Life satisfaction of patients receivingContinuous Ambulatory Peritoneal Dialysis
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Authors Klein, Julie Ellen
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LIFE SATISFACTION OF PATIENTS RECEIVING
CONTINUOUS AMBULATORY PERITONEAL DIALYSIS
by
Ju lie Ellen Klein
A Thesis Submitted to the Faculty of the
COLLEGE OF NURSING
In P artia l F u lfillm e n t of the Requirements For the Degree of
MASTER OF SCIENCE
In the Graduate College
THE UNIVERSITY OF ARIZONA
1 9 8 1
STATEMENT BY AUTHOR
This thesis has been submitted in p a rtia l fu lf i l lm e n t of requirements fo r an advanced degree at The University o f Arizona and is deposited in the University Library to be made available to borrowers under rules of the L ibrary.
B rie f quotations from th is thesis are allowable w ithout special permission, provided tha t accurate acknowledgement o f source is made. Requests fo r permission fo r extended quotation from or reproduction o f th is manuscript in whole or in part may be granted by the head o f the major department or the Dean o f the Graduate College when in his judgment the proposed use of the material is in the in terests o f scholarship. In a ll other instances, however, permission must be obtained from the author.
SIGNED: (LLa t %
APPROVAL BY THESIS DIRECTOR
This thesis has been approved on the date shown below:
ALICEMJ. LONGM#^"" Associate Professor o f Nursing
DATE
ACKNOWLEDGEMENTS
The author wishes to express her sincere gratitude to
Dr. Katherine Young and Anne Gassmann fo r serving as members o f her
thesis committee, and fo r th e ir assistance in the guidance o f th is
study.
Special appreciation and thanks are given to the chairperson
o f the thesis committee. Dr. A lice J. Longman, fo r her encouragement,
support and guidance throughout the development o f th is study.
The author also would lik e to extend sincere appreciation to
the s ta f f o f the in s t itu t io n where the data were collected and to
the patients who were so w ill in g to cooperate and pa rtic ipa te in
th is study.
TABLE OF CONTENTS
Page
LIST OF TABLES .................................. vi
LIST OF FIGURES............................................... ' .................... v i i
ABSTRACT...............................................................................................................vi i i
CHAPTER
1. INTRODUCTION . 1
Statement o f the Problem .................................. 2Statement of Purpose .............................................. 2Significance of the P ro b le m ....................... ~ . ...................... 3Conceptual Framework.......................................... 5D e fin ition of Terms ...................................... . 11
2. SELECTED REVIEW OF LITERATURE.............................. 12
L ife S a t is fa c t io n ...................................................................... 12L ife Satis faction of Patients Receiving
Hemodialysis and Renal Transplantation ........................... 15Continuous Ambulatory Peritoneal D ialysis . . ................... 18
3. METHODOLOGY.......................... 22
Research D e s ig n ...................................... ................................... 22S e t t in g ......................................................................................... 22Sample . ................................................................................ . 23Approval fo r the Study ................................... . . . . . . . 23Method of Data Collection .......................................... 23Data Collection Instruments . . . . 24Method o f Data Analysis ........................... 27Lim itations of the Study . . . . . . . . . . .................... 29
iv
V
TABLE OF CONTENTS—Continued
Page
4. PRESENTATION AND ANALYSIS OF DATA . 30
Characteristics of the Sample . . ....................................... 30Results of the Personal Interview ................ 35
Scores and M e a n s ....................... 35Individual Item Scores and M e a n s ............................... .. . 35Verbal Responses.............................................. 40
5. DISCUSSION AND RECOMMENDATIONS . ....................... 47
Findings in Relation to the ConceptualFramework and L ite ra tu re Review . . . 47
C o n c lu s io n s .......................... 52Implications fo r Nursing .......................................................... 52Recommendations . ................................................................. 53
APPENDIX A: LETTER OF APPROVAL FOR STUDY . . . . . 54
APPENDIX B: DISCLAIMER . . . . . . . 55
APPENDIX C: DEMOGRAPHIC SHEET ................. 56
APPENDIX D: PERSONAL INTERVIEW ....................................... 57
APPENDIX E: INTERVIEW CARDS....................................... 59
LIST OF REFERENCES .......................... 60
)
LIST OF TABLES
Page
TABLE
1. Characteristics o f the Sample: Sex and Marital Status . . . 31
2. Sources From Which Subjects Learned o f ContinuousAmbulatory Peritoneal D ialysis . . . . . . . . .................... 33
3. Reasons Subjects Received Continuous AmbulatoryPeritoneal D ia ly s is ...................... . . 34
4. D is tribu tion o f Subjects' L ife Change Scores, D irectiono f Change and Current L ife Satis faction Scores .................... 36
5. D is trib u tion of Each L ife Change Item Total Score, MeanScore and Direction o f Change fo r the Total Sample . . . . 38
6. Mean Scores o f Current L ife Satis faction Ratings ofSelect Groups o f the Sample....................... 39
vi
LIST OF FIGURES
Page
FIGURE
1. Conceptual Framework fo r Study . ...................................... . 10
v i i
ABSTRACT
This study was conducted to describe change in the various
components of the l i f e o f patients receiving Continuous Ambulatory
Peritoneal D ia lysis and to obtain ratings of current l i f e sa tis fa c tion .
An interview was conducted and consisted o f 19 l i f e change items and
one item to measure current l i f e sa tis fa c tio n .
The sample fo r the study was comprised o f 11 subjects. A ll
o f the subjects had experienced change in th e ir lives since receiving
Continuous Ambulatory Peritoneal D ia lys is . Eight subjects indicated
the overall change o f th e ir lives was fo r the better and three
indicated the overall change was fo r the worse. The mean and d irection
o f change fo r each change item in the interview was obtained.
The subjects then selected a number from one to 10 to rate
th e ir current l i f e sa tis fac tion with one ind ica ting low l i f e sa tis
faction and 10 ind ica ting high l i f e sa tis fa c tio n . The range o f the
ratings was from three to 10 with a mean score o f 6.6 fo r the to ta l
sample. Means Of current l i f e sa tis fac tion ratings were compared
between subjects who had been on hemodialysis p r io r to receiving
Continuous Ambulatory Peritoneal D ia lysis and subjects who had not;
married and unmarried subjects; and male and female subjects.
CHAPTER 1
INTRODUCTION
Prior to I960, there was no treatment fo r patients in chronic
renal fa ilu re with end-stage uremia. These patients were c lass ified
as "terminal uremics" and were le f t to su ffe r and die (Abram, 1972).
Patients with end-stage renal disease are now offered the chance to
extend th e ir lives e ithe r through d ia lys is or renal transp lanta tion.
Decisions about the form of treatment tha t o ffe r the pa tien t optimum
survival and q ua lity o f l i f e is made jo in t ly by the pa tien t, fam ily
and physician (T ilney, e t a ! . , 1975; Kress, 1975). Medical and
social factors a ffec ting the patien t should be considered in the
choice o f treatment. Psychological factors should also be considered,
as chronic d ia lys is and transplantation have been shown to be
psychologically s tressfu l to patients who have undergone these forms
o f treatment (Kress, 1975; De-Nour and Shanan, 1980).
From 1960 to 1978, there was only one form o f d ia ly s is ,
hemodialysis, used on a long-term basis fo r the m ajority o f patients in
end-stage renal disease. Studies have shown that hemodialysis
increased the chances fo r survival fo r patients in end-stage renal
disease, but i t also created problems fo r the patient and his family
(Kress, 1975).
1
Another form o f d ia ly s is , Continuous Ambulatory Peritoneal
D ia lys is , was developed by Popvich and Moncrief in 1976 and refined
by Oreopoulos and associates in 1978. With these developments.
Continuous Ambulatory Peritoneal D ia lysis has been accepted and
used throughout the world as a standard procedure o f d ia lys is
(Oreopoulos, 1980). I t is claimed that there are many medical and
psychological advantages fo r patients who undergo treatment w ith
Continuous Ambulatory Peritoneal D ialysis when i t is compared to
hemodialysis and in te rm itte n t peritoneal d ia lys is .
The focus o f nursing in the past has been la rge ly concerned
with the technical procedures o f chronic d ia lys is w ith l i t t l e emphasis
on the q u a lity o f l i f e of the person (Jackie, 1974). Nurses can
assess i f Continuous Ambulatory Peritoneal D ialysis can o ffe r advantages
that may enhance l i f e sa tis fac tion fo r patients receiving th is form of
treatment fo r end-stage renal disease.
Statement of the Problem
How do patients describe aspects o f l i f e change and current
l i f e sa tis fac tion while receiving Continuous Ambulatory Peritoneal
Dialysis?
Statement o f Purpose
The purpose of th is study was to describe l i f e change and
current l i f e sa tis fac tion ratings o f patients who are receiving
Continuous Ambulatory Peritoneal D ia lys is . This study should make
nurses aware o f needs o f patients who are receiving Continuous
Ambulatory Peritoneal D ia lys is ; with th is knowledge, nurses can help
patients adjust to treatment o f Continuous Ambulatory Peritoneal
D ia lys is .
Significance of the Problem
Now fo r the f i r s t time there is a growing population of long
term survivors o f end-stage renal disease who are being maintained
on chronic d ia ly s is . Many refinements have been made in d ia lys is since
1960, when i t was a new and experimental procedure. The m ajority o f
nursing and medical l ite ra tu re , in the past, has been devoted to the
technical improvements and the physiological e ffects o f d ia lys is on
patients. Health professionals working with the d ia lys is population
now perceive tha t th is long-term maintenance therapy has both a
psychological as well as a physiological impact on the lives o f the
patients and th e ir fam ilies .
Hemodialysis has been the treatment of choice fo r the m ajority
Of patients in end-stage renal fa ilu re . From its advent in 1960 u n til
1972, patients were ca re fu lly screened and selected fo r hemodialysis
due to the lack o f fa c i l i t ie s available (Kress, 1975). Hemodialysis
was made widely available to patients in end-stage renal disease by the
United States Government with the 1972 Amendment to the Social Security
Act which helped "to assure that any ind iv idua l who suffers from
chronic renal disease w il l have availab le to him the necessary l i f e -
saving care" (Kress, 1975:41). Another advance was made when Medicare,
in 1973, undertook financ ia l re sp o n s ib ility fo r the treatment of the
m ajority o f patients undergoing d ia lys is (Kress, 1975).
The patient undergoing hemodialysis must adhere to the s t r ic t
regimen he is put on in order to survive (O'Brien, 1980). The regimen
is comprised o f spending approximately s ix hours on the machine three
times a week, d ie tary and f lu id re s tr ic tio n s , taking medications
several times a day and e lim inating some physical a c t iv i t ie s . Patients
on hemodialysis usually have uremic symptoms the day before d ia lys is
such as lethargy, headache, lack o f a lertness, muscle weakness,
nausea, p ru r it is , hypertension and others (Burton, et a l . , 1981).
Continuous Ambulatory Peritoneal D ialysis uses the peritoneum
as the d ia lys is membrane 24 hours a day. Dialysate in two l i t e r
p la s tic bags is exchanged four times a day by the patien t using aseptic
technique. Three o f the exchanges stay in the peritoneal cavity fo r
f iv e hours during waking hours and the fourth exchange stays in the
peritoneal cav ity overnight. The semi-permanent catheter, su rg ica lly
placed in the abdomen, serves to both f i l l and drain the peritoneal
cav ity . The average time required to drain the peritoneal cavity with
the used dialysate and to f i l l the peritoneal cavity w ith fresh
dia lysate takes approximately 30 minutes fo r each exchange (Sorrels,
1979).
There are few d ie tary and f lu id re s tr ic tio n s w ith Continuous
Ambulatory Peritoneal D ia lys is . . Because the d ia lys is process is on
going and the person is maintained in a steady s ta te , d isequilibrium
symptoms disappear tha t are seen with hemodialysis and in te rm itte n t
peritoneal d ia lys is (Oreopoulos, et a l 1979; Moncrief and Nolph,
1980; Oreopoulos, 1980). Other medical advantages seen in patients
receiving Continuous Ambulatory Peritoneal D ialysis are the removal
o f sodium, potassium, small and middle molecules, and water (Oreopoulos
and Katirtzoglou, 1979). Calcium and phosphorus are usually maintained
w ith in normal lim its and patients use minimal doses o f phosphate-
binding oral agents, i f they are needed a t a l l . Blood pressure control
is easier to a tta in with l i t t l e or no use o f anti-hypertensive
medication (Weinman, e t a l . , 1980; Nolph, 1980). Other advantages of
Continuous Ambulatory Peritoneal D ia lysis cited are the omission of a
partner, machine and shunt (Moncrief and Nolph, 1980).
Most patients on Continuous Ambulatory Peritoneal D ialysis
have reported an improvement in well-be ing, an increase in energy,
improved appetite, an increase in a c t iv ity , the a b i l i t y to liv e a more
normal l i f e s ty le and most im portantly, the sense o f freedom that they
experience (Gokel, et a l . , 1980; Sorrels, 1979; Burton, e t a l . , 1981).
Considering the advantages o f Continuous Ambulatory Peritoneal D ia lys is ,
do patients perceive change in various aspects of th e ir lives and how
do they rate current l i f e sa tis fac tion while receiving th is form o f
treatment?
Conceptual Framework
The concepts chronic illn e s s , treatment, l i f e change and current
l i f e sa tis fac tion comprised the conceptual framework. The framework
described the re la tionsh ip tha t treatment of chronic renal fa ilu re
Continuous Ambulatory Peritoneal D ia lysis may have on l i f e change and
current l i f e sa tis fa c tio n .
Quality o f l i f e is an abstract concept to study and define
(Jackie, 1974). In the past, American society has thought tha t
q u a lity o f l i f e could be measured in objective terms o f economic
sa tis fac tion and material possessions and tha t they were the only
important factors fo r human welfare and happiness (Laborde and Powers,
1980; Campbell, 1976). Social indicators such as educational achieve
ment and occupation have been used by social sc ien tis ts to ob jective ly
assess the q ua lity o f a person's l i f e (Laborde and Powers, 1980). I t
was implied by Campbell (1976) that these objective measures may
describe conditions tha t influence l i f e experience, but they do not
assess l i f e experience d ire c tly . Assessment of the q u a lity o f l i f e has
now sh ifted from variables that are material to those tha t are psycho
log ica l and less tangib le. These include variables such as social
prestige, dominance, group id e n tif ic a tio n and sense o f achievement, or
what Mas1ow referred to as the "higher needs" (Laborde and Powers, 1980
Campbell, 1976). •
A major component o f an inc lus ive view o f q ua lity of l i f e is
l i f e sa tis fac tion (Jackie, 1974). L ife sa tis fa c tio n , or a person's
general appraisal of his l i f e , is s p e c if ic a lly defined as
the pleasure one takes from the round o f a c t iv it ie s thatconstitu te his d a ily l i f e , one's perception of his l i f e as meaningful and capable o f continued development, and one's view o f his own s itua tion as sa tis fy in g in terms o f what is and what might be fo r him, in l ig h t o f his own purpose (Jackie, 1974:362).
L ife sa tis fac tion should be a major component of. any comprehensive
conception o f "adjustment" or "mental health" (S e lls , 1969).
I t is not known i f factors can be ranked in importance to one
another when assessing l i f e sa tis fa c tio n . L ife events in which there
are psychological gains and losses .such as b ir th s , deaths, marriages,
accidents, illnesses and unemployment may have a short-term impact on
the way the person appraises his l i f e (Campbell, 1976). When dealing
w ith subjective measures, the ratings may not have the same meaning to
d iffe re n t people and w il l not have the precision of objective ind ica
to rs . However, what they do measure is the in d iv id u a l's sense of
well-being (Campbell, 1976; Jackie, 1974).
Pal more and Lu ikart (1972), in a study o f l i f e sa tis fac tion in
early and middle age, reported tha t se lf-ra ted health was the strongest
variable related to l i f e sa tis fa c tio n . Other variables id e n tif ie d in
th e ir study were social a c t iv ity , socio-economic status and age. They
concluded tha t people who are more sa tis fie d with th e ir lives "tend to
be hea lth ie r, more so c ia lly active , tend to have more income and
education and tend to be younger" (Palmore and Lu ika rt, 1972:68).
Other studies have been conducted to determine i f other
components of l i f e were highly related to l i f e sa tis fa c tio n . These
included m arital sta tus, presence or absence o f ch ild ren, employment
sta tus, sex o f the person, re lationships w ith others and fam ily re la
tionships. These variables were less strongly related to l i f e
sa tis fac tion than se lf-ra ted health (Palmore and Lu ika rt, 1972). The
importance o f the variable o f se lf-ra ted health was s im ila r to the
results o f other studies o f l i f e sa tis fac tion in old age (Neugarten,
Havighurst and Tobin, 1961).
Pal more and Lu ikart (1972) implied that i f se lf-ra ted health
is a highly related variable to l i f e sa tis fa c tio n , then a person's
perception of his health influences his over-a ll op tim is tic or
pessim istic view o f l i f e sa tis fa c tio n . The person's subjective
evaluation o f his health has been shown to influence his l i f e more
than an objective evaluation by a physician. I t was stated "tha t a
person with poor objective health may s t i l l have a high l i f e sa tis fac tion
i f he believes his health is re la tiv e ly good and s im ila r ly a person with
good objective health may have low sa tis fac tion i f he is convinced
his health is re la tiv e ly poor" (Palmore and Lu ika rt, 1972:73). De-Nour
and Czackes (1976) concluded that the pa tie n t's reaction and a ttitu d e
toward illn e ss is influenced by his personality.
Chronic illn e ss may have an impact on a person's view of l i f e
sa tis fa c tio n . The m ajority o f health p rac titione rs assume that the
person who is su ffe ring from a chronic illn e ss does have some type o f
change in varying degrees o f l i fe - s ty le . This may be the re su lt o f the
underlying disease process i t s e l f or the re su lt of the treatment of the
disease. The change may be physiological or psychological involving
a c t iv it ie s that the person may associate with a fu l l and productive l i f e .
Therefore, there may be a reduction in the qua lity of l i f e of that
person (Laborde and Powers, 1980).
Burton, et a l . (1981) stated tha t "o f a ll chronic illnesses,
perhaps no condition is as stressfu l as chronic kidney fa ilu re " (p. 25).
The person undergoing d ia lys is is constantly aware that th is form o f
treatment does replace the function o f his ir re v e rs ib ly damaged
kidneys, but tha t d ia ly s is , in i t s e l f , is not a cure fo r end-stage
renal fa ilu re (Burton, et a l . , 1981; Kress, 1975). The ch ron ic ity o f
th is s itua tion may have an impact on what the patient undergoing
d ia lys is perceives his own health status to be.
There are many sources o f stress fo r patients receiving hemo
d ia lys is . Psychological stressors include dependence on a machine,
dependence on the medical s ta f f or a partner, loss o f mastery of one's
l i f e because the machine is run by others, fru s tra tio n of drives, the
in a b il i ty to plan fo r the fu ture and the fear o f death. Physiological
stressors lis te d in the lite ra tu re are the d ie t, f lu id and physical
re s tr ic tio n s o f the hemodialysis regimen and complications o f shunts
and f is tu la s (B r it is h Medical Journal, 1980; De-Nour and Czaczkes,
1976). These stressors a ffe c t the autonomy o f the person receiving
hemodialysis by re s tr ic t in g his freedom o f choice (Jackie, 1974).
A c tiv it ie s may also be affected by these stressors, resu lting in a
change in l i f e s ty le of the person receiving d ia lys is . The conceptual
model fo r th is study is shown in Figure 1.
According to Dimond (1979), nursing is ju s t s ta rtin g to explore
the p a tie n t's adaptation to chronic illn e s s . Nursing is beginning to
set up models to guide nursing care fo r the patient who requires long
term care. The goal of nursing, when se tting up these models, is to
id e n tify factors which help the person lead a l i f e s ty le as close as
possible to the one he experienced before the onset of the illn e s s .
ChronicIllness
ChronicRenalFailure
Treatment - L ife Change
- Current L ife
Satisfaction
Continuous ________ L ife Change____ ___ Current L ifeAmbulatory Scale ~ SatisfactionPeritoneal ScaleDialysis
Figure 1. Conceptual Framework For Study
In order fo r nursing to reach th is goal, there must be id e n tif ic a tio n
or major variables of l i f e sa tis fac tion important to the person
su ffe ring from chronic disease (Dimond, 1979). The variables of
m arital sta tus, sex o f the person and whether the person has received
p rio r treatment o f hemodialysis need to be id e n tif ie d in the patient
population who is receiving Continuous Ambulatory Peritoneal D ia lys is .
Variations in current l i f e sa tis fac tion ratings may be apparent in the
patient receiving Continuous Ambulatory Peritoneal D ia lysis due to the
influence of these variables.
D e fin ition o f Terms
L ife Satis faction - A person's appraisal o f various components o f his
l i f e .
Continuous Ambulatory Peritoneal D ia lysis (CAPD) - A form o f s e lf-
d ia lys is that the pa tien t has undergone independently
fo r at least two weeks.
CHAPTER 2
SELECTED REVIEW OF LITERATURE
U ntil recen tly , there were few studies about l i f e sa tis fac tio n .
The studies reported were exploratory in nature and tr ie d to define
s ig n ific a n t aspects o f l i f e of people in d iffe re n t populations. Some
studies on th is subject have been conducted on patients on hemodialysis
and very few on patients receiving Continuous Ambulatory Peritoneal
D ia lys is. This review o f lite ra tu re is divided in to three sections:
l i f e sa tis fa c tio n , l i f e sa tis fac tion studies o f patients on hemo
d ia lys is and renal transp lanta tion, and Continuous Ambulatory Peritoneal
D ia lys is.
L ife Satisfaction
According to Campbell (1976), early research studies conducted
on l i f e sa tis fac tion used three major methods to obtain subject
ind icators o f well-being^ In the f i r s t method, the subject was asked
to compare his perception o f his present l i f e s itua tion to a l i f e
s itua tion he aspired to , expected or thought he deserved. The d is
crepancy between his perceived l i f e ra ting and aspired l i f e ra ting would
be used to measure sa tis fac tion or d issa tis fac tion with greater sa tis
faction ind ica ting a sense of well-being.
12
13
The second approach studied subjective fee ling states that
people encountered in th e ir da ily live s . These states were assessed
by the assignment o f numbers to p a rticu la r pos itive and negative events
tha t had occurred in the subjects' lives in the recent past.
The th ird major method was derived from psych ia tric practice.
This strategy consisted o f questions about symptoms, experiences and
general fee lings. Questions regarding l i f e sa tis fac tion re flected
positive responses of well-being and questions regarding worries,
anxieties and emotional crises which re flected negative responses o f
well-being.
Campbell (1976) reported tha t studies were conducted using these
three methods of measurement and reported tha t general sa tis fac tion w ith
l i f e tends to be low among young people and tends to increase with age.
Happiness was reported to be higher in young people and tended to
decrease with age. Happiness with marriage was reported to increase
with the level of education of the subjects, but as the level o f
education increased, feelings of inadequacy as a marraige partner
increased.
Neugarten, Havighurst and Tobin (1961) conducted a study to
describe the psychological well-being of older people. The l i f e s a tis
faction ra ting scale used in th is study was composed o f f iv e components:
1) i f the person took pleasure from everyday a c t iv it ie s o f his l i f e ;
2) i f the person regarded his l i f e as meaningful; 3) i f the person f e l t
he had succeeded in achieving major l i f e goals; 4) i f the person had a
14
positive self-image; and 5) i f the person maintained a happy and
o p tim is tic a ttitu d e and mood. These components were summed to determine
an overall ra ting of l i f e sa tis fac tion fo r each subject.
With these measures, Neugarten, e t a l . (1961) reported that
there was no co rre la tion between l i f e sa tis fac tion ratings and age.
They reported a pos itive re la tionsh ip between l i f e sa tis fac tion and
socioeconomic status. They found that there were no s ig n if ic a n t
differences o f l i f e sa tis fac tion ratings between the two sexes of the
e lderly population. They found lower l i f e sa tis fa c tio n ratings by
people who were not married. This included people who were e ithe r
s ing le , divorced, separated or widowed in both sexes and in both the
older and younger subgroups w ith in the e lde rly population.
Pal more and Lu ikart (1972) conducted a long itud ina l study to
analyze the soc ia l, psychological and physical determinants of
adaptation of people to middle age. Variables measured in th is study
were l i f e sa tis fac tion ra tings , health variables, a c t iv ity variables,
social-psychological variables and socio-economic variables. They
reported tha t older middle-aged people were inclined to be s lig h t ly less
sa tis fie d with l i f e than younger middle-aged people. Pal more and
Luikart also reported tha t employment was a s ig n ifica n t fac to r o f l i f e
sa tis fac tion only to the males in the population studied. They related
that the sex o f the person was the lowest variable related to l i f e
sa tis fa c tio n . I t was also implied in th e ir study that the to ta l number
of social contacts of the population in th e ir study had l i t t l e
significance on l i f e sa tis fac tion ra tings.
Campbell (1976) conducted a study to assess. the q u a lity of
American l i f e . Each subject in the study was given a structured
questionnaire and partic ipated in an interview which consisted of
describing and assessing 15 domains of l i f e . They chose one word
from a pa ir o f adjectives that described th e ir lives with both a
positive and negative connotation. S ign ifica n t variance in measures
o f well-being in th is study was contributed to the factors o f age with
the related variable of l i f e cycle which was the combination of age
with the presence or absence o f marriage and children. Subjects whose
children were grown and were s t i l l married themselves had consistently
high scores o f ind iv idua l well-being. Scores of divorced women were
consistently low and unemployed people reported a s lig h t decrease in
th e ir fee ling of well-being.
L ife Satis faction o f Patients Receiving Hemodialysis and Renal Transplantation
Kemph (.1977) stated tha t the person who is undergoing
hemodialysis faces a compromise in his q u a lity of l i f e . He faces a
reduction in to ta l ca p a b ilit ie s tha t he had p rio r to renal fa ilu re , but
a t the same time he has improvement o f uremic symptoms such as anorexia,
dizziness, seizures, apathy and organic brain syndrome. Laborde and
Powers (1980) stated tha t d ia lys is may increase the pa tie n t's physio
log ica l status so much that the threat o f treatment is'overcome.
In a study by Brown, et a l . (1974) o f l i f e sa tis fac tion o f
patients on hemodialysis, i t was found tha t a ll patients reported a
decrease in physical and emotional well-being described commonly in
16
phrases such as "lack o f energy", "lack o f ambition" and/or a "loss of
in te re s t." Levy and Wynbrandt (1975) studied a group o f 18 patients
on hemodialysis. Several o f these patients reported a drop in th e ir
income and a decline in th e ir fam ily l i f e since they began d ia lys is .
Brown, et al'. (1974) in the same study o f l i f e sa tis fac tion of
patients on hemodialysis described tha t well-adjusted patients on
hemodialysis "tended to minimize th e ir losses and emphasize the
ca p a b ilitie s they s t i l l retained" (p. 68). They tended to understand
th e ir lim ita tio n s and had many varied in terests and a c t iv it ie s that
p rim arily were not physica l. These a c t iv it ie s became important factors
fo r the person who experienced a decrease in physical well-being.
These people tended to understand th e ir financ ia l status and had more
financia l resources and reserves. Well-adjusted patients also led more
active and productive lives because they developed a sense of indepen
dence from the hemodialysis machine.
The less well-adjusted patients on hemodialysis tended to be
much more aware of the decrease in th e ir physical and mental capab ili
t ie s . I t was suggested that th is could have been due to the fac t that
th e ir work and recreational a c t iv it ie s were p rim arily physical p rio r to
the development o f kidney fa ilu re . Levy and Wynbrandt (1975) stated
tha t hopelessness and despair were seen in the less well-adjusted
patients on hemodialysis.
A study conducted by Cantril (1965) compared the ratings of
l i f e sa tis fac tion o f patients on d ia ly s is to a large sample o f the
United States population. Both groups were given a ladder with a
17
number ranging from 1 to 10 on each step and asked to place themselves
on the ladder step tha t they believed they were on fo r past, present
and fu ture l i f e sa tis fac tion scores.
For th e ir present l i f e sa tis fac tion ra tings, the average score
fo r the patien t on d ia lys is was 5.5, half-way between the best and
worst possible l i f e . The normative group o f the United States
population rated th e ir present lives at seven. Rating th e ir lives in
the past, patients on d ia lys is averaged a score near the top o f the
ladder as compared to the normative group, which on the average, rated
the past almost a step below the present. In ra ting the fu tu re ,
patients on d ia lys is rated i t s lig h t ly higher than the present as
compared to a ra ting o f a f u l l step higher by the normative group.
Hope, a component of l i f e sa tis fa c tio n , was displayed by both groups
in th is study by ra ting the fu ture as the same or higher than the
present and not resigning themselves to a de te rio ra ting fu ture (Jackie,
1974).
Levy and Wynbrandt (1975) reported that women were more w e ll-
adapted t o . l i f e on hemodialysis than men. They concluded tha t th is
adjustment may have been due to a more f le x ib le schedule of household
duties and a v a ila b il ity o f others to help as compared to the man whose
employment is usually outside the home. In a study o f compliance of
hemodialysis pa tien ts , O'Brien (1980) found tha t patients who had never
been married had a low compliance score on the d ia lys is regimen, and
tha t patients who were married had a bette r compliance score.
18
Abram (1972). concluded from a study conducted on patients
receiving kidney transplants that th e ir q u a lity o f l i f e was impeded
by th e ir constant awareness o f the underlying chronic renal fa ilu re
and the uncertainty o f the fu tu re . O verall, he concluded tha t patients
who had transplants were sa tis fie d with th e ir lives in general and tr ie d
to liv e them fu l ly .
In view of these factors that may decrease l i f e sa tis fac tion of
patients who are on hemodialysis, Naish (1979) quoted s ta t is t ic s from
the United Kingdom Transplant Annual Report o f 1977-1978 s ta ting that
two-thirds of patients receiving hemodialysis were employed f u l l time
and an additional seven percent worked part time. He also stated that
four out of f iv e successfully transplanted recip ients achieved: the
l i f e s ty le that they hope fo r.
Continuous Ambulatory Peritoneal D ia lysis
In the past, peritoneal d ia lys is was used only fo r patients who
had contraindications to or complications o f hemodialysis (Karanicolas,
1977). With the advent o f Continuous Ambulatory Peritoneal D ia lys is ,
peritoneal d ia lys is may advance to be a major type o f maintenance
therapy fo r patients in chronic renal fa ilu re (F a lle r and Marichal 1980).
Burton, et a l . (1981) reported tha t patients on Continuous
Ambulatory Peritoneal D ia lys is , who carry two l i te r s o f f lu id in th e ir
peritoneal ca v itie s , saw themselves as less in the ro le of sick and
handicapped. These patients tended to be more focused toward l i f e
rather than the life -th re a ten in g menace o f th e ir condition. They
19stated that patients on hemodialysis appeared to spend a ll o f th e ir
energies to stay a live , while patients receiving Continuous Ambulatory
Peritoneal D ialysis could devote th e ir energies toward some o f the
a ttrac tions o f l iv in g .
Oreopoulos, et a l . (1979) stated tha t as soon as patients s ta rt
Continuous Ambulatory Peritoneal D ia lys is , they notice a fee ling o f
well-being. They did not know i f th is is a placebo e ffe c t or i f i t is
due to the physiological factors o f the removal o f small molecules in
the blood such as blood urea nitrogen and creatin ine or the removal o f
unknown tox ic substances that are o f middle molecular size.
Continuous Ambulatory Peritoneal D ia lysis may have advantages
fo r several pa tien t populations. For ch ild ren, in addition to the
treatment being simpler, allowing a better d ie t and giving more freedom
than hemodialysis, i t may also contribute to better growth. Advantages
to persons with diabetes, such as better control o f blood sugar and ’
hypertension, may arrest or improve d iabetic complications (Oreopoulos
and Kartirtzog lou , 1979). This form o f treatment may be useful fo r the
e lde rly pa tien t w ith cardiovascular problems (F a lle r and Marieha1 1980).
Continuous Ambulatory Peritoneal D ialysis does not act as
rap id ly as hemodialysis in acute uremia, hyperkalemia, severe acidosis,
drug in tox ica tion or poisoning (Moncrief and Nolph, 1980). Since
Continuous Ambulatory Peritoneal D ia lysis is s t i l l a re la tiv e ly new
procedure, the long-term e ffects of th is treatment are unknown at th is
time. Studies are being done to determine the long-term effects o f the
20
continual absorption o f glucose and la c ta te ; amino acids may replace
glucose in the fu ture (Moncrief and Nolph, 1980; F a lle r and Marichal,
1980).
P e rito n it is is one o f the main problems seen with Continuous
Ambulatory Peritoneal D ia lys is . The frequency of p e r ito n it is has
decreased from one episode every e ight to 10 weeks to one to two
episodes per year. This decrease was seen with the advent o f use of
p la s tic bags to store the dialysate instead o f glass bo ttles . Most
in fections are due to catheter contamination during bag changes.
P e rito n it is is usually treated by the patien t himself on an outpatient
basis by adding a n tib io tic s to the d ia lys is solution (Nolph, 1980).
Some patients have lo s t the a b i l i t y to lose water through u l t r a f i l i -
t ra t io n . This is seen very often a fte r an episode o f p e r ito n it is in
which there is a decrease o f the peritoneal surface area due to the
thickening of the membrane (Oreopoulos, et a l . , 1981).
Weight gain and hyperlipidemia have been seen in patients
receiving Continuous Ambulatory Peritoneal D ia lys is . F a lle r and
Marichal (1980) reported that 14 patients had an average weight gain o f
5.3 kg when they were treated with Continuous Ambulatory Peritoneal
D ialysis fo r more than three months. They hypothesized tha t th is may
have been due to a better appetite and the amount o f glucose absorbed.
Some contraindications have been lis te d fo r the use of
Continuous Ambulatory Peritoneal D ia lysis by some patien ts. They are
patients who display an unwillingness to learn the technique, a lack o f
s e lf-d is c ip lin e and visual or neurologic problems (Lacke, e t a l . , 1981).
Nolph, e t a l . (1980) stated that there were cu rren tly more
than 670 patients in more than 116 medical centers in the United States
receiving Continuous Ambulatory Peritoneal D ia lys is. I t was also
suggested from reports o f the November 1979 International Symposium on
Continuous Ambulatory Peritoneal D ia lysis that more than 2000 patients
may be undergoing th is treatment in the world (Nolph, e t a l . , 1980).
With the increasing widespread use o f th is form o f treatment, i t is
important fo r nurses to better understand the needs o f these patients
by id e n tify in g change in various aspects of th e ir liv e s .
CHAPTER 3
METHODOLOGY
This chapter consists.o f: the research design, the se tting ,
the sample, approval fo r the study, method o f data co lle c tio n , data
co llec tion instruments, method of data analysis and lim ita tio n s of
the study.
Research Design
This was a descriptive study designed to describe components
of l i f e change and current l i f e sa tis fac tion o f patients receiving
Continuous Ambulatory Peritoneal D ia lys is. This description was
obtained through the semi-structured personal interview consisting of
aspects o f l i f e change and a current l i f e sa tis fac tion ra ting chosen
from a review of the lite ra tu re .
Setting
This study was conducted in a large c ity located in the
southwest. The subjects fo r the interviews were being treated in a
d ia lys is center with a specia lty o f Continuous Ambulatory Peritoneal
D ia lys is .
22
Sample
A convenience sample of 11 patients were interviewed. They
met the fo llow ing c r ite r ia : 1) had a diagnosis o f end-stage renal
disease; 2) were receiving Continuous Ambulatory Peritoneal D ia lys is ;
3) had been undergoing Continuous Ambulatory Peritoneal D ia lysis
independently fo r at least two weeks a fte r the two week ins truc tion
session at the d ia lys is center; 4) were able to understand English;
5) were Caucasian; 6) were 18 years or o lder; and 7) agreed to
pa rtic ipa te in the study. A ll o f the patients in th is sample received
a prescribed two week home tra in ing session on Continuous Ambulatory
Peritoneal D ia lysis at the d ia lys is center a fte r discharge from the
hospital fo r placement o f the abdominal catheter.
Approval fo r the Study
Approval fo r th is study was obtained from the Human Subjects
Committee o f the University of Arizona, the agency where the interviews
were conducted and from each patien t interviewed in th is study. The
study was reviewed and approved as exempt from University review by the
College of Nursing Ethical Review Sub-committee o f the Research
Committee and the D irector of Research. A copy of the le t te r o f
approval fo r th is study is contained in Appendix A.
Method o f Data Col 1ecti on
Four o f the patients were approached fo r the interview when they
reported to the d ia lys is center fo r a monthly scheduled appointment
fo r a tubing change by the nursing personnel. Seven o f the patients
were contacted at th e ir homes fo r the interview . When the patients
24
agreed to pa rtic ipa te in the study, arrangements were made to conduct
and complete the interview .
Data Collection Instruments
The interview schedule was composed o f a d iscla im er, demographic
data sheet and a semi-structured personal in terview .
The cover sheet consisted o f a b r ie f explanation o f the study,
or a disclaim er. Included in th is disclaimer was the r ig h t of the
p a rtic ipan t to ask questions or withdraw from the study at any time
during the interview and the assurance o f privacy to the pa rtic ipan t by
the assignment o f a code number to each subject (Appendix B).
The demographic data sheet was designed by the investiga to r
w ith input from a registered nurse who worked with the patien t
population receiving Continuous Ambulatory Peritoneal D ia lys is . The
demographic sheet consisted of the fo llow ing items: age, sex and
marital status o f the subject, with whom the subject live d , how long
the subject had been receiving CARD, i f the subject had been on hemo
d ia lys is p r io r to s ta rtin g CARD, how the subject i n i t ia l l y learned
about CARD, why the subject was on CARD, i f the subject had complications
while receiving CARD, and i f the subject had any other medical problems
other than end-stage renal disease at the time o f the interview (Appendix
C). These variables were deemed appropriate to th is study. Variations •
in l i f e sa tis fac tion ratings could have been due to the influence of
these variables.
The personal interview was composed of 19 l i f e change items and
one item to measure current l i f e sa tis fac tion adapted from an interview
schedule developed by Young and Longman (1980) fo r patients with cancer.
Subjects were asked to respond fre e ly on how these aspects o f l i f e have
changed since receiving Continuous Ambulatory Peritoneal D ialysis
(Appendix D), The subjects were then handed a card and asked to
indicate the amount of change experienced in each area since they had
received Continuous Ambulatory Peritoneal D ialysis (Appendix E).
Seventeen of the cards had numbers that ranged from 1, which indicated
no change at a l l , to 6, which indicated a great deal of change. I f the
subjects indicated there was a change, they were asked i f the change ■
was fo r the better or the worse and th is was recorded on the bottom
section of the card.
Some modifications were made in the l i f e change items used in
the Young and Longman study (1980). Some items were deleted because
they were deemed inappropriate fo r subjects with end-stage renal disease
or condensed in to broader, more generalized categories, A nurse who
worked with patients receiving Continuous Ambulatory Peritoneal D ialysis
was consulted fo r content v a lit id y o f the items in the interview . The
item, feelings about s e lf , was elim inated from the interview because
th is area was judged to be covered by several other categories such as
physical appearance, s ty le o f dress, physical endurance, sense of
independence, decision making and sense o f achievement. The items,
re lationships with spouse, re lationships with children and re lationships
with inlaws, re la tives were incorporated in to one item, re lationships
with fam ily (spouse, ch ild ren, re la tiv e s ). This new item was judged to
be inc lus ive because the investiga tor did not antic ipate many of the
subjects to be married. The item, re lationships with physician or other
health professionals was modified to read re lationships w ith health
professionals. This was done because the patient who is receiving CARD
works c losely not only with the physician, but also has regular monthly
appointments with nurses and a technician at the d ia lys is center. The
items, re la tionships with associates at work, job performance and job
sa tis fac tion were asked only i f the subject was employed at the time o f
the interview . The item, church or re lig ious group involvement, was
combined with social a c t iv it ie s to form the new item social a c t iv it ie s
(including re lig ious group involvement). The item, social support, was
elim inated from the in terview , as th is was judged to be covered by the
items of re lationships with fam ily , re la tionships w ith health
professionals, re la tionships with friends and social a c t iv it ie s ( in
cluding re lig ious group involvement). The item, changed by treatment,
was omitted from the interview because th is area was judged to be
covered by the new item, change in l i f e sa tis fac tion since CARD began.
The item, thought of stopping treatment, was deleted from the interview
because the patient in end-stage renal disease is dependent on treatment
by d ia lys is to survive. This varied from the o rig ina l in terview by
Young and Longman (1980) in which persons with cancer were asked i f
they thought o f stopping treatment.
The items from the Young and Longman instrument, rate sa tis
faction with current q ua lity of l i f e and rate level of current qua lity
of l i f e were combined in to the new item, current l i f e sa tis fa c tio n . An
example o f the personal interview is contained in Appendix D.
27
Following these adjustments, cards on which the subject
indicated the degree of change fo r each item were given to the subject
fo r 17 out o f the 19 change items o f the interview . Cards were not
given with the two change items, same choice o f treatment and what things
are meaningful to you. Scores fo r each o f the 17 l i f e change item
cards had the range of 1, which indicated no change in the subject's
l i f e , to 6 which indicated a great deal o f change since receiving
Continuous Ambulatory Peritoneal D ia lysis (Appendix E).
Current l i f e sa tis fac tion ratings were also measured with a card
tha t had a score range o f 1 to 10. The score o f 1 indicated low current
l i f e sa tis fac tion and 10 indicated high current l i f e sa tis fa c tio n . An
example o f the two types o f cards used in th is interview is contained in
Appendix E. Each subject was asked to choose the number that closely
measured the degree o f . l i f e change since receiving Continuous Ambulatory
Peritoneal D ialysis fo llow ing discussion o f the item (Appendix E).
Method o f Data Analysis
Scores o f the l i f e change items were tota led fo r each subject
interviewed. I f the subject answered a ll 17 items, the scores could
range from 17 to 102, the la t te r indicated greatest change since
receiving Continuous Ambulatory Peritoneal D ia lysis.
I f the subjects indicated change in a change item o f the
in terview , they indicated i f the change was fo r the bette r or fo r the
worse on the bottom o f the interview card. The number o f items checked
fo r the better were to ta led and the number o f items checked fo r the
worse were tota led fo r each subject. The d irec tion o f the subject's
28
overall l i f e change was determined by the highest number of the sums of
change fo r the better and change fo r the worse. This d irec tion of
change was recorded fo r each subject.
Total scores and means fo r 14 out o f the 19 l i f e change items
of the interview were obtained from the data. This was done to indicate
the degree of change by item in the interview . The number of times
the subjects indicated the change in the item was fo r the be tte r was
recorded and to ta led and the number o f times change in the item was
fo r the worse was indicated was also recorded and to ta led . The d irec tion
o f change fo r each item was determined by the highest to ta l between the
sums o f change fo r the better and change fo r the worse.
Comparisons were made between mean scores of current l i f e
sa tis fac tion ratings of subjects who had been on hemodialysis p r io r to
receiving Continuous Ambulatory Peritoneal D ialysis and subjects who
had not ; between married and unmarried subjects; and between male and
female subjects. Variations in the l i f e sa tis fac tion ratings may have
been related to the variables o f whether the subject had received
hemodialysis p r io r to s ta rtin g Continuous Ambulatory Peritoneal D ia lys is ,
marital status of the subject and sex o f the subject. These variables
may be related to a subject's perception of l i f e sa tis fac tion as
reported in studies conducted in the review of the lite ra tu re . The
verbal comments obtained during the interview were grouped and categor
ized.
Lim itations o f the Study
1. The interview used fo r th is study was modified fo r use by
a d iffe re n t population o f patients in end-stage renal disease receiving
Continuous Ambulatory Peritoneal D ia lys is .
2. The modified interview fo r th is study has not been tested
fo r v a lid ity and r e l ia b i l i t y fo r the population of patients receiving
Continuous Ambulatory Peritoneal D ia lys is.
CHAPTER 4
PRESENTATION AND ANALYSIS OF DATA
The findings and the s ta t is t ic a l analysis fo r the data
co llec tion are presented in th is chapter. -
Characteristics o f the Sample
The convenience sample fo r th is study consisted o f 11 patients
receiving Continuous Ambulatory Peritoneal D ia lysis at a regional
d ia lys is center who met the c r ite r ia fo r the study. There were fiv e
females and s ix males; the age range o f the sample was 25 to 62 years,
with a mean age of 43.5 years. Nine subjects reported tha t they were
married, one was single and one was separated (Table 1). Five o f the
subjects lived with th e ir spouse, four lived with th e ir spouse and
ch ild ren, one lived with a ch ild and one lived with friends.
Seven of the subjects had been on hemodialysis before s ta rting
Continuous Ambulatory Peritoneal D ia lysis and four had not been on
hemodialysis. The range fo r the length o f time that the subjects
received hemodialysis was three months to 120 months with a mean o f 57
months. . The length o f time that the subjects had been receiving
Continuous Ambulatory Peritoneal D ia lysis ranged from one month to 22
months with a mean o f 8.6 months.
30
31
Table 1. Characteristics of the Sample: Sex and M arital Status
Sex: Marital Status:
Male 6 Married 9
Female 5 Single 1
Separated 1
Total 11 Total 11
32
When the subjects were asked how they in i t ia l l y learned about
Continuous Ambulatory Peritoneal D ia lys is , f iv e responded tha t they
learned about i t so le ly from a nurse, two from a physician, one from
the newspaper and magazines and one from a social worker. Two subjects
gave m u ltip le answers. One responded nurse, physician, patients, on
CARD, newspaper and magazines, and medical l ite ra tu re and one cited
nurse, and newspaper and magazines (Table 2). In response to the
question, "Why are you on CARD?", e ight c ited voluntary choice between
CARD and hemodialysis, one stated complications on hemodialysis, one
stated recommendation o f physician and one stated distance to the
d ia lys is center and convenience fo r the fam ily (Table 3).
Seven o f the 11 subjects reported complications since receiving
Continuous Ambulatory Peritoneal D ia lys is . Four have had p e r ito n it is a
to ta l o f seven times, two have had an in fec tion around the catheter s ite
a to ta l of two times and two have had a blockage of the abdominal cathe
te r a to ta l o f three times. Other responses were from two subjects who
have dislodged the abdominal catheter a to ta l o f two tim es, one subject
had bleeding around the catheter s ite one time and two subjects experienced
slow drainage many times the f i r s t two months a fte r s ta rtin g CARD.
Seven of the 11 subjects stated tha t they had medical problems
other than renal fa ilu re a t the time o f the interview . Three subjects
stated they had hypertension, two stated they had diabetes, two had h ia ta l
hernias and two had heart problems. One subject stated hypotension, one
stated scleroderma, one reported lupus erythematosus which was currently
in remission and one subject has become b lind and has had a leg amputation
secondary to diabetes.
33
Table 2. Sources From Which Subjects Learned o f Continuous Ambulatory Peritoneal D ialysis
n = 11
Source Number o f Patients *
Nurse 7
Physician 3
Social Worker . 1
Patients on CAPD 1
Family and Friends 1
Newspaper and Magazines 3
Medical L ite ra tu re 1
* Two subjects named more than one source.
34
Table 3. Reasons Subjects Received Continuous Ambulatory Peritoneal D ialysis
Reason Number o f Patients
Voluntary Choice Between CAPD andHemodialysis 8
Complications on Hemodialysis 1
Recommendation o f Physician 1
Distance to the D ia lysis Center andConvenience fo r Family 1
Total 11
35
Results o f the Personal Interview
Scores and Means
The 11 subjects were interviewed using the personal interview .
The interviews lasted 20 to 90 minutes depending on the ind iv idual
interviewed.
The range o f l i f e change item to ta l scores o f the subjects in
th is study was 21 to 63 with a mean score o f 44.3 (Table 4). Total
possible scores could range from 17 to 102 i f the subjects answered a ll
items; most did not. The mean score fo r the ind iv idua ls ' responses to
the interview items was obtained by d iv id ing the subjects' to ta l scores
by the to ta l number o f items they responded to . The ind iv idua l mean
scores ranged from 1.5 to 4.5, w ith an overall mean o f 3.1 fo r the
sample. Eight o f the subjects indicated the overall d irec tion o f
change in th e ir lives was fo r the better since receiving Continuous
Ambulatory Peritoneal D ia lys is . Three indicated the overall d irection
of change was fo r the worse.
Current l i f e sa tis fac tion ratings were obtained from the sample.
The range o f current l i f e sa tis fac tion ratings o f the subjects was from
three to 10 with a mean score o f 6.6 (Table 4).
Individual Item Scores and Means
Total scores, means, and d irec tion o f change were obtained fo r
14 out o f the 17 items of the' interview . The l i f e change items
concerning employment o f re la tionships with associates at work, job
performance and job sa tis fac tion were not included in th is analysis as
they were only answered by two subjects.
36
Table 4. D is tribu tion o f Subjects' L ife Change Scores, D irection of .Change and Current L ife Satis faction Scores
-
L ife Change Score
L ife Change Mean Score
Direction o f Change
Current L ife Satisfaction Score
63 4.5 Worse 561 4.4 Worse 558 4.1 Better 757 4.1 Better 860 3.5 Worse 346 3.5 Better 542 3 Better 832 1.9 Better 1024 1.7 Better 723 1.6 Better 821 1.5 Better 6
MeanScore:
44.3 3.1 6.6
37
The range of to ta l scores o f the l i f e change items was 20 to
50 (Table 5). The mean scores of the change items ranged from 1.8 to
4.5. The subjects indicated that the overall d irec tion o f change fo r
e ight of the l i f e change items was in the d irec tion fo r the be tte r; the
overall d irec tion o f change fo r three was in the d irec tion fo r the worse
(Table 5).
The l i f e change items of re la tionships with associates at work,
job performance and job sa tis fac tion were answered by two subjects who
were employed at the time of the interview . Both subjects indicated no
change in re la tionships with associates at work. Both subjects indicated
a change in job performance; one indicated a change fo r the better
because he did not t i r e easily with CARD and one indicated a change fo r
the worse as he became tire d more easily since he had begun CAPO. One
subject indicated no change to the item o f job sa tis fac tion and the
other subject indicated a change fo r the worse because he had not been
fee ling w e ll.
Means o f current l i f e sa tis fac tion ratings were compared
between current l i f e sa tis fac tion ratings o f subjects who had been on
hemodialysis p r io r to receiving Continuous Ambulatory Peritoneal
D ialysis and subjects who had not; married and unmarried subjects; and
male and female subjects (Table 6). A mean score o f current l i f e s a tis
faction ratings o f 6.3 was obtained from the seven subjects who had
received hemodialysis previously; a mean score o f seven was obtained
from the four subjects who had not received hemodialysis previously.
Table 5. D is tribu tion of Each L ife Change Item Total Score, Mean Score and Direction of Change fo r the Total Sample *
L ifeChange Item
Physical Appearance Style o f Dress Physical Endurance Sense o f Independence Decision Making Sense o f Achievement Relationships with Family Relationships with Health
Professionals Relationships with Friends Financial S ituation .Hobbies or Recreational
A c tiv it ie s Social A c tiv it ie s (Including
Religious Group Involvement) Change in L ife Satisfaction
Since CAPD Began (Past) Outlook Toward the Future
Totalo f D irection
Scores Mean of Change
34 3.1 Worse35 3.2 Worse45 4.1 Better44 4 Better32 2.9 Better34 3.1 Better36 3.3 Better
26 2.4 Better23 2.3 Better23 2.1 Worse
33 3 Better
20 1.8 Better
50 4.6 Better37 3.4 Better
*L ife Change Items o f Relationships with Associates at Work, Job Performance and Job Satisfaction not included.
39
Table 6. Mean Scores o f Current L ife Satisfaction Ratings o f Select Groups of the.Sample
___________________ _________ (n = ll)
Select Mean Score of CurrentGroup L ife Satisfaction Ratings
Subjects on Hemodialysis Previously 6.3
Subjects Not On Hemodialysis Previously 7
Married Subjects 6.6
Unmarried Subjects 6.5
Male Subjects 6.1
Female Subjects 7
40
A mean score o f 6.6 was obtained from the nine married subjects with a
mean score o f 6.5 by the two unmarried subjects. The mean score o f the
s ix male subjects of the sample was 6.1 and a mean score o f seven was
obtained from the five female subjects.
Verbal Responses
There were varied responses by the subjects in th is study to
each l i f e change item in the in terview . A summary of the responses
fo llows.
The f i r s t l i f e change item dealt with physical appearance.
Four o f the subjects indicated a change fo r the worse c it in g that they
now had a bigger stomach, had gained some weight and tha t the catheter
affected th e ir sexuality and body image. Since they had been receiving
Continuous Ambulatory Peritoneal D ia lys is , four subjects reported no
change and three related a change fo r the better. These subjects
reported tha t th e ir skin color improved and they had regained some o f
the weight they had lo s t p r io r to s ta rtin g Continuous Ambulatory
Peritoneal D ia lys is .
The second l i f e change item dealt with change in the s ty le of
dress. Six subjects c ited there was a change fo r the worse because
they now had to wear baggier clothes, th e ir clothes had to be made
la rger, sh irts were now being worn outside th e ir pants. Most of these
subjects cited tha t they had liked wearing fo rm -fitt in g clothes in the
past but had to give them up now. Three subjects stated tha t there had
been no change in s ty le o f dress. Two stated there had been
41
improvement because they had lo s t a great deal o f weight and th e ir
clothes f i t them since they had gained weight a fte r receiving Continuous
Ambulatory Peritoneal D ia lys is.
Seven o f the subjects' responses to the item of physical
endurance were in the d irec tion o f a change fo r the bette r. One
subject stated there was an improvement due to.an increase in breathing
capacity because he was now keeping f lu id o f f with Continuous Ambula
to ry Peritoneal D ia lys is. Three subjects stated tha t they were doing
much be tte r. One subject stated tha t she had not f e l t th is well in
five years because of progressive kidney fa ilu re and now she did do much
more since receiving Continuous Ambulatory Peritoneal D ia lys is . One
subject stated tha t there had been an increase in physical endurance
the f i r s t few months a fte r beginning Continuous Ambulatory Peritoneal
D ia lys is , but i t cu rren tly was lower than i t was before on hemodialysis
at the time of the interview . One other subject stated tha t his current
level of physical endurance was lower than when he was on hemodialysis
p r io r to receiving Continuous Ambulatory Peritoneal D ia lys is ; two
subjects indicated no change.
The fourth item o f the interview dealt with a sense of in
dependence. The overall response by the subjects was p o s itive , withi
seven subjects sta ting tha t they f e l t much more independent because
they did everything themselves and did not have to depend on others.
One subject stated that his spouse was freed from running the home
d ia lys is machine. Other subjects stated that they traveled much more
. 42
and two subjects stated tha t they re a lly f e l t tied down only when they
did an exchange. Two subjects indicated there was no change and two
indicated there was a change fo r the worse.
Responses to the item of decision making consisted o f four o f
the subjects s ta ting there had been a change fo r the be tte r. One o f
these subjects stated there was an improvement because she f e l t more
secure knowing how to do her own exchanges and that she did not know
how to operate the hemodialysis machine. Five of the subjects
responded tha t there had not been a change. Two subjects responded tha t
there had been a change fo r the worse; one o f these subjects related
that a ll decisions were based around the exchanges.
Change in the sense o f achievement was the s ix th item o f the
in terview . Five of the subjects stated tha t there had been a change fo r
the be tte r. They stated they were getting more done and two o f these
subjects stated they were doing more things now in comparison to when
they were on hemodialysis. Three o f the subjects stated there was no
change and three stated tha t they were not doing the things tha t they
want to do. One o f the subjects stated a great deal o f change fo r the
worse and tha t he only made i t "day to day."
The seventh item dealt with re lationships with fam ily. Five
subjects stated tha t there had been an improvement because they f e l t
better and also because they had more time to spend with th e ir fam ilies .
Four subjects related tha t there had been no change. Two subjects
related there had been a change fo r the worse, and one o f these sub
jec ts c ited tha t he did not go out and do things with them lik e he
used to .
43
The eighth l i f e change item discussed the subjects' re lationships
with health professionals since receiving Continuous Ambulatory Peri
toneal D ia lys is . Seven of the subjects responded there was no change
and that the re la tionships had remained the same. Three subjects
related there was a change fo r the better w ith one s p e c if ic a lly c it in g
tha t i t had been better because she f e l t more independent now that she
was responsible fo r her own care. One subject stated tha t there had
been a change fo r the worse.
Four subjects responded there was change fo r the be tte r fo r the
item o f re la tionships with friends. Reasons cited fo r the change fo r
the bette r were because the subjects had more time to see others and
were able to get out and meet more people. Five o f the subjects cited
no change and one reported a change fo r the worse. Some subjects who
stated tha t there had been no change commented that th e ir friends did
not understand that they were not as free as they used to be, they did
not get around as much and did not see them lik e they used to . One
Subject did not respond to th is item. 1
Eight of the subjects' responses to the item o f financ ia l
s itua tion were no change. One subject stated that Continuous Ambulatory
Peritoneal D ia lysis had been cheaper because o f less hosp ita liza tion .
Two subjects stated the change had been fo r the worse and one subject
c ited an increase in tr ip s to the d ia lys is center. The other subject
c ited he had been unable to work.
The view of most o f the subjects to the item o f hobbies or
recreational a c t iv it ie s was change fo r the better. Five o f the subjects
44
who indicated a change fo r the better c ited the reasons of being able
to travel more and being able to do more a c t iv it ie s . Four subjects
responded that there had been no change and two subjects responded
change fo r the worse.
Eight subjects related there had been no change in social
a c t iv it ie s (including re lig ious group a c t iv it ie s ) since they had been
receiving Continuous Ambulatory Peritoneal D ia lys is . Two subjects cited
a change fo r the better and stated tha t th is was because they were
getting out more and were p a rtic ip a tin g more regu la rly in church
a c t iv it ie s . One subject indicated change fo r the worse.
With the item o f change in l i f e sa tis fac tion since CAPD began,
eight subjects responded change fo r the be tte r. Some o f these subjects
cited tha t there had been an improvement because they were gradually
fee ling worse before receiving Continuous Ambulatory Peritoneal D ialysis
because o f progressive kidney fa ilu re . One subject c ited the change
was fo r the better as he had more freedom and can drink a l l he wanted.
Another subject related the change was fo r the better because of
freedom from the d ia lys is machine. One patient related tha t he was
able to get around much better since receiving Continuous Ambulatory
Peritoneal D ia lys is. Two subjects replied that there had not been a
change and one subject related a change fo r the worse.
Five subjects related that they anticipated change fo r the
better with the item of outlook toward the fu tu re . Most o f these
subjects stated that they f e l t op tim is tic about the fu tu re . Five
subjects did not an tic ipa te change in the fu ture with one o f these
45
subjects s ta ting , " I don't th ink my condition can get any worse." One
subject responded a change fo r the worse because "you don 't look to the
fu ture with th is disease."
Comments from subjects who responded to the question o f ra ting
th e ir current level o f l i f e sa tis fac tion were, " I am very s a tis fie d ,"
" I l ik e my fle x ib le schedule, the hemodialysis regimen was not f le x ib le ,"
" I t 's good and getting be tte r, but there are things I want to do,"
" I t 's better than being on hemodialysis" and " I am in the process of
improving." Other comments received were, " I can 't do things lik e I used
to ," " I t 's not good, because I am not fee ling w e ll," and " I t has
decreased."
The subjects were asked i f they would now choose the same type
o f treatment o f Continuous Ambulatory Peritoneal D ia lys is . Eight o f
the subjects replied that they preferred CAPD and hoped to use i t as
long as they f e l t well using i t . Most of these subjects stated that
they hoped tha t they would not have to go back on hemodialysis. One
subject preferred CAPD to hemodialysis but would prefer a transplant to
have more freedom and con tro l. One subject was fa ir ly sa tis fie d with
Continuous Ambulatory Peritoneal D ia lysis but was not fee ling well and
talked about the p o s s ib ility of going back on hemodialysis. One subject
was not sa tis fie d with Continuous Ambulatory Peritoneal D ialysis
because " i t is a never-ending process, you have a schedule."
The subjects were also asked the question, "What things are
meaningful to you?" Seven of the subjects replied fam ily ; seven o f the
46
subjects c ited staying a live or keep on liv in g ; and four subjects
responded re lig io n . Other responses obtained were frie nd s , recreational
a c t iv it ie s , the need to enjoy the things of l i f e and the accomplishments
that they wanted to make.
A ll of the subjects were receptive to the in terview . They a ll
responded openly to share th e ir personal view of l i f e on Continuous
Ambulatory Peritoneal D ia lys is.
CHAPTER 5
DISCUSSION AND RECOMMENDATIONS
This chapter discusses the findings in re la tion to the conceptual
framework and lite ra tu re review, conclusions, im plications fo r nursing
and recommendations fo r fu ture studies.
Findings in Relation to the Conceptual Framework and L ite ra tu re Review
The concepts o f chronic illn e s s , treatment, l i f e change and
current l i f e sa tis fac tion comprised the conceptual framework fo r th is
study. The conceptual framework described the re la tionsh ip o f treatment
of chronic renal fa ilu re with Continuous Ambulatory Peritoneal D ialysis
may have on l i f e change and current l i f e sa tis fa c tio n . Studies have
shown that the physiological characte ris tics o f a chronic illn e ss may
influence the psychological, social and cu ltu ra l environments of the
ind iv idua l (Dimond, 1980). Change may occur in these areas as a d ire c t
re su lt o f the illn e ss and may a ffe c t the person's adaptation to the
chronic illn e s s . Treatment fo r the illn e ss may diminish or enhance
change in the l i f e o f the patien t. Assessment of change in the pa tien t's
l i f e when receiving a spec ific treatment fo r a chronic illn e ss should
help nurses id e n tify problem areas in the pa tien t's adaptation to the
treatment regimen.
47
48
This study was conducted to describe change in the various
components o f l i f e of patients receiving Continuous Ambulatory
Peritoneal D ia lysis and to obtain ratings o f current l i f e sa tis fa c tion .
A ll of the patients interviewed indicated tha t there had been change in
th e ir lives since receiving Continuous Ambulatory Peritoneal D ia lysis.
The lowest possible to ta l score i f the subject answered a ll items of
the interview o f 17 indicated no change in the pa tie n t's l i f e and the
highest possible to ta l score o f 102 indicated a great deal of change.
The range o f scores obtained from the subjects was 21 to 63 with a mean
score o f 44.3 fo r the patien t sample.
Subjects who indicated change in each item in the interview
were asked to ind icate i f the change was fo r the better or fo r the
worse. Eight of the subjects indicated the overall change in th e ir
lives since receiving Continuous Ambulatory Peritoneal D ia lysis was fo r
the better and three indicated the overall change in th e ir lives was fo r
the worse.
The ind iv idual items of the interview were assessed fo r change
by the to ta l patient sample. The three items with the highest to ta l
score o f l i f e change were change in l i f e sa tis fac tion since CAPD began*
physical endurance and sense of independence and a ll were in the overall
d irection o f change fo r the better. Overall, the subjects indicated
that 11 o f the 14 change items o f the interview were in the d irection
of change fo r the bette r. The three change items o f physical appearance,
s ty le o f dress and financ ia l s itua tion were the items tha t received an
overall ra ting by the population to be in the d irec tion o f change fo r
• 49
the worse. The find ing of change fo r the worse in the item o f financ ia l
s itua tion was s im ila r to a find ing o f a study conducted by Wynbrandt
(1975) o f l i f e sa tis fa c tio n o f patients receiving hemodialysis. The
patients of his study reported a decrease in th e ir income a fte r they
began receiving hemodialysis.
Current l i f e sa tis fac tion ratings were also obtained from the
sample with a scale of 1 to 10 with 1 ind ica ting low current l i f e
sa tis fac tion and 10 ind ica ting high current l i f e sa tis fa c tio n . The
range o f current l i f e sa tis fac tion scores was from 3 to 10 with a mean
o f 6.6 fo r the sample. A study conducted by Cantril (1965) to determine
current l i f e sa tis fac tion o f patients receiving hemodialysis used the
same scale as in th is .study to determine ratings o f current l i f e s a tis
fac tion . The Cantril study revealed tha t the average score o f current
l i f e sa tis fac tion of a sample o f patients receiving hemodialysis was 5.5
and a sample o f the normative population o f the United States population
had an average score o f seven. Using these ind ica to rs , the mean score
o f current l i f e sa tis fac tion o f 6.6 of the subjects who received
Continuous Ambulatory Peritoneal D ia lysis in th is study resembled the
current l i f e sa tis fac tion ratings o f the normative group o f the United
States population more closely than the ratings o f the patients
receiving hemodialysis in the Cantril study. This find ing resembled
the find ing by Burton, et a l . (1981) that patients who received
Continuous Ambulatory Peritoneal D ia lysis saw themselves as less in
the ro le of sick and handicapped.
50
The results of th is study showed tha t the overall d irec tion o f
l i f e change in the subjects' lives may have a re la tionsh ip with th e ir
perception o f current l i f e sa tis fa c tio n . Three out of the four subjects
who indicated the lowest l i f e sa tis fac tion scores were the three
subjects o f the sample who indicated that the overall change o f th e ir
lives was fo r the worse.
A great deal of change may have affected the overall d irection
o f change o f the subjects' liv e s . This was supported by the find ing
th a t three o f the five highest l i f e change scores and ind iv idua l l i f e
change mean scores were from the three subjects who indicated an overall
change fo r the worse in th e ir live s .
Means o f current l i f e sa tis fac tion ratings were compared between
subjects on hemodialysis p r io r to Continuous Ambulatory Peritoneal
D ia lysis and subjects who had not; between married and unmarried
subjects; and between male and female subjects. A higher current l i f e
sa tis fac tion ra ting mean was obtained by the subjects who had not
received hemodialysis p r io r to Continuous Ambulatory Peritoneal
D ia lys is , by the married subjects and the female subjects o f the sample.
The findings o f a higher current l i f e sa tis fac tion mean rating
by the married patients were s im ila r to the results o f the l i f e
sa tis fac tion study of old age conducted by Neugarten, et a l . (1961).
They related that lower l i f e sa tis fac tion ratings were reported by
unmarried people in th e ir sample. A higher mean ra ting score o f current
l i f e sa tis fac tion by the female subjects in th is sample correlated w ith
the results o f a study conducted by Levy and Wynbrandt (1975) of
patients on hemodialysis. They reported tha t women were more w e ll-
adapted to l i f e on hemodialysis than men.
C antril (1965) reported that in his study of l i f e sa tis fac tion
of patients receiving hemodialysis and a sample o f the normative
population o f the United States that hope, a component of l i f e sa tis
fac tion , was displayed by both groups. This was measured by ra ting the
future as the same or higher than the present and not ind ica ting that
they were resigning themselves to a de te rio ra ting fu tu re . This was
also seen in the sample o f th is study; f iv e subjects indicated a change
fo r the better fo r the fu tu re ; f iv e subjects did not. an tic ipa te a change;
and only one subject anticipated a change fo r the worse.
The eight subjects who indicated tha t the overall change in
th e ir lives was fo r the better a ll responded that they would now choose
the same type of treatment o f Continuous Ambulatory Peritoneal
D ia lys is . Of the three subjects who indicated the overall change in
th e ir lives was fo r the worse, two subjects indicated tha t they might
chose an a lte rna tive therapy and one of these subjects stated that he
had not f e l t well shortly a fte r receiving Continuous Ambulatory Peritoneal
D ia lys is. The th ird pa tient responded tha t he did not lik e the
continuous ongoing regimen of Continuous Ambulatory Peritoneal D ia lys is.
In summary, the treatment of Continuous Ambulatory Peritoneal
D ialysis did a ffe c t the lives o f a ll o f the subjects in th is study.
This form o f treatment affected various aspects of the subjects' lives
and possibly th e ir perception o f l i f e sa tis fa c tio n .
52
Conclusions
Few so lid conclusions can be drawn from th is study. From th is
study, i t can be suggested that a pa tient may experience change in his
l i f e when receiving Continuous Ambulatory Peritoneal D ia lys is . The
change may be fo r the better in some areas, depending on the circum
stances o f the in d iv id u a l. From th is study, nursing can be aware that
patients may encounter some d i f f ic u l t y in adjustment in the areas of
physical appearance, s ty le o f dress and financ ia l s itua tio n when
receiving Continuous Ambulatory Peritoneal D ia lys is.
Implications fo r Nursing
An unexpected find ing of th is study was that of the seven
subjects who indicated tha t they in i t ia l l y learned o f Continuous
Ambulatory Peritoneal D ia lys is from a nurse; five lis te d a nurse as
th e ir primary source. Nurses should be aware o f the importance of
th e ir ro le as a member o f the health care team in the area o f patient
education fo r advancements in medical treatments.
Nurses should also be aware tha t the person who w il l be
receiving Continuous Ambulatory Peritoneal D ialysis may experience
change in various aspects o f his l i f e . These changes may a ffe c t the
person's adaptation to l i f e on Continuous Ambulatory Peritoneal
D ia lys is . This information can serve as a foundation fo r nurses to
assess and plan interventions fo r these patients. Nurses who are aware
o f these changes can id e n tify and discuss problem areas with patients
p r io r to and pe riod ica lly a fte r receiving Continuous Ambulatory Peri
toneal D ia lys is.
53
Recommendations
1. Further tes ting o f the modified personal interview used in th is
study fo r v a lid ity and r e l ia b i l i t y .
2. Use o f a larger sample to make the results more generalizable.
3. Conduct a longitud ina l study of patients when they in i t ia l l y begin
receiving Continuous Ambulatory Peritoneal D ia lysis and s ix months
la te r. .
4. Conduct a study comparing current l i f e sa tis fac tion ratings and
degree o f l i f e change between patients receiving Continuous
Ambulatory Peritoneal D ia lysis and patients receiving hemodialysis.
APPENDIX A
LETTER OF APPROVAL FOR STUDY
THE UNIVERSITY OF ARIZONA COLLEGE OF NURSING MEMORANDUM
TO: Julie Klein____________________ -_
250 N. Arcadia #1113, Tucson 85711
FROM: Ada Sue Hinshaw, R.N., Director of Research
Ph.D. - Margarita Kay, R.N., Ph.D.Chairman, Research Committee
DATE: October 12, 1981
RE: Human Subjects Review: "Life Satisfaction of Patients Receiving
Continuous Ambulatory Peritoneal Dialysis"
Your project has been reviewed and approved as exempt from University review by the College of Nursing Ethical Review Su