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Hemodialysis is a treatment for end-stage renal disease which affects multiple domains

of patients’ lives as it involves a manifold regimen of frequent dialysis sessions, dietary

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and fluid restrictions, multiple medications and prescription of physical exercise (Lai,

Loh, Mooppil, Krishnan, & Griva, 2012). The experience of dialysis is often associated

with negative emotions and a reduction of patients’ quality of life (QoL) (Lacson et al.,

2010; Song et al., 2011).

A recent and promising approach for the maintenance of an adequate QoL for these

patients is empowerment (patient-oriented) (Kaptein et al., 2010). Patient empowerment

refers to patients’ use of autonomous decision-making in order to better self-manage

their condition, gain control over their health and remain socially integrated (Delbono &

Cachia, 2007; Lancet, 2012).

As the population ages, chronic disease will continue to be an issue requiring significant medical interventions by healthcare providers, placing added stress on an already compromised healthcare system, and thus, affecting care costs and resources. It is imperative to include

patients in their care and encourage them to take some responsibility for their self-care to help control chronic disease and the healthcare costs associated with it. Several studies indicate

that patients involved in self-management of disease processes often have better patient outcomes (Costantini, 2006; Curtin & Mapes, 2001; Curtin, Mapes, Petillo, & Oberley, 2002;

Curtin, Mapes, Schatell, & Burrows- Hudson, 2005).

The number of patients with ESRD will continue to rise, causing an increased need for medical and nursing intervention.


Theoretical Underpinnings of the Model

This paper will use the Consumer Direction Theory of Empowerment (CDTE) and self-care theory. CDTE argues that increased patients’ participation and involvement are important in all programmes at different levels of operation (Seelman & Sweeney, 1995). The concept of direction describes an orientation, whereby informed individuals have control over the policies and practices that directly affect their lives (Kosciulek, 1999, 2000). In the context of health services, this construct implies patients’ ability to control and direct the delivery of services, to

participate in policy-making processes, the availability of a variety of service options

and appropriate information and long-term supports.

According to CDTE, greater patient direction in policy formulation and services

delivery, together with an increased community integration, would facilitate an empowerment

process leading to a better QoL (Kosciulek, 2000). In Kosciulek’s (2005) model,

community integration refers to the level and quality of patients’ integration in different

environments, including home and family as well as community life; a higher

integration increases patients’ skills to take control of their lives.

In this paper, patient direction and community integration are considered part of

the same empowering process, which enhances patients’ efficacy in disease management

(McCarley, 2009). Self-efficacy plays a central role in the empowerment of patients

with chronic conditions (like hemodialysis patients). For these patients’ self-efficacy in

illness, management implies the perceived capacity of working in partnership with carers

and health professionals to manage their diseases and related treatments (McCarley,

2009; Stack & Martin, 2005).

Dorothea Orem believed that people have a natural ability for self-care and that nursing should focus on affecting that ability (Orem, 1995). According to Orem’s theory, individuals whose needs for self-care outweigh their ability to engage in self-care are said to be in a self-care deficit (Isenberg, 20 06). People in or at risk for self-care deficit are those in need of nursing intervention strategies to assist in becoming self-sufficient in managing their disease processes. This theory can act as a guide to nursing practice in multiple settings and can involve patients throughout the life span in various stages of the health-illness continuum. Patients include those who require nursing care and are incapable of self-care related to an illness or injury, individuals who may require partial nursing care as they recover from an illness or injury, and those who are self-care sufficient but need ongoing support and education (Isenberg, 2006).

The goal of nursing practice is to assist patients to become adequately prepared to engage in their own care, and thus, have improved patient outcomes and a better quality of life. Curtin and Mapes (2001) defined self-management as “clients’ positive efforts to oversee and participate in their health care to optimize health, prevent complications, control symptoms, marshal medical resources, and minimize the intrusion of the disease into their

preferred lifestyle” (p. 386). Self-care for the dialysis population encompasses many dimensions, such as following the prescribed medical regime (including fluid and dietary restrictions),

medications, hemodialysis treatment, communication and being a self-advocate, monitoring for signs and symptoms of potential complications, seeking out medical attention,

kidney disease knowledge, and enjoying a lifestyle that provides an acceptable quality of life for the patient. Orem’s theory, which rests on meeting the basic needs of the individual

as described in Maslow’s Hierarchy of Needs, has been applied in a variety of settings, including

patients with cardiac disease, patients with pulmonary disease, people who are mentally ill, and those with diabetes (Morgan, 1998). This theory can be related to the body of nursing knowledge in that it uses assessment skills, builds a nurse-patient relationship, plans how to meet the objective of self-care, implements interventions, and evaluates how effective the interventions were to attaining health and self-care, with changes as needed (Parker, 2006).

Theory Application to Dialysis Setting

Dialysis involves caring for patients who have a key role in self-care. As healthcare professionals who provide direct care, nephrology nurses can assist with these lifestyle changes by providing educational opportunities and strategies to patients encouraging self-care agency.

In order to maximize the health of patients with ESRD, patients must make considerable life style changes which include dietary and fluid restrictions, medication regime, recognizing

signs and symptoms associated with potential complications, and vascular access care (Richard,

20 06). Self-care deficit occurs when the patient new to dialysis lacks the knowledge to participate in self-care.

 Contextual Background of the Model (the reason, definition, importance)

Clients in hemodialysis centers need an attention of the nurse who cares and empowers them.  Empowerment of self-care is necessary for them to develop their potentials and thus promotes quality of life.

Empowerment of Self Care

Nurse-Patient Relationship

The first step is to establish and maintain a trusting nurse-patient relationship, interacting with the individual to provide support and knowledge toward regaining self-care. It is important

to focus on the individual, making nursing interventions patient-specific by including the patient in the planning process (Simmons, 2010).

Staff Support

Staff support is crucial for efforts made by patients. Nurses can provide regular feedback to patients for every treatment on issues that present themselves. For example, a patient reports for hemodialysis with a larger-than-recommended weight gain between treatments. The nurse can discuss ways to prevent fluid overload rather than reprimanding and belittling the patient. Nurses can also provide reinforcement for patient successes (Constantini, 2006). During the process of empowerment, the most important thing is to recognize the subjects’ needs during the intervention. The researcher interviewed all the participants about their needs in terms of group activities and found that many participants described a lack of self-care knowledge and life- adaptation skills. One possible reason for this may be the short time these patients had been in HD and therefore they needed more illness management, suffered from adaptation problems and this made them feel disturbed and uncomfortable. Thirst was the most important physical symptom in this study and results from the patient being restricted in their fluid intake; this result is consistent with other studies. According to Chen and Ku (1998) and Lee and Wang (2001), thirst, fatigue, restriction in fluid intake and sleep disturbance are the top four most common symptoms during HD. Mok and Tam (2001) and Tsay (2003) found that restriction in fluid intake, itchy skin and fatigue to be the factors that caused the most stress during life adaptation among HD patients (Chen, Pai, & Li, 2008)

Evaluation and Coping Mechanisms

Patients with ESRD often feel as if they have lost control over their situation with the prescribed medical regime. At the same time, staff often perceive non-compliance actions may be the only way a patient can exhibit some control over their situation. Kuther (2001) asserts that non-compliance to the medical regime may be the patient’s way of trying to regain

some control over his or her life. Nurses need to reconsider preconceived notions and labeling a patient as non-compliant. Nurse also need to embrace the idea that they have an opportunity to educate patients to help with the control of their disease and the impact it can have on life

(Graham, 2006). Breiterman-White (2004) recommends adding patient focused care, continuous nursing education, and working to remove perceived barriers. Patients need to become involved

as active members of the healthcare team to regain some control over their situations. Staff members monitor patients through assessment, patient interview, laboratory work and

reassessment, intervening with appropriate patient education as well as making necessary changes in a patient’s care plan. Thus, patients move from a dependent relationship

to developing self-care. The nurse must continually evaluate and change the interventions to meet the needs of the individual.

Educational Strategies

Patients can benefit from educational strategies, including prevention for those at risk of developing ESRD, teaching prior to the initiation of dialysis, and ongoing education regarding

the management of lifestyle changes. Education in dialysis is continual. Repeated over and over with a little different twist each time, it re-enforces what has already been learned by the

individual, keeping them self-care sufficient. Quinan (2007) suggests that educating patients with essential information will assist them in making informed choices concerning their

care and treatment. Quinan (2007) proposes that “…knowledge helps patients on hemodialysis to regain a sense of control over their experience and environment and helps reduce feelings of vulnerability” (p. 189). Nephrology nurses can take an active role in coaching and educating

patients about their medications, thus empowering them to provide their own “safety net” (Castner, 2011).


The final way to empower self-care in the hemodialysis population is by encouraging patients to participate in their hemodialysis treatment. Patients reporting for treatment often get their weight, temperature, and standing and sitting blood pressures measured prior to the initiation of treatment. In addition, they may be given the opportunity to learn how to insert their own needles for treatment. The buttonhole technique may be used to establish fistula access while providing patients with instruction on inserting needles and the importance of infection

control. The literature also suggests that patients learn to prepare the dialysis machine prior to the initiation of therapy (Quinan, 2007).


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