Factors influencing Taiwanese patients’ resilience and satisfaction with dialysis: a cross-sectional survey

Abstract

Background

Resilience is a crucial feature of the nursing workforce, particularly among those working in dialysis care. Patients with end-stage kidney disease (ESKD) or chronic kidney disease need to be able to adjust and survive despite hardship. Studies have shown that enhanced resilience is correlated with increased life satisfaction and psychological endurance in individuals undergoing hemodialysis. Resilience is an adaptive coping capacity that can strengthen the benefit of structured care on trust while buffering reliance on interpersonal support, potentially yielding opposing moderation patterns across pathways. This study investigated the psychosocial determinants that influence the satisfaction and resilience of patients in dialysis and explored global challenges, including healthcare environment, provider–patient interactions, and medical procedures in Taiwan.

Methods

A cross-sectional survey was conducted with 380 stable dialysis patients who had undergone dialysis for more than 3 months without complications at a medical center in Taiwan between September and October 2022. Participants completed Brief Resilience Scale (BRS) questionnaires assessing resilience, trust, treatment satisfaction, and perceived quality of environmental conditions. The questionnaires were primarily self-administered (paper-based). The data were analyzed using partial least squares structural equation modeling (PLS-SEM) to evaluate relationships and moderating effects. Analysis with PLS-SEM was selected for its suitability to prediction-oriented modeling with interaction (moderation) effects and complex latent constructs.

Results

Resilience significantly enhanced the positive relationship between medical processes and patient trust but negatively moderated the association between nursing care and trust. High-quality environmental facilities (featuring cleanliness, comfort, privacy, adequate physical layout, and adequate equipment in the dialysis unit) and physician interactions were crucial factors that strengthened patient resilience. Moreover, patient trust strongly predicted satisfaction with dialysis care. Demographic variables, including age, gender, and dialysis modality, were not significant predictors of satisfaction.

Conclusions

Resilience substantially influenced patient trust and satisfaction in dialysis care. The integration of resilience-focused strategies, enhancement of care environments, and facilitation of effective communication among healthcare providers are recommended as essential measures for optimizing patient outcomes in chronic dialysis settings. Negative moderation suggests that, when resilience is high, patients may rely more extensively on internal coping and less on interpersonal reassurance, thus weakening the incremental effects of nursing support on trust. The findings may inform settings with comparable dialysis care structures and frameworks of patient-experience monitoring.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14615-x.

Background

Chronic renal failure is a persistent condition that impairs a patient’s life patterns and daily activities, producing physical, psychological, and economic repercussions [1].

Dialysis is an essential life support for millions of people worldwide who are living with end-stage renal disease [2]. In 2020, Taiwan spent US$1.87 billion on treatments for kidney disease, making it the largest category of healthcare spending. Dialysis for patients with end-stage renal failure accounted for 84% of these expenditures, or US$1.57 billion [3, 4].

Patients on dialysis must rely on machines for prolonged periods, which impacts their ability to perform their everyday activities and duties, lowering their biopsychosocial status. The most common stressors related to dialysis include reliance on machines, changes in diet, and limitations in sexual and physical function. However, such challenges present different levels of difficulty for patients undergoing dialysis for renal insufficiency [5].

The capacity to manage stress has a marked influence on several domains of life. Being diagnosed with renal failure can have an adverse effect on an individual’s biopsychosocial status, causing them to shift their roles and obligations in daily life [5]. This process is influenced by individuals’ resilience to stress. Resilient individuals can better withstand hardship and misfortune while safeguarding their mental health [6].

Resilience refers to an individual’s capacity to cope with changes and challenges. It does not imply the absence of stress but rather the capacity to adapt and persist through times of adversity [7]. A crucial feature that enables resilient individuals to effectively adapt to such changes is their psychological flexibility. One way that resilient people effectively adjust to life’s constantly shifting circumstances and terrible events is through such psychological flexibility [8]. Resilience has a crucial role to play in the lives of dialysis patients, through helping them manage the physical discomfort and difficulties that are associated with long-term treatment. This encompasses factors such as illness resistance, adaptability, and recovery capability [9]. While providing care for dialysis patients, nurses must prioritize resilience as a critical aspect of their plans of care [10].

The optimization of one’s performance and well-being in one’s personal and professional environments requires an understanding of and commitment to resilience [8]. Highly resilient individuals can effectively and adeptly confront stress and trauma and confidently manage the challenges they face. This ability can substantially mitigate psychological distress [11]. Beginning in 2012, the United States has implemented standardized evaluations for patients receiving hemodialysis through the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey [12]. Beginning in 2015, patient satisfaction surveys for patients on dialysis in Taiwan have been conducted annually. However, these surveys have not yet been integrated into incentive programs or tailored to address the specific needs of diverse patient populations. Data from the Taiwan Society of Nephrology (2023) indicate the following progressive survival rates for patients on dialysis: 90% at 1 year, 70.7% at 3 years, 54.9% at 5 years, and 33.8% at 10 years after initiation of treatment. Although Taiwan’s comprehensive health insurance system significantly mitigates the financial burden on patients, those who receive dialysis continue to experience an average of 11.8 days of hospitalization annually. Furthermore, many of these patients must confront challenges such as progressive disability and depression, where research indicates that distinct personality traits are strongly correlated with resilience with respect to management of their health conditions [13]. Nurses play a pivotal role in establishing and sustaining long-term trust among hospitals, patients, and families, particularly in dialysis care, where the frequency of their interactions surpasses that of other healthcare professionals. Nurses continuously interact with patients and can develop strong relationships with them, often acquiring a more profound understanding of their care needs and preferences than others in the medical system. This enables nurses to provide tailored support reflecting the unique circumstances of each patient, thus enhancing their overall quality of care [14]. The regular evaluation of patient experiences allows healthcare institutions to prioritize the areas that patients find most important, which can enhance patient satisfaction and promote loyalty [15]. This study investigates the psychological factors affecting resilience and satisfaction with dialysis in Taiwanese patients. Resilience can affect (i) patient experience, (ii) trust and satisfaction, and (iii) resilience as a psychosocial moderator for chronic illness.

Methods

The Institutional Review Board of Taipei Veterans General Hospital, Taiwan, approved the research protocol (approval number: 2019-06-003 A). All participants were provided with comprehensive information regarding the study’s objectives and methodology before their participation.

Research design and methodology

The research framework, as shaped by the literature review and hypotheses, is organized as follows:

Core Constructs

The principal constructs in this study are the medical process, trust in healthcare providers, nursing support, and patient satisfaction with services.

Moderating Variables

Environmental facilities (cleanliness, comfort, privacy, physical layout, and equipment adequacy in the dialysis unit), physicians, and patient resilience are moderating variables in the relationship between the medical process and trust, as well as between nursing and patient trust.

Control Variables

To ensure the findings’ validity, this study incorporates control variables, including age, gender, treatment type (either hemodialysis or peritoneal dialysis), and years of dialysis experience. These factors account for the individual differences that influence patient satisfaction and trust [Fig. 1].

Fig. 1.

Combined impact of environmental, professional, and psychological factors on patient experience and satisfaction within the context of hemodialysis care

Questionnaire content design

A cross-sectional study was conducted at a medical center in Taiwan between September and October 2022 that involved 527 patients receiving treatment with stable hemodialysis or peritoneal dialysis. Stability was defined as having received maintenance dialysis for ≥ 3 months and being clinically well enough to complete the survey without acute complications that would require emergency care at the time of recruitment. The survey was based on established definitions and scales based on international research grounded in the ICH-CAHPS survey [16, 17]. The measures were administered in Chinese. The translation/adaptation of the measures followed standard procedures (expert review and patient comprehension testing) to ensure linguistic and cultural appropriateness. A small pilot (n = 5) was conducted to assess the comprehension of the items and the burden of response; wording was refined based on participant feedback. The measures were administered in Chinese. The translation/adaptation followed standard procedures (expert review and patient comprehension testing) to ensure their linguistic and cultural appropriateness.

The semantics and language of the questionnaire were meticulously reviewed to ensure their clarity and precision. Following this, the revised questionnaire [Supplementary File 1] underwent pilot testing with five patients on dialysis, whose feedback was integrated into the final version [Table 1].

Table 1.

26 items, structured questionnaire design

Construct	Question item
Environmental facilities	1. Are you satisfied with the overall cleanliness and brightness of the dialysis room? 2. Are you satisfied with the overall environment and cleanliness of the waiting area? 3. The dialysis room has clear escape route indicators. 4. The dialysis room has sufficient leisure equipment, such as TVs and sound systems.
Physicians	1. The physician listens patiently to my condition, examines it carefully, and explains the condition in a way that I can understand. 2. The physician can explain my test report data and provide advice.
Nurses	1. Nursing staff introduce themselves, are polite, friendly, and willing to answer or help solve problems. 2. When you first undergo dialysis, the nursing staff will introduce you to the dialysis environment and explain routine matters such as monthly blood draws, applications for major injury, and disability manuals. 3. When you feel uncomfortable or use the call bell, nursing staff can quickly visit you or contact a doctor. 4. Nursing staff are always available to provide nursing guidance or group health education, such as catheter care, diet and medication, and daily life care knowledge. 5. Are you satisfied with the emergency handling and referral process for emergency medical treatment in this room?
Medical process	1. When administering treatment, nursing staff demonstrate skilled operation techniques and respect your privacy. 2. You agree with the timing of needle insertion and removal in the dialysis unit. 3. The dialysis unit accommodates your personal needs (e.g., shift changes, leaves of absence).
Trust	1. Do you feel that the medical staff are capable of resolving the situations you encounter? 2. You trust the medical staff in this room. 3. The service attitude of other staff (helpers, administrative personnel) is friendly and kind.
Overall satisfaction	1. Overall, are you satisfied with the clinical situation-handling ability of the medical staff? 2. Overall, are you satisfied with the dialysis environment of the hospital? 3. Overall, are you satisfied with the care provided in the hospital’s dialysis room?
Resilience	1. When I encounter difficulties, I can recover quickly. 2. I find it hard to get through the difficulties of dialysis treatment. 3. I do not need much time to recover from stressful events. 4. It is difficult for me to recover when I feel unwell after dialysis. 5. I usually can easily get through difficult moments. 6. It usually takes me a long time to overcome setbacks in life.

• A 5-point Likert scale was used to measure each item on the questionnaire, where:

• 1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree

Sample

We used a consecutive sampling of eligible patients who attended the dialysis unit during the survey period. The research team introduced the study, confirmed patient eligibility, and obtained written informed consent. The participants completed a structured questionnaire including the Brief Resilience Scale (BRS) along with various constructs that measured trust, patient satisfaction, and environmental conditions [Table 1]. The BRS is a widely recognized instrument for the evaluation of resilience among individuals with chronic conditions. This scale provides an efficient and reliable assessment of personal resilience and demonstrates robust internal consistency and validity [18]. The BRS can also be used to assess patients’ physical and mental resilience following their dialysis treatment, as shown in Fung’s (2020) study that validated the BRS in a Chinese sample [19].

The (paper-based) surveys were completed on-site after treatment initiation/while waiting for treatment, with optional standardized assistance provided to explain items to patients without suggesting answers to them. The questionnaire was intended to evaluate and improve the quality of the medical service environment and care provided to patients on dialysis. The medical process reflects the coordination and clarity of care procedures (e.g., explanations given to patients, scheduling, and the responsiveness of the care environment). Nursing support reflects interpersonal and informational support. The environmental facilities reflect the quality of the physical environment. Patients were approached and invited to participate voluntarily, with the assurance that their responses would remain confidential and anonymous.

Data collection

Data collection using these surveys generally included both questionnaires and individual interviews, which primarily focused on the following areas:

1. The evaluation of hospital facilities involves considerations of cleanliness, comfort, and the condition of the equipment, all of which are essential for patient satisfaction.

2. The evaluation of doctors and nursing staff: includes their communication, professional knowledge, and attentiveness to patients’ needs, which are essential aspects of their caregiving.

3. Perspectives on dialysis treatment, including their views on treatment effectiveness, service procedures, and safety [20].

4. Assessment of support and care: Patients on dialysis rely heavily on their social support and additional measures of care, as they often require additional emotional and logistical assistance [21].

5. Trust in medical care by patients on dialysis.

6. Patient satisfaction and the measurement of medical quality: Disease accreditation and patient satisfaction surveys are vital tools for the assessment and improvement of the quality of healthcare services.

7. Resilience and its relationship with patients receiving dialysis. We hypothesized that this would play a moderating role because trust formation may differ by care context (environment/physicians) and by the patient’s coping capacity (resilience).

Statistical analysis

Statistical analyses were performed using Smart Partial Least Squares (PLS) 4.0 software with structural equation modeling (SEM) for descriptive statistics, correlation analysis, and reliability assessment. PLS-SEM was chosen because of the study’s prediction-oriented objective, the inclusion of interaction terms, and the emphasis on the explanation of variance in key outcomes [22].

Confirmatory factor analysis was performed to verify the validity of the seven core constructs: medical process, trust, nurses, service satisfaction, environmental facilities, physicians, and resilience. The composite reliability was calculated for each variable, where a threshold of 0.70 indicated adequate convergent validity. Hypothesis testing was performed using path analysis to evaluate the relationships among constructs. Path coefficients with p-values below 0.05 were considered significant, highlighting meaningful relationships, and a p-value above this indicated nonsignificance.

Significance testing used bootstrapping (e.g., 5,000 resamples; two-tailed) to obtain the t-values, p-values, and confidence intervals.

Data were screened for completeness before modeling. Records with missing key construct items were excluded; the remaining analyses used complete-case data.

Results

Description of preliminary sample characteristics

Table 2 provides a breakdown of demographic characteristics from the 527 valid responses, including gender, age, dialysis experience, and type of dialysis treatment. Valid responses included a higher proportion of male participants (54.1%) than female participants (45.9%). Most of the respondents were 50–59 years old (28.1%), followed by those aged 60–69 years (21.6%), indicating that a significant portion of the sample included middle-aged and older adults, aligning with the typical demographics identified in dialysis patients. Patients with 0–2 years of dialysis experience were the largest group (28.3%), followed by those with 3–5 years (25.0%). This distribution suggests a range of levels of experience among participants, which allows for a comprehensive analysis of patient satisfaction across different stages of dialysis stages. In the sample, hemodialysis was more prevalent than peritoneal dialysis, with 75.1% of respondents undergoing hemodialysis, while 24.9% were undergoing peritoneal dialysis. This distribution is consistent with trends in preferences for dialysis treatment at many medical centers. These characteristics serve as control variables in the statistical analysis to ensure that any findings reflected actual relationships among constructs instead of demographic confounders. The model fit indices were acceptable (the estimated model SRMR = 0.070; NFI = 0.792). The effect sizes (f²) were reported for the key paths for quantifying practical impact. Collinearity was assessed using VIF diagnostics; the values supported the robustness of structural estimates.

Table 2.

Demographic data of the participants

Characteristic	Category	Sample Size	Percentage (%)
Gender	Male	285	54.1
	Female	242	45.9
Age	20–29	28	5.3
	30–39	55	10.4
	40–49	102	19.4
	50–59	148	28.1
	60–69	114	21.6
	70 and above	80	15.2
Dialysis experience	0–2 years	149	28.3
	3–5 years	132	25.0
	6–8 years	114	21.6
	9–10 years	79	15.0
	More than 10 years	53	10.1
Patient type	Hemodialysis	396	75.1
	Peritoneal Dialysis	131	24.9

Descriptive statistics

A total of 147 patients were excluded from the analysis because of incomplete data, and data from 380 patients were available for analysis. This section provides an analysis of the seven key dimensions in this study: medical process, trust, nurses, service satisfaction, environmental facilities, physicians, and resilience. Among the 380 hemodialysis respondents, mean (SD; range) scores were as follows: medical process 4.12 (0.60; 2.00–5.00), nursing care 4.11 (0.63; 2.00–5.00), environmental facilities 4.23 (0.61; 1.75–5.00), physicians 4.35 (0.65; 1.00–5.00), resilience 3.64 (0.48; 2.50–5.00), trust 4.30 (0.68; 1.00–5.00), and service satisfaction 4.46 (0.62; 1.00–5.00).

These results indicate that all dimensions exhibited good reliability and validity, making them robust for analyzing patient attitudes and behaviors. The highest scores for healthcare professionals underscore their positive impact on patient satisfaction, whereas the lower scores for resilience suggest that additional efforts could help patients manage the psychological challenges associated with dialysis treatment. The scores are based on a 5-point Likert scale (1 to 5, with higher scores indicating greater agreement across various items) (Table 3; Fig. 2).

Table 3.

Reliability and validity metrics for each dimension

Dimension	Item Code	Min	Max	Mean	Std. Deviation	Factor Loading	Composite Reliability	Cronbach’s α	Average Variance Extracted (AVE)
Environmental facilities	ev1	1.0	5.0	4.537	0.576	0.904	0.939	0.913	0.793
	ev2	1.0	5.0	4.480	0.612	0.910
	ev3	1.0	5.0	4.472	0.642	0.915
	ev4	1.0	5.0	4.364	0.757	0.831
Physician	dr1	1.0	5.0	4.554	0.604	0.976	0.975	0.948	0.951
	dr2	1.0	5.0	4.579	0.582	0.975
Nurse	nu1	1.0	5.0	4.615	0.573	0.921	0.964	0.954	0.844
	nu2	1.0	5.0	4.615	0.549	0.926
	nu3	1.0	5.0	4.632	0.542	0.922
	nu4	1.0	5.0	4.598	0.566	0.928
	nu5	1.0	5.0	4.588	0.536	0.896
Medical process	pr1	1.0	5.0	4.573	0.570	0.896	0.947	0.916	0.857
	pr2	1.0	5.0	4.503	0.619	0.935
	pr3	1.0	5.0	4.526	0.600	0.945
Trust	confi1	1.0	5.0	4.575	0.545	0.964	0.954	0.926	0.873
	confi2	1.0	5.0	4.609	0.525	0.947
	confi3	1.0	5.0	4.459	0.636	0.890
Service satisfaction	sat1	1.0	5.0	4.603	0.523	0.960	0.975	0.962	0.929
	sat2	1.0	5.0	4.558	0.571	0.954
	sat3	1.0	5.0	4.586	0.544	0.977
Resilience	res1	1.0	5.0	4.268	0.688	0.821	0.915	0.893	0.641
	res2	1.0	5.0	4.118	0.813	0.838
	res3	1.0	5.0	4.072	0.802	0.835
	res4	1.0	5.0	3.472	1.253	0.755
	res5	1.0	5.0	3.359	1.277	0.783
	res6	1.0	5.0	3.416	1.267	0.768

Fig. 2.

Effects of resilience on the relationship between the medical process and patient trust

Reliability and validity analysis

The reliability and validity of the survey items given in this study were assessed through factor loadings, composite reliability, Cronbach’s α, and average variance extracted (AVE).

Factor Loadings

All items in the seven dimensions demonstrated strong factor loadings (0.755–0.977), well above the threshold of 0.5, indicating that each item reliably measured its own construct.

Composite Reliability and Cronbach’sα

Composite reliability scores ranged from 0.915 to 0.975, and Cronbach’s α values spanned from 0.893 to 0.962, both exceeding the 0.7 threshold. This suggests that all constructs had strong internal reliability (Table 4). The diagonal values, which represent the square roots of the AVE values for each construct, exceed the off-diagonal correlation coefficients for the corresponding rows and columns, confirming that discriminant validity met the required standards. This indicates that each dimension was distinct from the others and that the constructs were appropriately differentiated, which supports further hypothesis testing in the structural model [Table 5].

Table 4.

Reliability and validity analysis of the survey items

Survey Order	Item Code	Survey Content	Environmental Facilities	Physician	Nurse	Medical Process	Trust	Service Satisfaction	Resilience
1	ev1	Are you satisfied with the overall cleanliness and brightness of the dialysis room?	0.904	0.733	0.794	0.769	0.755	0.790	0.424
2	ev2	Are you satisfied with the cleanliness of the waiting area?	0.910	0.695	0.735	0.741	0.731	0.721	0.412
3	ev3	The dialysis room has clear escape route indicators.	0.915	0.690	0.783	0.768	0.742	0.728	0.420
4	ev4	The dialysis room has sufficient recreational facilities, such as TV, audio, etc.	0.831	0.584	0.637	0.664	0.611	0.595	0.375
5	dr1	The doctor listens patiently and explains my condition in a way I can understand.	0.732	0.976	0.818	0.760	0.748	0.764	0.418
6	dr2	The doctor explains my test results and offers advice.	0.752	0.975	0.848	0.769	0.763	0.771	0.410
7	nu1	Nursing staff introduce themselves courteously, answer questions, and solve issues.	0.770	0.782	0.921	0.793	0.783	0.817	0.380
8	nu2	When you first received dialysis, did the nurse introduce the environment and explain the procedures?	0.757	0.795	0.926	0.797	0.757	0.778	0.410
9	nu3	When you feel unwell or use the call button, the nurse promptly attends to you.	0.752	0.775	0.922	0.797	0.785	0.808	0.370
10	nu4	Nurses provide guidance, group education, and daily life care knowledge.	0.777	0.801	0.928	0.817	0.807	0.795	0.392
11	nu5	Are you satisfied with the emergency treatment and referral process?	0.755	0.767	0.896	0.858	0.895	0.896	0.465
12	pr1	Nurses demonstrate skilled procedures and respect your privacy.	0.779	0.772	0.868	0.896	0.798	0.781	0.424
13	pr2	Do you find the schedule for needle insertion/removal reasonable?	0.748	0.710	0.794	0.935	0.842	0.829	0.475
14	pr3	Does the dialysis unit accommodate your personal needs, such as shift changes or leave?	0.772	0.699	0.805	0.945	0.873	0.871	0.470
15	confi1	Do you believe that the medical staff can address your concerns?	0.764	0.742	0.858	0.878	0.964	0.898	0.434
16	confi2	Do you trust the medical staff in this unit?	0.733	0.748	0.873	0.844	0.947	0.915	0.401
17	confi3	Are other staff members friendly and helpful (e.g., janitors, administrative staff)?	0.745	0.679	0.729	0.814	0.890	0.807	0.490
18	sat1	Overall, are you satisfied with the staff’s clinical handling ability?	0.751	0.746	0.889	0.852	0.927	0.960	0.432
19	sat2	Overall, are you satisfied with the dialysis environment in this hospital?	0.782	0.729	0.819	0.866	0.877	0.954	0.459
20	sat3	Overall, are you satisfied with the care provided in the dialysis unit?	0.776	0.800	0.877	0.869	0.902	0.977	0.446
21	res1	I can quickly recover when facing difficulties.	0.458	0.471	0.510	0.548	0.527	0.515	0.821
22	res2	I find it challenging to get through the difficulties of dialysis.	0.429	0.355	0.381	0.436	0.400	0.380	0.838
23	res3	I recover from stressful events quickly.	0.413	0.327	0.348	0.417	0.371	0.353	0.835
24	res4	I struggle to recover from discomfort following dialysis.	0.228	0.260	0.234	0.262	0.266	0.285	0.755
25	res5	I can usually get through tough times easily.	0.273	0.262	0.250	0.280	0.278	0.280	0.783
26	res6	It generally takes me a long time to overcome setbacks.	0.297	0.276	0.275	0.296	0.307	0.312	0.768

Table 5.

Discriminant validity of survey items

Trust	Trust	Physician	Environmental Facilities	Nurse	Medical Process	Resilience	Service Satisfaction
	0.934
Physician	0.826	0.975
Environmental facilities	0.869	0.816	0.891
Nurse	0.930	0.898	0.887	0.919
Medical process	0.983	0.843	0.905	0.948	0.926
Resilience	0.491	0.438	0.480	0.445	0.511	0.801
Service satisfaction	0.990	0.824	0.850	0.930	0.952	0.474	0.964

Bolded diagonal values represent the square root of the Average Variance Extracted (AVE) for each dimension, while the values in the lower triangle represent the correlation coefficients among the research dimensions

Structural model analysis

The PLS structural model analysis showed that all hypotheses in this study were supported (Table 6; Fig. 3). The significant relationships among the dimensions underscore the roles played by environmental factors, healthcare professionals, and resilience in the shaping patient trust and satisfaction.

Table 6.

Summary of research hypotheses and test results

Hypothesis	Dimension Relationship	Path Coefficient	t-value	Test Result
H1	Environmental facilities positively impact patient resilience.	0.321	5.912***	Significant
H2	Physicians positively impact patient resilience.	0.180	3.552***	Significant
H3	Medical processes positively impact patient trust.	0.769	10.041***	Significant
H4	Nurses positively impact patient trust.	0.174	2.305**	Significant
H5	Resilience moderates the effect of the medical process on patient trust.	0.334	4.606***	Significant
H6	Resilience moderates the effect of nurses on patient trust.	−0.309	4.251***	Significant
H7	Patient trust positively impacts service satisfaction.	0.936	62.004***	Significant

* t > 1.96; ** t > 2.58; *** t > 3.29

Fig. 3.

Path coefficients and R² values of the structural model. Note 1: Solid lines represent significant relationships, while dashed lines represent nonsignificant relationships

In addition, the control variables of age, gender, dialysis type (hemodialysis or peritoneal dialysis), and dialysis experience had no significant effect on service satisfaction, which reinforces the robustness of the model’s core constructs.

Note 1: Solid lines represent significant relationships, and dashed lines represent nonsignificant ones.

The R² values that are depicted in Fig. 3 demonstrate the explanatory power of the constructs, with a final value of 0.876. This indicates that the relationships among the constructs were reasonably and effectively explained. Overall, this study’s structural model analysis revealed significant relationships among the constructs and possessed considerable explanatory power with respect to the variance in each construct. This contributes to a deeper understanding of the roles played by each construct in patients’ resilience, trust, and service satisfaction, providing a valuable reference for future research and practical applications of these results. This high level of explanatory power indicates that the model accurately captured the key factors that influenced patient satisfaction in dialysis care, offering a robust framework for enhancing patient care strategies. The high explained variance may reflect the inherently interrelated nature of patient-experience constructs collected with a single survey. We therefore assessed discriminant validity and collinearity, cautiously interpreting the magnitude of effects.

Analysis of the moderating role of resilience

Resilience plays an essential role in moderating the effects of the medical process and of nurses on patient trust, highlighting the distinct roles of environmental factors, physicians, nurses, and the medical process in influencing patient trust. Resilience positively moderates the effects of the medical process on patient trust. Patients with higher resilience tend to have greater trust in the medical process. This may be due to their ability to better adapt to treatment routines, thereby reducing their stress and enhancing their confidence in the medical system. Resilience negatively moderates nurses’ effects on patient trust. For patients who have higher resilience, the influence of nurses on trust is diminished. This may be because resilient patients are more self-sufficient in managing their illness, leading to a reduced dependency on nursing staff [Fig. 4].

Fig. 4.

Moderating effect of resilience on the relationship between nurses and patient trust

Interaction effects were probed using simple-slope visualization (± 1 SD) to aid interpretability; plots are provided in Fig. 2.

Discussion

This study investigates the factors that influence Taiwanese patients’ resilience and their satisfaction with dialysis. The behaviors of dialysis patients and their satisfaction with healthcare may be influenced by the burden and complications of their disease, which, in turn, affect their care experiences overall. The results of this survey could help hospitals and medical personnel enhance patient satisfaction and service quality in Taiwan. This study emphasizes the importance of institutional trust in healthcare professionals’ expertise and reputation, in particular in the case of patients who are willing to endure prolonged travel or extended wait periods to receive reliable, high-quality care [Table 6]. In the healthcare system, patient trust refers to the anticipation of optimal performance from the treatment team. Trust affects behaviors and attitudes concerning patients’ health, including the disclosure of confidential information, acceptance of therapy, and compliance with treatment recommendations [23].

These insights indicate that institutional trust is paramount in patient satisfaction and treatment adherence. Trust and resilience are characterized as tools for managing complexity [24]. Negative moderation suggests that, when resilience is high, patients could rely more on internal coping and less on interpersonal reassurance, weakening the incremental effects of nursing support on trust. Nurses stand at the forefront of patient care in hospitals and various environments, and they are frequently present in the absence of physicians, being responsible for making critical clinical choices [25]. Patients’ confidence in their nurses, along with a heightened readiness to communicate problems, can enhance their satisfaction with their care. Patients who have confidence in their nurses exhibit increased cooperation in enhancing their health, experience a greater degree of security, and have a stronger propensity to forge trusting relationships. Mistrust of the treatment team adversely affects a patient’s adherence to treatment recommendations and increases significant expenses for both the patient and the treatment system [23, 26].

The regular assessment of patient experience provides valuable feedback for healthcare institutions, allowing them to address gaps in care, enhance patient satisfaction, and improve loyalty. Positive patient experiences can bolster trust in a healthcare provider, facilitating its patients’ understanding of their dialysis treatment, enhancing their self-management, and improving their capacity for decision-making [27, 28].

When patients who are on dialysis are able to maintain high trust in their healthcare providers, they demonstrate a greater degree of treatment acceptance and adherence, which results in improved clinical outcomes and higher levels of satisfaction [29, 30]. Conversely, low levels of trust can lead to doubts, hesitancy, and resistance against recommended treatment and advice, which can negatively impact treatment outcomes and satisfaction [31]. Several factors may shape the trust that dialysis patients have in medical care, including both the patient’s and accompanying family members’ past healthcare experiences, the size and reputation of the institution, the state of the disease progression, patient resilience, and the presence of a support system [32]. Beyond the immediate impact on treatment and satisfaction, trust in physicians and institutions plays a critical role in patient advocacy and the strength of a medical brand that supports the long-term sustainability of healthcare institutions [33]. Patients’ trust in their physicians forms the primary driver behind their healthcare decisions, which directly affects their loyalty and willingness to undergo treatment [34, 35]. Effective communication, thorough explanations, and transparent discussions of treatment options and outcomes can foster a trusting physician–patient relationship and empower patients to actively engage in their treatment journeys [36].

Studies indicate that dialysis patients tend to exhibit long-term loyalty to the nephrologists whom they trust, and patient loyalty to their physicians sometimes surpasses their loyalty to a specific hospital [37, 38]. Therefore, it is pivotal to establish strong patient trust in both the medical team and the institution for enhancing a healthcare brand and fostering sustainable operations. In addition, nurses are essential for delivering care, fostering trust, and developing a sophisticated grasp of patient preferences [39]. Furthermore, dialysis patients tend to require substantial support from nursing staff, who play a pivotal coordinating role due to their frequent contact with patients across the length of the long treatment journey [40, 41].

Healthcare institutions and medical personnel should work together to establish stable, trustworthy medical relationships to build the confidence of dialysis patients in their medical providers, promoting better treatment outcomes and overall satisfaction [42]. When dialysis patients choose medical facilities, factors such as travel distance, institutional size, service offerings, medical quality, and institutional accreditation are significant considerations [43]. This continuous improvement in quality, coupled with healthy competition, fosters public trust and identification with healthcare institutions, providing patients with a reliable basis for confidently accessing medical services [33]. Real-time experiences, such as waiting times and the actual treatment process, significantly impact satisfaction and loyalty in patients [14, 44]. The results of this study indicate that medical processes, trust, nurses, service satisfaction, environmental facilities, and physicians have good reliability and validity as factors, making them robust for analyzing patient attitudes and behaviors. The high scores found for healthcare professionals indicate the positive impact that they have on patient satisfaction. Respondents to this study expressed high levels of agreement on most dimensions, with mean scores ranging from 4.072 to 4.632, particularly in dimensions related to nurses, physicians, and service satisfaction. The dimensions of trust, service satisfaction, and nurses exhibit lower standard deviations, reflecting consistent evaluations among the participants. The seven dimensions of this study (environmental facilities, physician, nurse, medical process, trust, service satisfaction, and resilience) exhibit robust reliability, convergent validity, and discriminant validity. The presence of high mean scores may indicate ceiling effects or halo responding in satisfaction surveys; cultural response tendencies may also contribute.

Among patients who have more than 10 years of dialysis experience, resilience is a crucial factor in coping. Resilient people are more likely to actively follow medical instructions, handle the psychological and physical strain of treatment, and have better treatment results. Less resilient patients, however, are more prone to negative emotions and psychological stress, and these factors may compromise the effectiveness of their treatment and their quality of life [45, 46]. The fact that older people tend to have decreased resilience implies that those who have lower resilience find it more difficult to adjust to the challenging parts of dialysis, as seen by their reduced extent of posttraumatic growth [8]. In addition, demographic traits such as age [47], exposure to stressors such as illness and treatment, and context can all have an impact on levels of resilience [48]. Poudel et al. found that advancing age is associated with a reduced level of resilience and reported lower levels of resilience in patients with a disease duration of five years or more. That study found factors that were associated with resilience, using convenience sampling and regression; it reported significant associations of resilience with illness cognition, self-efficacy, and self-esteem [48].

A similar finding was described by Keskin [7], who found that resilience is lower with increasing age. This study reveals statistically nonsignificant associations among age, duration of dialysis, and resilience.

This study identified that resilience positively moderates the effects of medical procedures on patient trust. Patients with greater resilience are more likely to trust the medical process. This could be a result of their ability to better adapt to treatment routines, lowering their stress and increasing their trust in the healthcare system. Medical teams can adopt a range of approaches, including tailored care, psychological counseling, exercise, and a healthy diet, to assist dialysis patients in becoming more resilient. Encouraging active participation in treatment improves patients’ treatment outcomes and overall quality of life [49, 50]. Beyond symptom reduction, psychological therapies such as mindfulness training have been shown to improve patients’ psychological well-being and their quality of life. To provide more thorough and efficient nursing care, nurses should concentrate on helping their patients develop resilience as part of their care approach. This focus would enable patients to better handle life’s stressors, adapt to their treatment, and experience improvement in their quality of life and treatment outcomes [51]. In this study, participants exhibited a high level of resilience, although the greater standard deviations (up to 1.277) indicated a broader range of responses, possibly due to varied personal experiences for coping with long-term dialysis. The results are consistent with those of Poudel et al. [48] who found that patients with ESKD who underwent dialysis had high resilience.

In contrast, participants with lower mean resilience scores indicate the need for improved support of patients’ psychological adaptability and their coping mechanisms. The scores for composite reliability range from 0.915 to 0.975, and Cronbach’s α values span from 0.893 to 0.962, both exceeding the 0.7 threshold. This suggests that all the constructs have strong internal reliability (Table 4), indicating that the questionnaire design and data collection methodology are reliable and valid, providing a solid foundation for the understanding of real-world scenarios in the context of dialysis care. Saedi et al. [49] demonstrated that resilience, together with spiritual health and mental well-being, significantly predicted treatment adherence in patients undergoing hemodialysis. Their results demonstrate the universal importance of fostering psychological resilience to ensure sustained clinical engagement and successful long-term outcomes. Similarly, Kim et al. [41] explored the ways in which nurses conceptualize and support patient resilience, advocating for resilience-building interventions grounded in emotional intelligence, adaptability, and empowerment. This study indicates that resilience and trust are more critical to patient satisfaction than demographic characteristics. To sustain high-quality care in chronic treatment settings, including those of dialysis, healthcare institutions should regularly assess their patients’ psychological resilience and their levels of perceived trust through structured feedback mechanisms and tailor care their strategies accordingly. A holistic approach—one integrating physical care with psychosocial support—can enhance satisfaction, foster loyalty, and ultimately improve health outcomes, offering a competitive edge for healthcare delivery.

Limitations

The limitations of this study include its single-institution sample scope, which may restrict the generalizability of its results across different healthcare settings. In addition, its cross-sectional research design limits its ability to observe changes in resilience and trust over the course of time. Future studies could expand on these findings using a longitudinal approach and a broader, more diverse sample. The participants in the study are stable dialysis patients at a medical centers, which introduces several important limitations. By excluding critically ill and unstable patients, the study omits subgroups that may experience markedly different psychosocial challenges, levels of resilience, and degrees of satisfaction with care. Furthermore, the number of patients in this study on peritoneal dialysis is small, which limits the generalization of results to all patients on dialysis.

Implications and recommendations

This study highlights the following actionable strategies for healthcare institutions to enhance patient trust and satisfaction:

• Improving Environmental Facilities: Comfortable, well-equipped facilities play an essential role in supporting patient resilience, fostering trust in healthcare processes. Institutions should invest in creating patient-centered environments to alleviate the stresses associated with prolonged treatment sessions.

• Healthcare Staff Training: Communication and empathy training for healthcare professionals, particularly for nurses and physicians, can strengthen patient trust and foster resilience. For patients who are reliant on regular care, the establishment of compassionate and supportive relationships is crucial.

• Psychological Support Services: The provision of access to psychological resources, including resilience-building programs and counseling, can empower patients to manage the emotional demands of dialysis, enhancing their overall healthcare experience and satisfaction.

Conclusions

The results of this study indicate that age, gender, type of dialysis, and dialysis experience have no significant effect on patient satisfaction. Resilience favorably influences the relationships between the medical process and patient trust, resulting in enhanced patient satisfaction with dialysis. Resilience reduces direct dependency on nurses, but these professionals remain central to patient care and trust building. Providing nurses with ongoing training focused on empathy, individualized care, and advanced clinical skills is essential for maintaining trust and enhancing patient experience.

These insights are especially pertinent for the context of Taiwanese healthcare, where nurses often form enduring therapeutic relationships with their patients undergoing dialysis and act as primary facilitators of resilience.

Future studies could build upon this model by exploring resilience as a dynamic factor that influences diverse patient outcomes, including trust, satisfaction, and treatment adherence. The incorporation of cross-national comparisons and diverse healthcare settings can strengthen the generalizability and global relevance of resilience-based care frameworks. Further research could examine additional psychological determinants such as self-efficacy or perceived social support and investigate resilience’s impact on clinical trajectories, including their recovery rates, rates of re-hospitalization, and patient recommendations. Longitudinal studies could provide richer insights into how resilience evolves and influences long-term health service experiences.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ESKD

End-stage kidney disease

BRS

Brief Resilience Scale

PLS-SEM

Partial least squares structural equation modeling

ICH-CAHPS

In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems

PLS

Partial least squares

f²

Effect sizes

AVE

Average variance extracted

Author contributions

Conceptualization: Hsin-Ling Tai, Jiu-Yun Tian, Der-Cherng Tarng; Methodology: Hsin-Ling Tai, Seng-Su Tsang, Jiu-Yun Tian; Formal analysis and investigation: Hsin-Ling Tai, Seng-Su Tsang; Resources: Hsin-Ling Tai, Ming-Yao Huang, Chaio-Hui Yang; Writing – original draft preparation: Hsin-Ling Tai, Seng-Su Tsang, Der-Cherng Tarng; Writing – review and editing: Hsin-Ling Tai, Seng-Su Tsang, Der-Cherng Tarng; Supervision: Der-Cherng Tarng Declarations. All authors read and approved the final manuscript.

Funding

None.

Data availability

All data generated or analyses during this study are included in this published article.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Taipei Veterans General Hospital, Taiwan (IRB No. 2019-06-003 A). Informed consent was obtained from all individual participants included in the study after a thorough explanation of the research was provided by the principal investigator and coinvestigators. Participation was permitted only after the consent form was signed.

Consent for publication

This manuscript does not contain any form of personal data, including individual details, images, or videos, and does not infringe upon the privacy or confidentiality of the participants.

Competing interests

The authors declare no competing interests.