queensland, Brisbane, Australia
| | - Elaine Pascoe
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Sydney Medical School, University of Sydney, Sydney
| | - Kevan R Polkinghorne
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Department of Nephrology, Monash Medical Centre Monash Health, Clayton Department of Medicine and of Epidemiology and Preventive Medicine, Monash University, Melbourne
| | - Neil Boudville
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - David W Johnson
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia Centre for Kidney Disease Research, Translational Research Institute, University of Queensland, Brisbane, Australia
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18
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Yau M, Carver M, Alvarez L, Block GA, Chertow GM. Understanding barriers to home-based and self-care in-center hemodialysis. Hemodial Int 2015; 20:235-41. [DOI: 10.1111/hdi.12357] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- May Yau
- Clinical Operations; Outset Medical, Inc.; San Jose California USA
| | - Michelle Carver
- Clinical Operations; Outset Medical, Inc.; San Jose California USA
| | - Luis Alvarez
- Division of Nephrology; Department of Medicine and Nephrology; Palo Alto Medical Foundation; Palo Alto California USA
| | | | - Glenn M. Chertow
- Division of Nephrology; Department of Medicine and Nephrology; Stanford University School of Medicine; Stanford California USA
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19
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Bennett PN, Schatell D, Shah KD. Psychosocial aspects in home hemodialysis: A review. Hemodial Int 2015; 19 Suppl 1:S128-34. [DOI: 10.1111/hdi.12258] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paul N. Bennett
- Western Health; Deakin University; Melbourne Victoria Australia
| | - Dori Schatell
- Medical Education Institute, Inc.; Madison Wisconsin USA
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20
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Walker RC, Hanson CS, Palmer SC, Howard K, Morton RL, Marshall MR, Tong A. Patient and Caregiver Perspectives on Home Hemodialysis: A Systematic Review. Am J Kidney Dis 2015; 65:451-63. [DOI: 10.1053/j.ajkd.2014.10.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/19/2014] [Indexed: 11/11/2022]
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21
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Freedom and confinement: patients' experiences of life with home haemodialysis. Nurs Res Pract 2014; 2014:252643. [PMID: 25587441 PMCID: PMC4281387 DOI: 10.1155/2014/252643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/04/2014] [Indexed: 11/17/2022] Open
Abstract
Patients with chronic end stage renal disease need dialysis to survive; however, they also need a treatment that suits their life situation. It is important that healthcare providers provide reliable, up-to-date information about different dialysis treatment options. Since home haemodialysis is a relatively new treatment, it is necessary to gather more knowledge about what the treatment entails from the patient's perspective. The aim of this study was to describe patients' experiences of having home haemodialysis. To gain access to the patients' experiences, they were asked to write narratives, which describe both their good and bad experiences of life with the treatment. The narratives were analysed with a qualitative method. The results of this analysis are subdivided into five themes: freedom to be at home and control their own treatment, feeling of being alone with the responsibility, changes in the home environment, need for support, and security and well-being with home haemodialysis. The conclusion is that home haemodialysis provides a certain level of freedom, but the freedom is limited as the treatment itself is restrictive. In order to improve patients' experiences with home haemodialysis, more research based on patients' experiences is needed and it is necessary to involve the patients in the development of the care.
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22
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Monaro S, Stewart G, Gullick J. A ‘lost life’: coming to terms with haemodialysis. J Clin Nurs 2014; 23:3262-73. [PMID: 24810661 DOI: 10.1111/jocn.12577] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Susan Monaro
- Sydney Nursing School; University of Sydney; Sydney NSW Australia
- Level 3 West Cardiovascular Service; Concord Repatriation General Hospital; Concord NSW Australia
| | - Glenn Stewart
- Level 4 North Renal Medicine; Concord Repatriation General Hospital; Concord NSW Australia
| | - Janice Gullick
- Master of Emergency Nursing; Master of Intensive Care Nursing; Sydney Nursing School; University of Sydney; Sydney NSW Australia
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23
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Kotronoulas G, Wengström Y, Kearney N. Sleep and sleep-wake disturbances in care recipient-caregiver dyads in the context of a chronic illness: a critical review of the literature. J Pain Symptom Manage 2013; 45:579-94. [PMID: 22926086 DOI: 10.1016/j.jpainsymman.2012.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 02/21/2012] [Accepted: 03/09/2012] [Indexed: 11/15/2022]
Abstract
CONTEXT Alterations in sleep-wake patterns of care recipients and their informal caregivers are common in the context of a chronic illness. Given the current notion that sleep may be regulated within and affected by close human relationships, concurrent and interrelated sleep problems may be present in care recipient-caregiver dyads. OBJECTIVES To critically analyze evidence regarding concurrent sleep patterns or changes in care recipient-caregiver dyads in the context of a chronic illness and address methodological and research gaps. METHODS Using a wide range of key terms and synonyms, three electronic databases (Medline, CINAHL, and Embase) were systematically searched for the period between January 1990 and July 2011. RESULTS Ten studies met prespecified selection criteria and were included for analysis. Study quality was fair to good on average. Seven studies were conducted in the context of dementia or Parkinson's disease, two in the context of cancer, and one study included a group of community elders with mixed related comorbidities and their informal caregivers. Bidirectional associations in the sleep of care recipient-caregiver dyads seem to exist. Concurrent and comparable nocturnal sleep disruptions also may be evident. Yet, inconsistencies in the methods implemented, and the samples included, as well as uncertainty regarding factors coaffecting sleep, still preclude safe conclusions to be drawn on. CONCLUSION The dyadic investigation of sleep is a promising approach to the development of truly effective interventions to improve sleep quality of care recipients and their caregivers. Nevertheless, more systematic, longitudinal dyadic research is warranted to augment our understanding of co-occurrence and over time changes of sleep problems in care recipient-caregiver dyads, as well as to clarify covariates/factors that appear to contribute to these problems within the dyad and across time and context of illness.
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24
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Xi W, Singh PM, Harwood L, Lindsay R, Suri R, Brown JB, Moist LM. Patient experiences and preferences on short daily and nocturnal home hemodialysis. Hemodial Int 2012; 17:201-7. [DOI: 10.1111/j.1542-4758.2012.00731.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Wang Xi
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
| | - P. Mony Singh
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
- Department of MedicineMarkham Stouffville Hospital Markham Ontario Canada
| | - Lori Harwood
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
| | - Robert Lindsay
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
| | - Rita Suri
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
| | - Judith Belle Brown
- Centre for Studies in Family MedicineDepartment of Family Medicineand Schulich School of Medicine and Dentistry,The University of Western Ontario London Ontario Canada
| | - Louise M. Moist
- Division of NephrologyLondon Health Sciences Center and Schulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
- Department of Epidemiology and BiostatisticsSchulich School of Medicine and DentistryThe University of Western Ontario London Ontario Canada
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