Factors Affecting Quality of Life In Persons on Hemodialysis
Factors Affecting Quality of Life
In Persons on Hemodialysis Continuing Nursing
Daria L. Kring
Patricia B. Crane
ore than 470,000 people live
The purpose of this cross-sectional, correlational study was to describe the quality of life
with end stage renal disease
(QOL) in persons with end stage renal disease and explore factors that may affect QOL.
(ESRD), the final stage of
Biological function, symptoms, function, general health perception, and characteristics of
chronic kidney disease, and
the individual and environment explained 61% of the variability in overall QOL. Only
each year, more than 100,000 addi-
anxiety, depression, and general health perception significantly contributed to QOL.
tional people are diagnosed with
QOL may be better predicted from psychological factors than physiological factors.
ESRD (U.S. Renal Data System
[USRDS], 2008). In 2006, Medicare
costs for ESRD topped $23 billion
To provide an overview of factors that affect the quality of life in persons on hemodial-
(6.4% of the entire Medicare budget)
(USRDS, 2008). Incidence of ESRD
has dramatically increased over the
past decade, increasing from 261.3
1. Describe the quality of life in persons with end stage renal disease as found in this
per million population in 1994 to
correlational, cross-sectional study.
348.6 per million in 2004 (Centers for
2. List factors that have been determined to affect quality of life.
Disease Control and Prevention,
3. Explain how those factors may affect quality of life in persons on end stage renal
2007), placing a significant financial
burden on the healthcare system.
Given these figures, it is imperative
that persons with ESRD receive not
only cost-effective care, but also care 1999), and in many dialysis centers, ceptual clarity regarding the meaning
that contributes to an acceptable qual- “life at any cost” is the unspoken rule of QOL. The more specific term
ity of life (QOL). However, the QOL (Russ, Shim, & Kaufman, 2007). The “health-related quality of life” is often
for persons with ESRD has been lower QOL associated with ESRD interchanged with the more holistic
shown to be lower than that of the may be related to physical complica- term “quality of life.” Health-related
general public (Cleary & Drennan, tions common in ESRD, such as QOL is often defined and measured
2005; DeOreo, 1997; Ferrans & fatigue, joint pain, and anorexia as “physical functioning,” a narrower
Powers, 1993; Frank, Auslander, & (Phillips, Davies, & White, 2001). view than general QOL. Thus, very
Weissgarten, 2003; Merkus et al., More concerning is that persons with little research has been conducted on
ESRD have a lower QOL than per- the broader concept of QOL in per-
Daria L. Kring, PhD, RN-BC, is the Director of sons with other chronic illnesses sons with ESRD and factors that con-
Nursing Research, Forsyth Medical Center, (Loos, Briancon, Frimat, Hanesse, & tribute to it. This broad concept is
Winston-Salem, NC, and a member of ANNA’s Kessler, 2003), and that QOL is cor- best defined as a person’s sense of
related with hospitalization and death well-being that stems from satisfaction
Patricia B. Crane, PhD, RN, FAHA, is an in persons with ESRD (DeOreo, or dissatisfaction with the areas of life
Associate Professor, the University of North Carolina 1997). However, studies using QOL that are important to him or her
at Greensboro, Greensboro, NC. as an outcome are difficult to interpret (Ferrans, Zerwic, Wilbur, & Larson,
Acknowledgments: The authors wish to thank to
and synthesize due to a lack of con- 2005).
Nita Gaines, RN, for her invaluable assistance with
Authors’ Note: This study was supported by a grant This offering for 1.4 contact hours is being provided by the American Nephrology Nurses’
made available by the American Nephrology Nurses’ Association (ANNA).
Association. The views expressed herein are those of ANNA is accredited as a provider of continuing nursing education (CNE) by the American
the authors, and no official endorsement by the Nurses Credentialing Center’s Commission on Accreditation.
American Nephrology Nurses’ Association is intend-
ed or should be inferred. ANNA is a provider approved by the California Board of Registered Nursing, provider number
Disclosure Statement: The authors reported no
actual or potential conflict of interest in relation to This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
this continuing nursing education article. ing nursing education requirements for certification and recertification.
NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 15
Factors Affecting Quality of Life in Persons on Hemodialysis
Revised Wilson and Cleary Model of Quality of Life
Characteristics of the
Symptoms Health Quality of
Characteristics of the
Note: Used with permission from Wiley Blackwell Publishing.
Purposes • Do biological function (serum serum hemoglobin), symptoms
albumin and serum hemoglobin), (dialysis symptoms, anxiety,
The purposes of this study were to symptoms (dialysis symptoms, depression, and fatigue), function-
describe the QOL in persons with anxiety, depression, and fatigue), al status, and general health per-
ESRD and examine factors which functional status, and general ception explain overall QOL in
influence QOL. health perception explain overall persons with ESRD?
QOL in persons with ESRD?
Conceptual Framework • Do biological function (serum Design
albumin and serum hemoglobin),
A revised version of Wilson and symptoms (dialysis symptoms, This non-experimental research
Cleary’s (1995) model for QOL anxiety, depression, and fatigue), study employed a cross-sectional, cor-
(Ferrans et al., 2005) was used to functional status, general health relational design to determine factors
guide this study (see Figure 1). perception, characteristics of the affecting QOL in persons on hemo-
According to this model, there are individual (age, gender, and race), dialysis. The data collection took
four main determinants of overall and characteristics of the environ- place in a free-standing, outpatient
QOL: biological function, symptoms, ment (marital status, socioeco- dialysis clinic located in the southeast-
functional status, and general health nomic status, and time on ern United States. Convenience sam-
perceptions. Characteristics of the hemodialysis) explain overall pling was used to obtain participants
individual and environment influence QOL in persons with ESRD? from the outpatient dialysis clinic.
all determinants, as well as QOL. • When controlling for characteris- Inclusion criteria consisted of actively
undergoing incenter hemodialysis, on
tics of the individual (age, gender,
hemodialysis for at least three months,
Research Questions and race) and characteristics of
at least 18 years of age or older, and
the environment (marital status,
The research questions were: able to speak and understand the
socioeconomic status, and time
• What is the QOL in persons with English language. Exclusion criteria
on hemodialysis), do biological
ESRD? consisted of a diagnosis of dementia
function (serum albumin and
16 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
or other condition that may impair used to collect information not cap- 8 for each subscale (Bjelland, Dahl,
the ability to answer questions and tured on the other instruments. It Haug, & Neckelmann, 2002). Con-
cognitive or medical changes occur- included characteristics of the individ- current and construct validity have
ring during the hemodialysis treat- ual (age, gender, and race), character- been reported in several studies
ment that prevented the person from istics of the environment (time on (Bjelland et al., 2002; Zigmond &
answering questions. hemodialysis, marital status, and Snaith, 1983). Cronbach’s alpha for this
An a priori power analysis was socioeconomic status), and most study for the total instrument was
conducted using nQuery Advisor® recent serum albumin and hemoglo- 0.779, for the anxiety subscale was
software to determine the needed bin levels. 0.805, and for the depression subscale
sample size to answer the research was 0.622.
questions. For multiple linear regres- Dialysis Symptom Index
sion analysis, with a significance level The Dialysis Symptom Index Fatigue Visual Analog Scale
of 0.05, 80% power, a total of 15 pre- (DSI) is a comprehensive instrument A visual analog scale (VAS) was
dictor variables, and an estimated that measures 30 common physical used to measure fatigue in this study.
moderate effect size (R2 = 0.25), 70 and emotional symptoms experi- The left VAS anchor indicated “no
subjects were needed. A conservative enced by persons on hemodialysis fatigue,” and the right anchor indicat-
R2 was estimated from a study using and the severity/frequency of those ed “severe fatigue.” Measurements
the Quality of Life Index – Dialysis symptoms (Weisbord et al., 2004). were made from the “no fatigue”
version with persons on hemodialy- Each participant was asked if a symp- anchor to the participant’s mark.
sis, in which the R2 was reported as tom was experienced during the past Thus, the higher the number, the
0.28 ( Jablonski, 2007). week. If yes, the participant was asked worse the fatigue. It is a quick, simple
to what degree the symptom was tool to complete and has correlated
bothersome on a 5-point scale, with 1 well with longer instruments, includ-
Protection of Human Subjects
= not at all, and 5 = very much. The ing Belza’s Multi-Dimensional Assess-
The study was approved by the responses on the severity dimension ment of Fatigue Scale (r = 0.80), the
Institutional Review Board (IRB) of were added together for a possible vitality subscale from the SF-36 (r =
The University of North Carolina at total symptom severity score of 0 to 0.71), and the Brief Fatigue Inventory
Greensboro. In addition, permission 150. The tool’s development, includ- (r = 0.76) (Wolfe, 2004).
to conduct the study at the dialysis ing validity assurance, is discussed
clinic was obtained from the corpora- elsewhere in the literature (Weisbord Inventory of Functional
tion’s department of clinical studies. et al., 2004). Test-retest reliability with Status – Dialysis
All participants were approached persons on hemodialysis 4 to 7 days The Inventory of Functional Status
by a nurse employee to briefly apart was high (M = 0.80, SD = 0.09). – Dialysis (IFS-D) was developed and
explain the study and ascertain inter- Cronbach’s alpha for this study was tested specifically for persons on dial-
est. All those indicating interest were 0.87. ysis (Thomas-Hawkins, 2005). The
fully informed regarding the purpose participant must rate each activity
of the study and expectations of par- Hospital Anxiety and according to the degree of participa-
ticipation. A written consent form Depression Scale tion in a typical week in the past
was reviewed and signed by each The Hospital Anxiety and Depress- month on a 4-point scale: 1 = did not
participant prior to collecting data, ion Scale (HADS) was developed as a do, 2 = did with a lot of help, 3 = did
and each participant received a copy. short tool to identify patients at risk for with some help, and 4 = did by
Confidentiality was maintained on all two common psychological disorders – myself. Points are given for each
data collection forms by using codes anxiety and depression (Zigmond & activity and averaged to determine an
to identify participants instead of Snaith, 1983). The HADS has 14 items overall functional status score, rang-
names or any other personal identi- – 7 related to anxiety and 7 related to ing from 1.00 to 4.00. A higher score
fiers. A master list of participant depression. Each item is a statement to indicates a higher level of functioning.
names was kept separate from the which respondents choose the degree Validity of the tool was documented
data collection forms. All data collec- to which the statement is true on a 4- by the tool’s author (Thomas-
tion forms are kept in a locked file in point Likert-type scale, from 0 to 3, Hawkins, 2005). Alpha reliability for
the investigator’s office separate from with 0 representing no symptoms, and the total scale score was 0.88, and
the master list. 3 representing the clear presence of subscale reliabilities ranged from 0.75
symptoms related to anxiety or depres- to 0.85 (Thomas-Hawkins, 2005). For
sion. The two subscales (HADS-A and this study, the alpha reliability was
HADS-D) are summed separately and 0.860.
Dialysis Demographic Form may also be added together for a total
score. The cut-off score for determining Palliative Performance Scale
The Dialysis Demographic Form,
the presence of anxiety or depression is The Palliative Performance Scale
an investigator-designed form, was
NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 17
Factors Affecting Quality of Life in Persons on Hemodialysis
(PPS) (Anderson, Downing, Hill, degree to which individuals are satis- Table 1
Casorso, & Lerch, 1996), a modifica- fied with a certain aspect of their life Demographic Statistics (N = 73)
tion of the Karnofsky Performance and is measured on a 6-point Likert-
Scale (KPS), measures the decline in type scale, with 1 = very dissatisfied, Frequency
function seen in terminal patients as and 6 = very satisfied. The second Variable (%)
they approach death. The index item asks the level of importance of Gender
ranges from 100% (normal, no evi- that aspect of their life, and is also
Female 40 (55%)
dence of disease) to 0% (deceased). measured on a 6-point Likert-type
The scale progresses in 10% incre- scale, with 1 = very unimportant, and Male 33 (45%)
ments within these two anchors to 6 = very important. The satisfaction Race/Ethnicity
describe overall level of function. scores are recorded and weighted
African American 56 (76%)
Persons are classified against 5 cate- according to the importance scores to
gories: ambulation, activity/evidence determine an overall QOL score. White 13 (18%)
of disease, self-care, intake, and level Possible range for the final score is 0 Hispanic 2 (3%)
of consciousness according to descrip- to 30, with higher scores indicating a
tors for each percentage from 0 to higher overall QOL. Validity for the Other 2 (4%)
100. Because the PPS was designed to QLI-D has been documented by the Marital Status
predict death, evidence of construct authors (Ferrans, 1990, 2006; Ferrans Married 24 (33%)
validity has been supported by its & Powers, 1985, 1992, 1993). Across
prognostic capacity (Anderson et al., 48 studies involving persons of vary- Never married 21 (29%)
1996; Harrold et al., 2005; Lau, ing diagnoses, Cronbach’s alpha has Divorced/separated 15 (20%)
Downing, Lesperance, Shaw, & ranged from 0.73 to 0.99, and 0.88 to
Widowed 12 (18%)
Kuziemsky, 2006; Virik and Glare, 0.93 for persons on dialysis (Ferrans,
2002). 2006). Cronbach’s alpha in this study Annual Family Income
was 0.937. Above poverty 41 (56%)
General Health Perceptions
Below poverty 22 (30%)
General health perception is often Procedures Do not know 6 (8%)
measured with one global question
that allows the individual to synthe- A letter explaining the study was Prefer not to answer 3 (4%)
size all objective and subjective expe- provided to each eligible, interested
riences regarding his or her personal person. All participants receiving a Missing data 1 (2%)
health (Wilson & Cleary, 1995). This recruitment letter were approached Likelihood of Transplant
factor was measured by one item, as by the investigator to answer ques- Not likely 37 (51%)
recommended by Ferrans et al. tions and obtain consent. Participants
(2005): “How would you rate your completed the study instruments dur- Probably not likely 5 (7%)
health on a scale from 1 to 10, with 1 ing a routine dialysis session. Data Somewhat likely 8 (11%)
= poor and 10 = excellent?” collection did not occur until the per-
Very likely 16 (22%)
son had been on dialysis for at least
Quality of Life Index – 60 minutes. I do not know 7 (9%)
Dialysis Participants received a thank you
The Quality of Life Index – letter from the primary investigator
Dialysis Version III (QLI-D) is a sub- and a $10 bill immediately following alpha = 0.05, but the overall model
jective, self-report measure composed completion of all instruments as a was set at alpha = 0.01. This higher
of 34 pairs of questions (Ferrans & token of appreciation for their time and significance level for the overall
Powers, 1985). Thirty-two items make willingness to share their experiences. model was chosen to prevent a Type I
up the core version of the QLI and error due to multiple analyses.
assess health care, physical health and Data Analyses
functioning, occupation, education,
leisure, the future, peace of mind, per- All data were entered into SPSS
sonal faith, life goals, personal version 15.0. Descriptive statistics The sample consisted of 73 patients
appearance, self-acceptance, general were calculated for each variable. on hemodialysis. Most participants
happiness, and general satisfaction. Various multiple regression models were female (55%), African American
Two additional questions are included were conducted to answer specific (76%), and not married (67%). Over
in the QLI-D that assess changes due research questions. Assumptions for half reported household incomes
to kidney failure and the possibility of multiple regression were verified above the federal poverty level (56%)
a kidney transplant. For each pair of prior to the analyses. Statistical signif- and felt they were not likely to receive
questions, the first item asks the icance for each variable was set at a kidney transplant (58%). Ages
18 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
Health-Related Variables (N = 73)
Variable Mean SD Range Possible Range
Serum Albumin 3.90 g/dL 0.40 2.1 to 4.6 3.5 to 4.5 (normal range)
Serum Hemoglobin 12.58 g/dL 1.67 9.4 to 17.8 12 to 16 (normal range)
Dialysis Symptoms 41.85 23.30 5 to 110 0 to 150
Anxiety 6.52 4.27 0 to 18 0 to 21
Depression 5.36 3.16 0 to 15 0 to 21
Fatigue 43.27 27.36 0 to 100 0 to 100
Inventory of Functional Status (IFS) 3.00 0.65 1.47 to 4.00 1 to 4
Functional Status (PPS) 75.89 12.42 50 to 100 0 to 100
General Health Perception 5.67 1.83 1 to 10 1 to 10
Quality of Life – Overall 21.14 4.87 7.45 to 30.00 0 to 30
Health and functioning 18.92 5.48 4.00 to 30.00 0 to 30
Socioeconomic 21.57 5.81 5.50 to 30.00 0 to 30
Psychological/spiritual 22.96 5.73 8.50 to 30.00 0 to 30
Family 24.71 5.40 8.20 to 30.00 0 to 30
ranged from 20 to 89 years old, with a variables were entered together as health-related variables to the model
mean age of 56 years (SD = 15.8). one block. This model significantly improved the explanation of variance
Time on hemodialysis ranged from 3 explained 59% (R2 = 0.589; R2adj = in overall QOL after the characteris-
months to 301 months (25 years) with 0.530) of the variance in overall QOL tics of the individual and the environ-
a mean of 56 months (SD = 58.3). (F = 9.887 [9, 62], p < 0.001). The sig- ment were already taken into account.
Demographic data are displayed in nificant variables contributing to the Characteristics of the individual and
Table 1. The health-related variables model were serum albumin (square characteristics of the environment
are summarized in Table 2. root), anxiety, depression, and gener- were entered into the multiple regres-
al health perception. sion model as the first block, and the
other 9 health-related variables were
Research Question #1: Overall
entered together as the second block.
Quality of Life Research Question #3:
Characteristics of the individual and
The overall QOL was 21.14 (SD = environment did not significantly con-
4.87) out of a possible score of 30. A This question included characteris- tribute to overall QOL (F = 1.310 [6,
higher score on the QLI-D indicates a tics of the individual and environ- 64], p = 0.266). However, after con-
higher QOL; thus, the average ment, in addition to the health-related trolling for individual and environ-
reported score is higher than the variables. All 15 independent vari- mental characteristics, model two sig-
midrange value of 15. Simple correla- ables were entered together as one nificantly explained 61% (R2 = 0.608,
tions were conducted to inspect the block. This model significantly R2adj = 0.501) of the variance in over-
relationships between all continuous explained 61% (R2 = 0.608; R2adj = all QOL (F = 7.781 [9, 55], p < 0.001).
variables in the study (see Table 3). 0.501) of the variance in overall QOL Again, anxiety, depression, and gener-
Six variables correlated significantly (F = 5.693 [15, 55], p < 0.001). The al health perception were the only sig-
(p < 0.05) with QOL: dialysis symp- significant variables contributing to nificant contributing variables.
toms, anxiety, depression, fatigue, the model were anxiety, depression,
palliative performance scale, and gen- and general health perception (see Interpretation of Results
eral health perception. These correla- Table 4).
tions were low to moderate in Quality of Life
strength (Munro, 2005). The mean QOL for this sample
Research Question #4: Controlling
For Characteristics Of Individual was 21.14 (SD = 4.87). This finding
Research Question #2: And Environment was similar to other studies reporting
Health-Related Variables Quality of Life Index-Dialysis (QLI-
Sequential regression was em- D) scores of persons with ESRD
All 9 health-related independent ployed to determine if the addition of (Bihl, Ferrans, & Powers, 1988;
NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 19
Factors Affecting Quality of Life in Persons on Hemodialysis
Intercorrelations of Continuous Variables (N = 73)
Variable 1 2 3 4 5 6 7 8 9 10 11 12
QLI-D – 099 -0.080 0.480** -0.502** -0.576** -0.282* 0.172 256** 0.583** 0.180 0.165
Albumin – 313** -0.104 -0.259* -0.294* -0.049 0.343** 0.283* 0.198 -0.197 0.327**
Hemoglobin – 0.066 -0.092 0.152 0.107 -0.283* -0.303** -0.097 0.043 0.141
DSI – 0.403** 0.390** 0.394** -0.067 -0.241* -0.465** -0.159 0.003
Anxiety – 0.352** 0.085 -0.019 -0.076 -0.244* -0.400** -0.208
Depression – 0.325** -0.350** -0.281* -0.394** -0.001 -0.352**
Fatigue – -0.159 -0.258* -0.280* -0.023 -0.165
IFS-D – 0.695** 0.296* -0.524** 0.213
PPS – 0.277* -0.407** 0.251*
GHP – -.024 0.135
Age – -0.119
Time on Dialysis –
QLI-D = Quality of Life Index – Dialysis PPS = Palliative Performance Scale
DSI = Dialysis Symptom Index GHP = General Health Perception
IFS = Inventory of Functional Status – Dialysis
*P < 0.05
**P < 0.001
Multiple Regression Summary for All Variables on Overall Quality of Life (N = 73)
Regression Coefficient t P
Albumin (square root) 0.151 1.333 0.188
Hemoglobin 0.096 0.890 0.378
Dialysis Symptom Index 0.014 0.119 0.906
HADS – Anxiety Subscale -0.286 -2.439 0.018*
HADS – Depression Subscale -0.413 -3.645 0.001*
Fatigue VAS -0.020 -0.198 0.844
Inventory of Functional Status – Dialysis -0.117 -0.797 0.429
Palliative Performance Scale (PPS) 0.230 1.671 0.100
Gernal Health Perception 0.363 3.303 0.002*
Age 0.046 0.361 0.719
Female Gender 0.064 0.604 0.549
African American Race 0.043 0.455 0.651
Time on Hemodialysis (square root) -0105 -1.027 0.309
Married Status 0.074 0.769 0.445
Income Above Poverty -0.002 -0.018 0.986
R2 = 0.608; R2adj = 0.501; F = 5.693
P < 0.001
*P < 0.05
20 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
Ferrans & Powers, 1993; Greene, 0.049), and when an outlier case was total DSI score for this study, which
2005; Jablonski, 2007; Laws, Tapsell, removed from the model, it was not takes into account the severity of
& Kelly, 2000). These studies report- significant (p = 0.055). When examin- symptoms, was 41.85 (SD = 23.30).
ed mean QOL scores between 20.70 ing bivariate correlations, albumin The median value was 38. Although
to 22.67. Reported mean QOL scores did not significantly correlate with Weisbord and colleagues (2005) did
using the QLI for other populations overall QOL (r = 0.099). These find- not report a mean, the median was
range from 17.4 (SD = 5.4) for persons ings are similar to an earlier study that 25. Therefore, participants in this
living with chronic pain (Gerstle, All, did not find a significant correlation study reported a greater number and
& Wallace, 2001) to 21.01 (SD = 4.27) between albumin and QOL (Patel, higher severity of symptoms than pre-
for persons with spinal cord injuries Shah, Peterson, & Kimmel, 2002). viously reported. Although the DSI
(May & Warren, 2002). Persons with Hemoglobin also did not con- correlated significantly with overall
ESRD in this study reported a QOL tribute to any of the regression mod- QOL (r = 0.480, p < 0.001), it did not
better than these populations. A sur- els and did not correlate with QOL. contribute significantly to overall
prising finding was that the mean Other studies report similar results QOL in the total model. These results
score in this study was only slightly (Frank et al., 2003; Kalantar-Zadeh, are intriguing given the heavy symp-
lower than a group of healthy persons Kopple, Block, & Humphreys, 2001; tom burden reported by participants.
(M = 21.9) using the general popula- Patel et al., 2002). Although 43% of Jablonski (2007) found that symptom
tion version of the QLI (Ferrans, participants in this study had hemo- scores, level of relief, and satisfaction
Cohen, & Smith, 1992). globin levels less than normal, the with relief accounted for 28% of the
The study findings suggest that reason they did not significantly con- variance in QOL for persons with
persons with ESRD experience a rel- tribute to QOL may be adaptation to ESRD. Because Jablonski’s model
atively comparable QOL. Given their persistently low levels. Thus, persons focused solely on symptoms, it may
symptom burden and intensive dialy- with ESRD may not experience the be that once a more complex model
sis regimen, such findings may seem symptoms or the intensity of the is created, symptoms no longer factor
curious. However, it has been sug- symptoms that other persons with in as a significant determinant of
gested that people adjust their life low hemoglobin levels might report. overall QOL.
aspirations according to changes in In fact, in the present study, hemoglo- Fatigue was also prevalent in this
life circumstances to maintain subjec- bin did not significantly correlate with study, with over 91% of participants
tive well-being (Ferrans & Powers, fatigue (r = 0.107, p = 0.368), a com- reporting some level of fatigue. Other
1993). The results of this study indi- mon symptom of anemia. Further, studies have reported fatigue preva-
rectly support such an adaptation. supplemental erythropoietin injec- lence between 77% and 90% (Curtin,
The comparatively normal QOL tions often assist patients on dialysis Bultman, Thomas-Hawkins, Walters,
score demonstrated in this study is a in maintaining adequate hemoglobin & Schatell, 2002; Frank et al., 2003;
particularly encouraging finding be- levels. Thus, persons on hemodialysis Jablonski, 2007; Merkus et al., 1999;
cause it suggests that the complex may be able to sustain normal hemo- Weisbord et al., 2003). Participants in
medical care required for this popula- globin levels or adapt to low levels, this study reported a mean fatigue
tion provides a manageable QOL. In rendering it an insignificant factor in level of 43.27 (SD = 27.36) using a 100
addition, it lends support to the large perceived QOL. As measures of bio- mm visual analog scale (VAS). This
amounts of federal funding dedicated logical function, the results of this result is similar to another study with
to the care of persons with ESRD. study did not provide convincing sup- African-American women on dialysis
port that either albumin or hemoglo- using a fatigue VAS in which the
Health-Related Factors bin contributes to overall QOL in reported mean was 44.6 (SD = 33.1)
The 9 health-related factors in the persons with ESRD. (Williams, Crane, & Kring, 2007).
model significantly explained 59% of Fatigue exhibited a low, negative cor-
the variance in overall QOL. This Symptoms relation with QOL but did not con-
finding lends support to the important Dialysis symptoms, fatigue, anxi- tribute to the overall model. There-
role that health-related factors play in ety, and depression were the symp- fore, fatigue, as well as other common
overall QOL. However, only albumin, tom factors selected for this study. dialysis symptoms, does not seem to
anxiety, depression, and general health Dialysis symptoms were prevalent. be a significant determinant of QOL in
perception were significant variables. Participants in this study reported a multi-factorial model. It may be that
from 2 to 29 symptoms, with a mean persons with ESRD are able to adapt
Biological Function of 12.95 (SD = 5.93) symptoms. The to their chronic symptom burden with-
Albumin significantly contributed mean number of symptoms in this out it interfering significantly with their
to QOL when the independent vari- study was more than other studies day-to-day QOL. Indeed, the symp-
ables were limited to health-related that have reported: 5.67 ( Jablonski, toms are not acute in nature, but might
factors. However, the significance 2007), 7.7 (Frank et al., 2003), and 9.8 be described by persons on dialysis as
level for albumin was borderline (p = (Weisbord et al., 2005). The mean dull and nagging. In addition, many
NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 21
Factors Affecting Quality of Life in Persons on Hemodialysis
symptoms might be adequately man- 2000). This difference may be due to a debilitation perceived their health sta-
aged with medication or other inter- scale modification that included a “not tus as good to excellent. Because
ventions rendering them less of a fac- applicable” choice. This modification ESRD is a chronic condition, many
tor in overall QOL. was made so that a person who can persons living with the disease may
Anxiety was also prevalent in the physically engage in an activity (such readjust their definition of health.
study sample. Using a cut point of 8 on as preparing meals) but chooses not to This “response shift” has been noted
the anxiety subscale of the HADS, could provide a more accurate in persons as a way to cope with the
41% of participants were anxious. This response. The modification resulted in effects of illness (Ferrans, 2005). The
finding is much higher than a general higher scale totals but did not yield sig- medical regimen associated with
population sample, who reported anx- nificant results. In addition, it did not renal failure, including diet, medica-
iety prevalence at 13% (Cohen, Magai, correlate with overall QOL nor con- tions, and dialysis, may become the
Yaffee, & Walcott-Brown, 2006), and tribute significantly to any of the new health baseline. Therefore, as
slightly higher than other studies, regression models. long as no other illness processes are
which have reported anxiety among The mean PPS score was 75.89 (SD occurring, health is maintained
persons with ESRD at 36% (Williams = 13.42). Other studies using the earli- according to the person’s adjusted
et al., 2007) and 38% (Murtagh, er KPS have had similar results. One internal standards.
Addington-Hall, & Higginson, 2007). study reported a mean KPS of 74.5
Unlike other symptoms examined (SD = 16.6) (Patel et al., 2002), and Characteristics of the
in the study, anxiety was an important another reported mean values Individual
health-related variable. It correlated between 63.80 to 80.70 (Laws et al., Three characteristics of the indi-
negatively with QOL and significantly 2000). These similarities lend support vidual were selected for inclusion in
contributed to every regression model. to the use of the PPS in the renal pop- the study: age, gender, and race/eth-
Interestingly, none of the ESRD QOL ulation. For this study, the PPS showed nicity. None of these variables were
studies reviewed included anxiety as a low, positive correlation with overall significant in any of the regression
an independent variable. Therefore, QOL. However, it was not a signifi- models. According to the most cur-
this finding may provide important cant contributor to any of the regres- rent USRDS (2006) report at the time
insight into a vital determinant of sion models. This finding may also be of this study, the mean age of all per-
QOL for persons with ESRD. related to adaptation by persons with sons with ESRD in the United States
Depression was another important ESRD to their chronic condition and is 57.9 years, over half of the persons
health-related variable in this study. the relative value of functional status to with ESRD are male (56%), 61% are
Using a cut-point of 8 on the HADS, overall QOL. White, and only 32% are African
27% of participants were depressed. American. Thus, participants in this
This finding mirrored other studies General Health Perception study were slightly younger and con-
that reported a 28% prevalence rate The general health perception sisted of both more females and sig-
(Drayer et al., 2006; Murtagh et al., mean score was 5.67 (SD = 1.83). nificantly more African Americans
2007; Weisbord et al., 2005). The General health perception correlated than the U.S. ESRD population.
mean of 5.36 (SD = 3.16) was identical higher, with overall QOL than any of
to another study using the HADS in the other independent variables and Characteristics of the
persons with ESRD in which the was a significant contributor to all the Environment
mean was 5.4 (SD = 3.52) (Williams et regression models. These results are Three characteristics of the envi-
al., 2007). Similar to anxiety, depres- similar to another hemodialysis study ronment were selected for inclusion
sion exhibited a negative correlation that also measured general health per- in the study: marital status, socioeco-
with QOL and significantly con- ception with a single 10-point Likert- nomic status, and time on dialysis.
tributed to every regression model. type scale in which the mean general Like characteristics of the individual,
health perception was 6.5 (SD = 1.94) none of these variables were signifi-
Functional Status and correlation with QOL (as meas- cant in any of the regression models.
Function was measured with two ured by the QLI-D) was also similar
instruments, the Inventory of Functio- (Bihl et al., 1988). The Revised Wilson and
nal Status-Dialysis (IFS-D) and the The significance of general health Cleary Model of Quality
Palliative Performance Scale (PPS). perception is an important finding. Of Life
The participants in this study had a When trying to evaluate QOL, results The conceptual framework guid-
mean IFS-D score of 3.00 (SD = 0.65). from the current study indicate that it ing this study was the revised Wilson
This finding is quite different from a may be important to understand the and Cleary model of QOL (Ferrans et
study by the instrument’s developer in burden of disease from the person’s al., 2005). Although the main antece-
which the mean IFS-D for 104 patients point of view. During data collection, dents to overall QOL in this model
on dialysis was reported to be between this researcher found it interesting are health factors, the model also
1.29 and 1.37 (Thomas-Hawkins, that some persons with considerable includes characteristics of the individ-
ual and characteristics of the environ-
22 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
ment, which make it a holistic schema for both anxiety and depression due clusion corroborates a meta-analysis
for understanding QOL. The frame- to nondescript symptoms, such as of 12 studies that found that mental
work provided guidance in selecting feeling tired and sleeping more, health had a much greater impact on
variables that may impact overall which may be accepted as normal QOL than physical function (Smith,
QOL. Together, the variables explain- consequences of dialysis. In addition, Avis, & Assmann, 1999). The meta-
ed 61% of the variance in QOL for patients may be embarrassed to dis- analysis included five different chron-
persons with ESRD. This is an impor- cuss these feelings with their health- ic diseases, although ESRD was not
tant finding because other ESRD care providers or consider their feel- represented. These studies coupled
QOL studies have only explained 3% ings trivial in relation to other physi- with the results of the present study
(Sesso, Rodrigues-Neto, & Ferraz, cal problems. However, because provide support for a holistic ap-
2003) to 28% ( Jablonski, 2007) of the emotional health appears to have a proach to QOL.
variance in QOL. These studies did large influence on QOL in this study, Nurses have the potential to direct-
not use as many variables as the pres- a comfortable rapport should be ly influence QOL through interven-
ent study, and thus, may have been developed with each person to allow tions that may help patients rebalance
limited in their explanatory power. expression of such feelings. Pharma- their lives. Innovative therapies that
cological and non-pharmacological use holistic approaches to healing may
interventions should be explored in promote healthier adaptations to
Implications for Nephrology Nurses
collaboration with the healthcare team ESRD. Examples of possible interven-
QOL is a complex construct with until psychological needs are met. tions include meditation, energy work,
numerous antecedents. It should be Fatigue is highly prevalent in the music therapy, support groups, and
an important outcome measure for all dialysis population. Besides having a spiritual counseling. Exploration of
persons with ESRD to ensure that physical impact, this debilitating these complementary approaches to
healthcare resources dedicated to this symptom can also take an emotional care may reveal beneficial interven-
population are providing a sense of toll. Assessing individuals for their tions that might improve overall QOL.
well-being and satisfaction with life. level of fatigue should be conducted Determination of QOL is an
Ascertaining QOL requires direct on a frequent basis. When fatigue important outcome measure for per-
input from the patient, and thus, can- cannot be adequately controlled, pro- sons on dialysis. Understanding fac-
not be assessed independently by a viding emotional support through tors that influence well-being will
clinician. active listening may provide some allow nurses to focus on specific inter-
Symptom burden can be extreme empathetic relief and build a trusting ventions for enhancing QOL. When
in persons on dialysis. Individuals nurse-patient relationship. examined from a holistic framework,
should be assessed for symptoms Determining general health per- such as the revised Wilson and Cleary
every dialysis session and a plan of ceptions may be an important way for model, targeting psychological factors
care communicated to all members of nurses to gain insight into patients’ may be one of the most beneficial
the healthcare team. Those on dialy- health experiences. According to this avenues to explore.
sis need to be encouraged to discuss study, a person’s perception of gener-
both physical and emotional symp- al health has significant bearing on References
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(1988). Comparing stressors and
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symptoms that require special vigi- study, three were particularly impor- Neckelmann, D. (2002). The validity
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may be quite significant, and thus, ety, depression, and general health Depression Scale: An updated litera-
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Prevention. (2007). Racial differences in
with anxiety is especially important functional, or demographic variables
trends of end-stage renal disease, by pri-
because anxiety may be more preva- adequately explained QOL. In the mary diagnosis: United States, 1994-
lent than depression in this popula- end, each person’s sense of internal 2004. Retrieved January 16, 2009,
tion. Persons with ESRD are at an emotional equilibrium ultimately from http://www.cdc.gov/mmwr/
added risk for being under-diagnosed determined overall QOL. This con- preview/mmwrhtml/mm5611a4.htm
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Ferrans, C.E., & Powers, M.J. (1992). Nephrology Nursing Journal Editorial Board Statements of Disclosure
Psychometric assessment of the qual- In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclo-
ity of life index. Research in Nursing sure are published with each CNE offering. The statements of disclosure for this offering are published below.
and Health, 15(1), 29-38.
Ferrans, C.E., & Powers, M.J. (1993). Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of
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patients. ANNA Journal, 20(5), 575-581. Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen,
Ferrans, C.E., Zerwic, J.J., Wilbur, J.E., & Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the
Larson, J.L. (2005). Conceptual recipient of unrestricted educational grants from OrthoBiotech and Roche.
model of health-related quality of Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc.
life. Journal of Nursing Scholarship, Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers’ Bureau for Watson Pharma, Inc.
24 NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1
Consequences of Chronic Kidney Disease – Mineral and Bone Disorder: A Progressive Disease
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NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 55
Factors Affecting Quality of Life in Persons on Hemodialysis
Daria L. Kring, PhD, RN-BC; Patricia B. Crane, PhD, RN, FAHA
1.4 Contact Hours Complete the Following:
Expires: February 28, 2011 Name: ____________________________________________________________
ANNA Member Price: $15
Regular Price: $25 Address: __________________________________________________________
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Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at
1. What would be different in your practice if you applied what you have
learned from this activity? To provide an overview of factors that affect the
quality of life in persons on hemodialysis.
____________________________________________________________ Please note that this continuing nursing education activity does not
____________________________________________________________ contain multiple-choice questions. This posttest substitutes the mul-
tiple-choice questions with an open-ended question. Simply answer
____________________________________________________________ the open-ended question(s) directly above the evaluation portion of
____________________________________________________________ the Answer/Evaluation Form and return the form, with payment, to
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2. By completing this offering, I was able to meet the stated objectives
a. Describe the quality of life in persons with end stage renal disease as found in this correlational, 1 2 3 4 5
b. List factors that have been determined to affect quality of life. 1 2 3 4 5
c. Explain how those factors may affect quality of life in persons on end stage renal disease. 1 2 3 4 5
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NEPHROLOGY NURSING JOURNAL January-February 2009 Vol. 36, No. 1 25