Purpose
We aimed to systematically review and synthesize qualitative evidence on the experiences of nurses caring for hemodialysis patients.
Methods
We used Noblit and Hare’s meta-ethnography. Seven databases (PubMed, EMBASE, CINAHL, Web of Science, RISS, KISS, National Assembly Electronic Library) were used for the literature search. There were no restrictions placed on publication dates. A total of 10 studies published in English and Korean up until July 2021 were finally selected for review.
Results
Three themes were identified from the literature review, which were then divided into six subthemes: acquiring the technical skills of hemodialysis, responsibility for prolonging patients’ lives, and maintaining stable hemodialysis in patients’ daily lives.
Conclusion
The results of this study provide basic data that emphasizes the specific role of nurses in the hemodialysis unit, a specialized area of nursing, and can be utilized as educational material for hemodialysis unit nurse education.
,1
and Eun Young Kim2
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
We aimed to systematically review and synthesize qualitative evidence on the experiences of nurses caring for hemodialysis patients.
We used Noblit and Hare’s meta-ethnography. Seven databases (PubMed, EMBASE, CINAHL, Web of Science, RISS, KISS, National Assembly Electronic Library) were used for the literature search. There were no restrictions placed on publication dates. A total of 10 studies published in English and Korean up until July 2021 were finally selected for review.
Three themes were identified from the literature review, which were then divided into six subthemes: acquiring the technical skills of hemodialysis, responsibility for prolonging patients’ lives, and maintaining stable hemodialysis in patients’ daily lives.
The results of this study provide basic data that emphasizes the specific role of nurses in the hemodialysis unit, a specialized area of nursing, and can be utilized as educational material for hemodialysis unit nurse education.
The number of patients with End-Stage Renal Disease (ESRD) worldwide is steadily increasing [1], leading to an increase in the number of patients undergoing hemodialysis (HD) [2]. In Korea, as of 2020, the incidence rate of ESRD increased to 18,379 patients. Among these, 82.1% chose to undergo HD, suggesting that the majority of ESRD patients choose to undergo HD [3]. Nursing HD patients is challenging process as it requires nurses exercise careful judgement in situations where complex problems can occur [1, 4]. Nurses are expected to provide patient-centered care in a highly technical environment, with the quality of nursing care having a significant impact on improving patient outcomes [4, 5]. Nurses should be skillful in HD techniques, including managing the procedure, maintaining vascular access, preventing infections, and administering drug treatment, along with possessing a general knowledge of kidney disease, anemia, cardiovascular disease, and diabetes [4, 6].
Nurses play a key role in HD treatment and should therefore be equipped with the appropriate competencies to provide adequate care to an increasing number of patients. In light of this, it is necessary to identify the problems faced by independent nurses engaged in providing HD nursing care and to develop measures to address the situation or improve the situation. An approach that uses quantitative indicators designed to determine their influence is not feasible for comprehensively reviewing and analyzing individual experiences; as such, it is necessary to conduct a qualitative study to understand nurses’ practical difficulties and their subsequent effects in the context of HD treatment [7]. Although the number of qualitative studies is relatively small compared to quantitative studies, an integrated analysis of such HD experiences would enable an in-depth understanding of the situational context of individual nurses’ experiences, providing meaningful data on particular phenomena [8, 9].
Qualitative meta-synthesis is a method of identifying common key concepts in the literature that cannot be revealed through individual studies alone, and is useful for providing a new interpretation of study results by deriving and integrating core concepts and respecting the uniqueness of each study through in-depth interpretations of individual study results [10]. Therefore, this study aimed to investigate HD nurses’ experiences by analyzing and synthesizing qualitative study results. It presents a conceptual framework beyond a simple aggregation of the primary outcomes of a qualitative study, and provides fresh insights into HD nurses’ experiences. Based on the results of this study, we intend to provide basic data for improving human resource management for nurses working in HD units and thereby ensure quality nursing care in the future, ultimately providing meaningful data for improving HD patients’ quality of life.
This qualitative meta-synthesis study aimed to analyze and synthesize the results of qualitative studies on the experiences of nurses working in HD centers, using Noblit and Hare’s meta-ethnographic approach [11]. This meta-ethnographic systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021270141). This study was conducted according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement guideline [12].
The literature search was conducted using the conventional literature review method. As this method is mainly used to retrieve works related to the overall subject of interest, it is particularly suitable for meta-synthesis studies [13]. The researchers examined four electronic databases (PubMed, Excerpta Medica Database [EMBASE], Cumulative Index to Nursing and Allied Health Literature [CINAHL], Web of Science) for foreign literature searches. The search terms used included “hemodialysis”, “nurses’ experience”, and “nursing experience” and were selected from a list of Medical Subject Headings (MeSH). For domestic literature, the Research Information Sharing Service (RISS), Korean Studies Information Service System (KISS), and the National Assembly Electronic Library databases were used. The search strategy is illustrated in Figure 1. The inclusion criteria for studies were as follows: (1) nurses aged 18 years or older as the target population, (2) published up until July 31, 2021, (3) published in English and Korean in peer-reviewed journals, and (4) with the full text available. In order to conduct a broad search, there were no restrictions placed on the earliest date of publication. The exclusion criteria for studies were as follows: (1) unsuitable for the purpose of this research, (2) not in English or Korean, (3) using quantitative methodologies, (4) involving children or adolescents, and (5) conducting secondary analysis.
Figure 1
Flow chart of the systematic review.
Through this search process, 689 studies were identified and 300 duplicate studies were excluded. The titles and abstracts of the remaining 389 studies were examined to determine whether they met the inclusion criteria. Subsequently, 298 studies that did not meet the inclusion criteria were excluded. After the entire text of the selected papers was investigated, 81 articles were considered inappropriate according to the exclusion criteria in this study. Data selection was conducted independently by two researchers; when their opinions differed, they were discussed to ensure the validity and reliability of the literature selection. A final total of 10 papers were selected for analysis.
Quality appraisal in this study was performed using the Critical Appraisal Skills Program (CASP), which is widely used to evaluate the quality of literature. The CASP qualitative checklist consists of 10 items, including a clear statement of aim, suitable qualitative methodology, appropriate research design, proper recruiting strategy, adequacy in data collection, adequate relationship between participants and researchers, ethical considerations, rigor of data analysis, clear statement of findings, and overall value of the research [14]. In this study, the quality of the ten selected papers was independently evaluated by two researchers. As CASP is suggested to enhance the understanding of individual papers, this study only evaluated whether each item of the CASP was met and did not use CASP as a selection criterion. The results of the quality appraisal are presented in Supplementary Material 1.
Researchers attempted to understand the details of each study as comprehensively as possible by repeatedly referring to the themes, categories, and citations presented in the results of each study. Each researcher extracted and organized the data regarding HD nurses’ experiences that were considered significant, and carefully extracted the content of the original text without altering it. To clarify the content during data extraction, the researchers conducted repeated extractions while continuously referring to the original texts.
The research question was “What are the experiences of nurses caring for patients undergoing HD?” The two researchers organized the selected papers in chronological order and repeated the process of deriving common concepts and themes from all selected papers, while carefully and repeatedly examining similarities, differences, and relevance between the papers and keeping the research question in mind. The Korean study was translated into English and synthesized. The translation process was performed through forward translation, expert validity review by bilingual speakers, and back-translation in accordance with the World Health Organization guidelines on translation to ensure validity and reliability [15]. The data analysis process comprised primary, secondary, and tertiary structures. Primary structure refers to participants’ interpretation of the original studies, secondary structure refers to the researcher’s interpretation of the primary structure, and tertiary structure refers to a new interpretation based on the secondary structure [11]. Core concepts from the primary structure were extracted and analyzed to form the secondary structure. The tertiary structure was constructed through the process of abstracting the secondary structure. The data analysis and synthesis were performed by each researcher. When disagreements in the interpretations of the derived results occurred, a consensus was reached through discussion and the synthesized themes were presented in a manner comprehensible to readers.
Ten studies were included, and the publication period was defined as between 2010 and 2020. A total of 118 nurses participated in the studies included in the review, and the age of the nurses varied from 30 to 69 years in the studies in which age was reported. Males were not included in the studies that presented a gender ratio. Nurses’ work experience in the HD unit varied from 6 months to 39 years (Table 1).
Table 1
Summary of the Studies included in the Review
Three themes (acquiring the technical skills of HD, responsibility for prolonging patients’ lives, and maintaining stable HD in patients’ daily lives) and six subthemes emerged as a result of the synthesis (Table 2; Figure 2). Nurses caring for patients undergoing HD attempt to understand and develop skills regarding the HD route Arteriovenous Fistula (AVF) based on theoretical knowledge. Simultaneously, they strove to acquire the skills necessary to use the HD machine. Nurses considered these skills to be essential, and based on them, they became more involved with patients, took responsibility, and provided nursing care to maintain a balance between unforeseen situations and healthcare. Through this process, trusting relationships were built between patients and nurses, and the harmonious execution of the processes formed the basis for the successful functioning of the HD unit. For nurses, adequate operation of HD units is ultimately a prerequisite for ensuring a stable life for patients.
Figure 2
Experiences of nurses caring for patients with hemodialysis.
Table 2
Synthesized Themes of Experiences of Nurses Caring for Patients with Hemodialysis
Nurses working in the HD unit wished to acquire the necessary skills and become proficient in HD techniques. In particular, AVF cannulation poses a significant challenge for nurses, and familiarity with the HD machine is one of the most important tasks they face.
For nurses, AVF cannulation is considered a major challenge and requires problem-solving ability. Nurses experienced rejection from patients due to their inexperience with AVF cannulation [16, 17, 18, 19, 20]. For nurses, the patient’s AVF condition was unpredictable [16, 18, 19, 20, 21], and the opportunities for AVF cannulation were insufficient [17, 18, 19, 20, 21]. The nurses feared unsuccessful AVF cannulation [16, 18, 19, 20, 21]. Examples of quotations that may be representative of their challenges are:
And then, see if they will let me put another needle in because, you know, I do have a personal rule that if I put two needles in and I am not successful, then I pass it on to someone else. [18, p. 305]
I think the opportunity (to cannulate) is not there. ...they (the nurses) are nervous because they have not done it as often. So, it’s a kind of double-edged sword, in a way.[20, p. 39]
Familiarity with HD machines is essential for patients’ nursing care [16, 17, 20, 21]. It is necessary for nurses to become accustomed to operating complex HD machines, handling various alarm systems, and performing dialysis [16, 20, 21, 22]. Nurses face various mechanical problems with HD machines and resolving these is one of their main tasks [16, 20, 21]. Representative quotes are:
By shadowing staff in preparing a HD machine. [16, p. 179]
Direct observation of preparing a HD machine and becoming familiar with alarm systems. [16, p. 179]
It requires about a year to be at ease with the HD machine. One year is huge. You do not need a year to be at ease at work. [21, p. 1081]
Nurses monitored patients’ health conditions and prepared for any emergencies that might occur. The nurses were aware of the disease characteristics of HD patients and attempted to take responsibility for their overall health.
Nurses were cognizant of patients’ usual health condition and strove to recognize abnormal health signs in this context compared to usual health condition [16, 17, 21, 22, 23, 24]. They acquired knowledge of HD risks and were prepared in advance to predict and prevent side effects during treatment [16, 17, 21, 22]. They understood that an emergency could occur at any time, and indeed experienced many actual emergency situations [16, 18, 21, 23, 24]. Thus, they realized that they should always think about and prepare for emergencies. Additionally, nurses regularly monitored patients’ health status [16, 17, 22, 23, 24] and attempted to balance their psychological and physiological health [16, 17, 18, 21, 23, 24]. Examples of this from the text include:
You can see they are breathing heavily. [22, p. 424]
They have so many additional diagnoses . . . and to remove fluid is difficult ... Many of them are very frail when we start dialysis. [22, p. 423]
Patients faced situations in which decision-making was necessary, and the nurses guided them to make the best choices [17, 22, 24, 25], continuously cared for them, and gave them hope [17, 18, 23, 24]. Nurses educated patients through providing health information and health-related records [16, 17, 18, 24, 25]. In addition, nurses shared information with patients on how to better manage themselves [17, 21, 22, 23, 24, 25] and provided coaching on overall health, including pain management [16, 17, 23]. Examples from the text are follows:
I would provide more specialized advice on issues such as eating, lifestyle, exercise, and managing diabetes. [17, p. 1459]
First I assess them and try to figure it out if it is related to dialysis or another issue-chronic condition. [23, p. 39]
Nurses in the HD unit undertook to help patients maintain stable daily lives, which they achieved by interacting with patients and forming trusting relationships. In addition, nurses were attentive to the efficient operation of the HD unit, ensuring that all patients requiring HD treatment would receive it without problems.
As nurses met with patients regularly, they shared details of their daily lives, talked about various topics, and formed close relationships with each other [16, 17, 18, 21, 23, 24, 25]. Nurses fostered patients’ trust through communication, empathy, and support [16, 17, 18, 21, 22, 23, 24]. In addition, nurses communicated with patients’ families and relatives to strengthen their relationships [17, 18, 21, 22, 23, 24]. Example from the text include:
I experienced a feeling of trust. I was the person who could offer trust, and I offered trust. [17, p. 1459]
You can always talk about how their home or job situations are going. [24, p. 7]
Many patients must undergo HD according to a fixed schedule in the HD unit, thus it is essential for nurses to operate the unit efficiently [17, 19, 20, 21]. Nurses are required to manage their time appropriately (so that many patients receive HD at a regular time), allocate time slots efficiently, and accurately calculate the time patients spend on the machine [19, 20, 21]. This was shown in the following statements from the text:
During inter-session, there are twice as many patients, two teams, and all the ‘machines’ waltz’ to manage. [21, p. 1081]
I mean, we are open until 11:00, but usually if there is a four-hour run they will usually say; Well, I can only do three and a half or three hours today because my ride is coming at such a time. [19, p. 14]
This study attempted to provide a comprehensive understanding of the experiences of nurses caring for HD patients. This study revealed that technical problems in the operation of the HD machine, along with vascular cannulation, were burdensome for nurses. Previous studies showed that nurses were stressed by very complex problems in HD units, and the technical problems of HD have been shown to be challenging for nurses to manage [26]. We should therefore be concerned about the perceived lack of opportunities for nurses to perform AVF cannulation and consider ways to help them become more familiar with the task by increasing opportunities to perform it.
Without regular dialysis, chronic renal failure can be fatal, and nurses must focus on detecting any unexpected situations presenting in patients. Previous studies have shown that patients undergoing HD experience improved quality of life when their physical health is maintained and when they feel supported by society [27]. Therefore, it is suggested that nurses’ efforts to maintain patients’ health can help to improve patients’ quality of life.
Nurses tried to maintain stable HD for patients, and through these efforts, they ultimately attempted to help patients lead a stable life in general. To achieve this, they tried to build a trusting relationship with their patients. Forming a trusting relationship with patients can be viewed positively from a nursing perspective; however, HD unit nurses were found to experience job stress due to emotional labor, fatigue, compassion, and somatoform disorder [28]. Thus, based on previous studies showing that improved resilience or interventions such as mindfulness are effective in reducing stress among nephrology nurses, it is essential to develop specific support and intervention programs that can help reduce stress among HD unit nurses [29].
Based on these results, we propose the following hypothesis: The field of HD differs from general nursing and is a specialized field that requires extensive knowledge of ESRD, and the machines and technology used in its treatment. However, there are insufficient training opportunities for HD unit nurses, and many require further specialized courses [30]. Therefore, we suggest developing various educational courses and programs specializing in renal care nursing to improve the quality and professionalism of HD unit nurses at the national level. At the institutional level, it is necessary to prevent negative experiences such as stress or burnout by evaluating the difficulties experienced by nurses through periodic monitoring. In addition, by analyzing the work systems of nurses in the HD unit, nurses should be able to effectively share their duties, thereby reducing the burden on individuals. At the individual level, nurses should make efforts to acquire relevant HD skills using various resources and educational programs to ensure professionalism, which will in turn help improve patient safety in the context of HD. In addition, nurses should try to form trusting relationships with patients and focus on effectiveness in their work by clarifying the division of tasks. Additionally, we suggest developing job guidelines for HD nursing to clarify the job requirements.
This study had certain limitations. Although it comprised studies from various countries, only two Asian studies were included; therefore, cultural and national differences in care experience could not be inferred from the results of the present study. For a more comprehensive understanding of HD nursing, studies using populations from various races and cultures are needed. A further limitation is that even though all studies included received a fairly high score of 80% or more in the quality evaluation, many studies did not satisfy Items 4 and 6, which related to recruitment strategy and the relationship between research and participants. As this study regarded HD unit nurses, the number of participants was very limited; therefore, this can be considered limited, which could be considered a problem. Based on these issues, future research will require clear specifications of the recruitment strategy and the relationship between research and participants.
This study emphasizes that HD nursing is a specialized area that requires a combination of technical and overall HD unit operation skills. Additionally, a deeper and more comprehensive understanding of HD unit nurses’ experiences is essential for the development of specialization programs for HD unit nursing care. Such programs may promote the need to develop a new, specialized field of study in renal nursing, in addition to playing an essential role in improving the quality of care for patients undergoing HD.
Quality Assessment Result of the Critical Appraisal Screening ProgramSupplementary Material 1
CONFLICTS OF INTEREST:The authors declared no conflict of interest.
AUTHORSHIP:
Study conception and design acquisition - LY-N and KEY.
Data collection - LY-N and KEY.
Analysis and interpretation of the data - LY-N and KEY.
Drafting and critical revision of the manuscript - LY-N and KEY.
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