Abstract
Background
Promotion of self-management is one of the effective ways to improve the quality of life of patients under haemodialysis. Therefore, a better understanding of the factors that are effective on self-management might help nurses find an appropriate method for the promotion of self-management.
Aims
This study aimed to examine self-management and its correlation with self-efficacy and knowledge of haemodialysis among patients under haemodialysis in Yazd, Iran in 2016.
Methods
This is a cross-sectional study conducted in four haemodialysis centres. All patients who were referred to these centres were selected. Demographic characteristic forms, self-management questionnaires, haemodialysis knowledge questionnaires and chronic diseases self-efficacy scales were used to collect data.
Results
The score of self-management was between 32 and 80. The mean scores of self-management, knowledge and self-efficacy were 58.88 ± 10.41 (possible score 20–80), 16.15 ± 2.91 (possible score 0–25), 5.24 ± 1.99 (possible score 0–10), respectively. There was a significant positive correlation among self-management, knowledge and self-efficacy.
Conclusions
The level of self-management was moderate among patients under haemodialysis. Effective interventions including training related to dialysis system, laboratory tests and diet are needed to improve self-management among patients under haemodialysis.
Keywords: end-stage renal disease, haemodialysis, knowledge, self-efficacy, self-management
Introduction
The last stage of chronic kidney disease, which leads to progressive and irreversible deterioration of renal performance, is called end-stage renal failure. Transplants are the best available treatment option for end-stage renal failure patients. However, the patient should undergo dialysis until the transplantation (Heidarzadeh et al., 2010). According to Hill et al.’s systematic and meta-analysis study (2016), the global prevalence of chronic kidney disease was 13.4% and global prevalence of end-stage renal disease was 0.1% (Hill et al., 2016).
Maintenance haemodialysis is considered the most common treatment for end-stage renal failure. In the United States, 64.9% of patients undergo dialysis but only 4.8% of them undergo peritoneal dialysis (Li et al., 2014). Patients experience many emotional and physical problems such as reduction of self-confidence, social separation, inactivity and occupational problems due to the nature of the disease and the conditions required for haemodialysis (Mousa et al., 2018). Unfortunately, social complications and spiritual pressure resulting from haemodialysis reduce survival rates and quality of life and increase mortality. For example, in a study conducted in Singapore, the survival rate of patients was 89.3% in the first year of haemodialysis and reduced to 58.7% after 5 years. However, one of the most effective methods to reduce the mortality rate and increase the quality of life of patients is the improvement of their self-management (Griva et al., 2011).
Self-management is the personal capability to control the symptoms, treatment side effects, physical outcomes, socio-mental effects and all other disease-related changes in lifestyle (Griva et al., 2011). The main components of self-management are the management of information, medication, mental signs, lifestyle and social support (Havas et al., 2016; Mousa et al., 2018). In contrast, the results of previous studies that examined the self-management of patients under haemodialysis indicate a low level of self-management. Such an effect may be due to some of the population variables and factors related to other diseases (Curtin et al., 2008).
According to the literature, a strategy that can improve the condition of patients with particular diseases is to increase their self-efficacy level (Moattari et al., 2012). Self-efficacy is a personal belief to become successful in a particular situation. In other words, self-efficacy is considering one’s opinions and judgments about the ability to do individual tasks in particular circumstances (Mousa et al., 2018).
It should be noted that insufficient knowledge and skills of the patients may cause a reduction of their motivation to take preventive methods and the reduction of self-management and self-efficacy. Therefore, the implementation of an empowerment programme is necessary to increase patient information and self-efficacy. This programme may increase self-management and promote the health and quality of life of the patients under haemodialysis (Havas et al., 2016; Sorat, 2018). The present study has been conducted to determine self-management and its association with self-efficacy and knowledge among patients under haemodialysis who were referred to haemodialysis centres in Yazd, Iran in 2016.
Materials and methods
Study design and setting
This cross-sectional study was conducted in four haemodialysis centres in Yazd, Iran in 2016. In Iran, dialysis centres provide both haemodialysis and peritoneal dialysis for inpatients and outpatients for free. The government also offers dialysis patients special insurance to help them buy medication more cheaply.
Sample size and sampling
We found that 130, 65, 45 and 20 patients underwent haemodialysis in Shahid Rahnamoun, Shahid Sadoughi, Seyedolshohada and Goodarz hospitals respectively. Thus, a total of 260 patients have undergone haemodialysis in Yazd. Of these 260 patients, 159 patients were eligible to participate in the study.
The instruments
Three questionnaires were used. A demographic characteristic form also was used to assess patients’ age, gender, marital status, economic and educational status, complementary insurance, duration of being under haemodialysis, the cause of renal failure.
Haemodialysis self-management instrument
Song first designed this instrument in 2009 and Li et al. also used it in their study (Song, 2009; Li et al., 2014). This scale contains 20 items in four subscales including (a) problem solving (five items), (b) emotional management (four items), (c) self-care (seven items) and (d) partnership (four items). The items were scored based on never, rare, sometimes and always and numbers one to four were allocated to them respectively. The score obtained from the final result is between 20 and 80. The higher score shows higher self-management in patients. Content validity (0.96) was acceptable (Li et al., 2014). According to Song (2009) and Li et al. (2014), the Cronbach’s α coefficients of the overall scale were 0.87 and 0.81 respectively (Song, 2009; Li et al., 2014).
Haemodialysis knowledge
This questionnaire included 25 items and was designed by Curtin et al. (2004). In this questionnaire anaemia, diet, medication, kidney function, haemodialysis, treatment and rehabilitation were assessed. The answers were designed as true and false. A score of one was allocated to the correct answers and zero was assigned to the wrong answers. The final score was between 0 and 25. The reliability of the questionnaire was 0.94 in Curtin’s study and its content validity index was reported to be 0.70 (Curtin et al., 2008).
The chronic disease self-efficacy scale
This questionnaire was designed by Lorig et al. (1996) and includes six items. The amount of self-efficacy has been measured from zero to 10. The higher the score, the better the self-efficacy. Its reliability was 0.91 (via Cronbach α) in Lorig’s study (Lorig et al., 1996).
Because Persian versions were not available, the questionnaires were translated into Persian by two translators, one of which was an approved medical translator. Another translator then edited them. In the next stage, Persian versions of the questionnaires were sent to two English translators for back translation. Then, the primary consensuses on the Persian versions of the questionnaires were obtained from the research team and translators. The Persian versions of the questionnaires should be equal to the original one concerning semantic, idiomatic, experiential and conceptual equivalences. In this stage, the questionnaires were revised. They were given to 10 nursing faculty members of Kerman University of Medical Sciences to assess the content validity. In this phase, according to expert opinions, one of the knowledge questions was deleted from the questionnaire (re-use means the patient sits in the same chair and uses the same dialysis machine each time they go for dialysis). The questionnaires were given to 30 patients of the target population and the internal consistency of items was calculated using Cronbach’s α. Cronbach’s α coefficients for self-management, knowledge and self-efficacy scales were 0.89, 0.73 and 0.95 respectively.
Data collection
In the present study, the inclusion criteria were undergoing haemodialysis for at least 3 months, being 18 years old or above, being able to read and write in Persian and being Iranian. Exclusion criteria were being hospitalised at the time of the study, history of psychological disease according to the patient’s record and physical limitation in self-care. After agreement and completion of the consent form, demographic and medical information was gathered from patients along with their medical history. Three parts of the questionnaire (self-management, self-efficacy and knowledge of patients) were completed in the researcher interview during, before or after dialysis based on the patient’s preference. The knowledge questions were asked last to reduce their effect on two other questionnaires. All three questionnaires were completed in one session. It took 20 minutes to complete all three surveys. Data collection lasted from December 2015 to May 2016.
Statistical analysis
All data were analysed by SPSS version 18. Frequency, percentage, mean and standard deviation were used to describe demographic characteristics. The Kolmogorov-Smirnov test was used to study the normalisation of quantitative variables. Only the self-management score variable had a normal distribution. Therefore, Spearman correlation test was used to study the correlation between self-management, self-efficacy and knowledge. Multivariate linear regression was used to check whether knowledge and self-efficacy are predictors of the self-management score. Independent t, analysis of variance and Kruskal-Wallis tests were used to determine the relationship between the self-management score and demographic characteristics.
Results
Demographic data
The mean age of participants was 58.69 ± 14.39 years (minimum = 25, maximum = 86). The mean duration of haemodialysis was 5.07 ± 4.61 years. Most participants (69.8%) were men; 95% of patients were married. Most subjects had a diploma or lower degree (93.7%). In total, 21.4% of them were employed and the income of 77.2% of patients was lower than 1 million tomans per month. Less than half of patients were under the coverage of complementary insurance (43.4%). Overall, 82.8% of patients underwent dialysis three times a week for 4 hours (Table 1).
Table 1.
Demographic characteristics of study sample and their associations with self-management.
| Variable | Frequency | Percent | Self-management |
Statistic test | p value | |
|---|---|---|---|---|---|---|
| Mean | Standard deviation | |||||
| Gender | ||||||
| Man | 111 | 69.8 | 59.93 | 10.58 | t = 1.95 | 0.053 |
| Woman | 48 | 30.2 | 56.46 | 9.69 | ||
| Marital status | ||||||
| Married | 151 | 95 | 58.4 | 10.19 | t = −2.59 | 0.01 |
| Single | 8 | 5 | 68 | 11.16 | ||
| Education | ||||||
| Being able to write and read | 83 | 52.2 | 57.29 | 10.4 | ||
| Diploma | 66 | 41.5 | 60.42 | 10.51 | F = 2.14 | 0.12 |
| University degree | 10 | 6.3 | 61.90 | 8.32 | ||
| Job | ||||||
| Employed | 34 | 21.4 | 62.41 | 8.61 | ||
| Retired | 63 | 39.6 | 58.97 | 9.24 | H = 12.86 | 0.005 |
| Housewife | 41 | 25.8 | 54.66 | 9.78 | ||
| Unemployed | 21 | 13.2 | 61.14 | 14.68 | ||
| Monthly income (tomans) | ||||||
| <500,000 | 45 | 28.5 | 58.69 | 9.72 | ||
| 500,000–1,000,000 | 77 | 48.7 | 57.99 | 10.75 | F = 1.71 | 0.17 |
| 1,000,000–1,500,000 | 31 | 19.6 | 62.29 | 10.04 | ||
| >1,500,000 | 5 | 3.2 | 53.8 | 12.4 | ||
| Complementary insurance | ||||||
| Yes | 69 | 43.4 | 59.72 | 11.14 | t = 0.89 | 0.37 |
| No | 90 | 56.6 | 58.23 | 9.83 | ||
| History of being under haemodialysis | ||||||
| 1–5 years | 100 | 62.9 | 58.65 | 11.26 | H = 2.33 | 0.31 |
| 6–10 years | 46 | 28.9 | 60.3 | 9.3 | ||
| >10 years | 13 | 8.2 | 55.61 | 6.17 | ||
| Dialysis sessions per week | ||||||
| Two | 11 | 7 | 61.09 | 10.81 | F = 0.40 | 0.67 |
| Three | 130 | 82.8 | 58.74 | 10.25 | ||
| Four | 16 | 10.2 | 60.37 | 11.17 | ||
| Duration of dialysis sessions | ||||||
| Three hours | 6 | 3.8 | 63.33 | 9.81 | F = 0.65 | 0.52 |
| Three hours and half | 23 | 14.5 | 59.52 | 10.43 | ||
| Four hours | 130 | 81.8 | 58.56 | 11.59 | ||
| Cause of renal failure | ||||||
| Hypertension | 69 | 43.9 | 59.19 | 10.84 | ||
| Diabetes | 61 | 38.9 | 57.34 | 10.89 | F = 1.87 | 0.14 |
| Medicinal side effects | 7 | 4.5 | 66.86 | 6.18 | ||
| Others | 20 | 12.7 | 59.5 | 7.75 | ||
Valid percent; t = independent t-test; F = analysis of variance; H = Kruskal-Wallis test (due to lack of equality of variances).
Self-management and its dimensions
Mean score of self-management was 58.88 ± 10.41. Mean score of patient’s partnership, problem solving, self-care and emotional management was 11.95 ± 3.06 (ranging from 4 to 16), 14.33 ± 3.33 (ranging from 5 to 20), 21.84 ± 4.19 (ranging from 7 to 28) and 10.76 ± 2.75 (ranging from 4 to 16) respectively. Therefore, self-management in the patients under study was the highest in the dimension of self-care. Concerning the answers given by patients to the items of the self-management questionnaire, ‘I take care of my fistula’ (60.4%), ‘talking with the healthcare provider about the bodily fluid I want to remove’ (57.2%) and ‘telling the healthcare provider about the parameters of the dialysis machine that I would like’ (47.8%) obtained the best scores in terms of self-management performance of patients (Table 2).
Table 2.
Patients’ responses to the haemodialysis self-management questionnaire.
| Items | Response (frequency/%) |
||||
|---|---|---|---|---|---|
| Never | Rare | Sometimes | Always | ||
| Partnership | 1. Checking the parameters of the dialysis machine during dialysis | 51 (32.1) | 30 (18.9) | 40 (25.2) | 38 (23.9) |
| 2. Talking with the healthcare provider about the bodily fluid I want to remove | 4 (2.5) | 6 (3.8) | 58 (36.5) | 91 (57.2) | |
| 3. Discussing the parameters of the dialysis machine that I would like with the healthcare provider | 15 (9.4) | 35 (22) | 33 (20.8) | 76 (47.8) | |
| 4. Discussing the puncture site | 18 (11.3) | 31 (19.5) | 44 (27.7) | 66 (41.5) | |
| Problem solving | 5. Correcting the potential causes of out-of-range blood tests | 16 (10.1) | 28 (27.6) | 83 (52.2) | 32 (20.1) |
| 6. Asking questions about kidney disease | 14 (8.8) | 16 (10.1) | 74 (46.5) | 55 (34.6) | |
| 7. Trying to figure out the underlying reasons for out-of-range blood tests | 15 (9.4) | 42 (26.4) | 62 (39) | 40 (25.2) | |
| 8. Trying to figure out what leads to uncomfortable symptoms | 8 (5) | 40 (25.2) | 58 (36.5) | 53 (33.3) | |
| 9. Adding phosphorus-lowering medications when eating food with high phosphorus | 17 (10.7) | 56 (35.2) | 51 (32.1) | 35 (22) | |
| Self-care | 10. Taking care of arterio-venous fistula | 4 (2.5) | 8 (5) | 51 (32.1) | 96 (60.4) |
| 11. Choosing appropriate food even when eating out | 8 (5) | 19 (12) | 62 (39) | 70 (44) | |
| 12. Cleansing the puncture site before dialysis | 15 (9.4) | 31 (19.5) | 62 (39) | 51 (32.1) | |
| 13. Choosing vegetables and fruit with low levels of potassium | – | 31 (19.5) | 70 (44) | 58 (36.5) | |
| 14. Trying to control fluid intake | 7 (4.4) | 26 (16.4) | 56 (35.2) | 70 (44) | |
| 15. Scalding greens before cooking | (15.7) 25 | (23.9) 38 | (37.7) 60 | (22.6) 36 | |
| 16. Controlling fluid intake to limit daily weight gain | (5.7) 9 | (14.5) 23 | (39.6) 63 | (40.3) 64 | |
| Emotional management | 17. Relieving emotional distress through exercise | 33 (20.8) | 73 (45.9) | 25 (15.7) | 28 (17.6) |
| 18. Seeking information when having questions about kidney disease | 6 (3.8) | 42 (26.4) | 72 (45.3) | 39 (24.5) | |
| 19. Discussing my emotional distress comfortably | 9 (5.7) | 33 (20.8) | 79 (49.7) | 38 (23.8) | |
| 20. Turning to others for help during emotional distress | 23 (14.5) | 41 (25.8) | 66 (41.5) | 29 (18.2) | |
Knowledge and self-efficacy
The mean score of knowledge was 16.15 ± 2.91 and the minimum and the maximum scores were 3 and 21 respectively. The mean score of self-efficacy was 5.24 ± 1.99 and the minimum and the maximum scores were 1 and 9.33 respectively.
The correlation between self-management, knowledge and self-efficacy
There was a significant positive correlation between self-management, knowledge and self-efficacy. Therefore, by increasing knowledge and self-efficacy, the amount of self-management increased. Regarding self-management dimensions, there was a significant positive correlation between the ‘patient’s partnership’ and ‘problem-solving’ dimensions and scores of knowledge and self-efficacy. No significant correlation was found between the ‘self-care’ dimension and the scores of knowledge and self-efficacy. Also, there was a significant positive correlation between the ‘emotional-management’ dimension and self-efficacy whereas no significant correlation was found between the ‘emotional-management’ dimension and knowledge (Table 3). Also, the results of multivariate linear regression showed that knowledge and self-efficacy are significant predictors of the self-management score (knowledge; B = 0.74, confidence interval (CI) = 0.2–1.28, p = 0.007; self-efficacy: B = 0.21, CI = 0.08–0.34, p = 0.002; R2 = 0.12, p < 0.001).
Table 3.
The relationship between the score of self-management, its dimensions and score of knowledge and self-efficacy.
| Variable | Knowledge |
Self-efficacy |
||
|---|---|---|---|---|
| Correlation coefficient | p value | Correlation coefficient | p value | |
| Self-management | 0.22 | 0.006 | 0.3 | <0.001 |
| Patient partnerships | 0.21 | 0.008 | 0.3 | <0.001 |
| Problem-solving | 0.29 | <0.001 | 0.31 | <0.001 |
| Self-care | 0.1 | 0.22 | 0.1 | 0.22 |
| Emotional management | 0.12 | 0.13 | 0.26 | 0.001 |
The correlation between self-management and demographic characteristics
There was a significant reverse correlation between self-management and age. In other words, the older the age, the lower the level of self-management (r = −0.21, p = 0.009). Singles showed higher self-management than married patients (p = 0.01). There was a significant correlation between self-management and type of jobs. Dunnett’s test showed the self-management of homemakers was less than that of employed patients (p = 0.005). No significant relationship was found between other variables and self-management (Table 1).
Discussion
Improvement of self-management in patients under haemodialysis may be an effective way to reduce the mortality and side effects of the disease and improve the quality of life (Griva et al., 2011). The results of the present study indicated the mean score of self-management is 58.88, so it is slightly higher than average (the mean score of self-management questionnaire is 50). In the study conducted by Li et al. in China, the mean score of self-management was 56.01 (Li et al., 2014). It is consistent with the results of the present study regarding self-management of patients under haemodialysis.
In the present study, the highest and the lowest mean scores of self-management dimensions belonged to self-care and problem solving respectively. In the studies conducted by Li et al. (2014) and Song (2009), the mean score of problem solving was higher than that of the other dimensions and the mean score of emotional management was lower than that of the other aspects (Song, 2009; Li at al., 2014). These results did not agree with those of the present study.
In this study, the highest mean score in the dimension of self-care was allocated to ‘taking care of fistula compared to diet and limitation in drinking fluids.’ This result agreed with the other studies (Song, 2009; Li et al., 2014). Because an arteriovenous fistula can be used to reach the arteries in dialysis, it is beneficial for successful treatment. Also, studies indicated that patients who use arteriovenous fistulas live longer than those who use catheters (Wasse et al., 2008). Therefore, an arteriovenous fistula is considered better for patients undergoing haemodialysis. Also, it seems that patients are more likely to take care of their fistula than adhere to dietary limitations. Taking care of fistulas includes cleaning the arm, avoiding lifting heavy objects and measuring hypertension via the arm, which seems easier than dietary restrictions (Furtado and Lima, 2006). Nutritional restrictions are more complex and challenging for patients and require limiting the consumption of sodium, potassium and phosphorus. They have to choose proper foods, correct cooking and add certain spices (Wang and Ma, 2005). Therefore, taking care of arteriovenous fistulas was easier than dietary limitation. This may result in a higher score for taking care of arteriovenous fistulas than for dietary programmes.
In patients’ partnerships, the items with the highest scores were ‘talking with the healthcare provider about the bodily fluid I want to remove’ and ‘telling the healthcare provider about the parameters of dialysis machine that I would like’. Such results agree with those of Song (2009). Therefore, patients will trust nurses’ skills and will support the nurses in placing the fistula more rapidly and accurately.
In problem solving, the two items with the highest scores were ‘asking someone else when having questions about kidney disease’ and ‘trying to figure out what leads to uncomfortable symptoms’. In the study conducted by Li et al. (2014), concentrating on the results of blood tests and behavioural changes for abnormal results obtained the highest scores (Li et al., 2014). These results did not support the results of the present study. The reason may be due to patients having different knowledge in the studies.
In their study (conducted on diabetic patients), Kanbara et al. showed that self-efficacy reduced stressful responses and increased health and the ability to actively fight against the disease (Kanbara et al., 2008). The self-efficacy and knowledge scores had a positive and significant correlation with self-management in such patients. Other studies emphasised the positive association between self-efficacy, knowledge and self-management in patients under haemodialysis especially in the dimension of self-care (Smith et al., 2010; Li et al., 2014).
In the present study, the correlation between demographic variables such as age, marital status, job and self-management was significant. Li et al.’s study showed a significant association between age, gender and education of patients (Li et al., 2014). Older patients had lower self-management than those who were younger in the present study. Because self-management depends on factors such as problem solving, aging is an obstacle for some patients. In contrast, sufficient knowledge about the disease and increasing knowledge of patients for problem solving are essential factors that affect self-management. This is especially true about young people because they have more motivation and an ability to promote their knowledge via the internet and scientific papers (Li et al., 2007). This is true in Iran where the older generation pays less attention to new technologies such as the internet and virtual networks. In this study, no significant relationship was found between gender and self-management, but the self-management score of men was higher than that of women. However, in different studies, self-management was significantly different in men and women and did not agree with the results of the present study. For example, in the results of Kugler et al. (2011) and Wang and Ma (2005), self-management of women was higher than that of men (Wang and Ma, 2005; Kugler et al., 2011). As women tend towards home responsibilities such as cooking and taking care of family members, their roles may have a positive effect on their self-management. Also, women have more of a tendency to pay attention to their appearance, taking more care of their skin and diet than men. Therefore, such factors magnify the self-care of women compared to men. However, such results were not confirmed in the present study. The reason may be due to the differences in study context. Iranian women, especially those who are married, are more responsible for family wellbeing so they pay attention to their children and husbands more than their health. Although the attitudes of younger generations of women towards their role and health are changing in Iran, in the present study most subjects were older women and men. Also, in the present study, single patients showed higher self-management than married ones. As the numbers of single patients were small in our study, the interpretation should be made with caution and further studies are needed to confirm this result.
This study has some limitations. First, the study has been conducted in one city in Iran. Therefore generalisations should made with caution. Second, the frequency of participants in some demographic characteristics was low. Therefore, interpretation should also be made with caution. Finally, we did not assess the participants' self-management across time. More longitudinal studies are necessary to evaluate self-management behaviours of patients under haemodialysis.
Conclusions
The results showed the amount of self-management in patients under haemodialysis was moderate. There was also a significant relationship between self-efficacy, knowledge and self-management. Therefore, the higher the level of self-management in patients, the higher the self-efficacy and knowledge. Caregivers, especially nurses, should provide comprehensive education on how to improve knowledge and self-efficacy levels of patients under dialysis. It is suggested that longitudinal studies be conducted to show the causal relationship between self-management and the factors affecting it. Also, interventional studies are proposed, such as self-efficacy intervention and its effect on the self-management of patients.
Key points for policy, practice and/or research
Moderate self-management has been reported in patients under haemodialysis.
It is necessary to evaluate the factors such as patients’ self-efficacy and knowledge about haemodialysis, which may effect self-management.
Moderate self-efficacy has been reported in patients under haemodialysis.
Moderate knowledge about haemodialysis has been reported in patients undergoing haemodialysis.
Knowledge about haemodialysis and self-efficacy are significant predictors of the self-management score.
Acknowledgements
This paper is derived from an MS thesis on critical care nursing and was approved by the Kerman University of Medical Science (ethics code = Ir.kmu.rec.2016.90). The researchers thank the staff of the nursing department and haemodialysis wards of Shahid Rahnamoun, Seyed Alshohada, Shahid Sadoughi and Goudarz hospitals and all patients who took part.
Biography
Abbass Hafezieh has an MSc in critical care nursing. He practises as a nursing supervisor in hospital and has a lot of experience with taking care of different patients.
Mahlagha Dehghan has completed her PhD at Kerman University of Medical Sciences, School of Nursing and Midwifery. She is Assistant Professor in Critical Care Nursing Department at the School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran.
Mojgan Taebi has completed her PhD at Kerman University of Medical Sciences, School of Nursing and Midwifery. She is Assistant Professor in Operation Room Department in Kerman University of Medical Sciences, Kerman, Iran.
Sedigheh Iranmanesh has completed her PhD at Luleå University of Technology, Sweden. She is Associate Professor in Medical Surgical Nursing in Kerman University of Medical Sciences, Kerman, Iran.
Contributor Information
Abbass Hafezieh, Critical Care Nursing MS Student, School of Nursing and Midwifery, Kerman University of Medical Sciences, Iran.
Mahlagha Dehghan, Assistant Professor, Nursing Research Center, Kerman University of Medical Sciences, Iran.
Mojgan Taebi, Assistant Professor, Operation Room Department, Kerman University of Medical Sciences, Iran.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethics
The ethics committee of Kerman University of Medical Sciences approved the protocol of this study (No.Ir.kmu.rec.2016.90). We provided the ethical code to the dialysis units and obtained their permission to start the study. For the privacy of patients to be respected, patients participated in the study after completing the consent form. The confidentiality of the information and voluntary partnership were explained.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Mahlagha Dehghan https://orcid.org/0000-0002-4205-829X
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