Quality of Life in Patients with End-Stage

Renal Disease on Hemodialysis

Tondra Ivey & Briaca Lane

This paper was written for Dr. Sauter.

Abstract
Patients with renal failure face many challenges due to their condition
which may leave them feeling fatigued and depressed. Most of these patients
choose to be placed on hemodialysis which can be debilitating and can
threaten body image, finances, relationships and independency. Studies have
been conducted to identify the factors that contribute to the quality of life in
patients who are on dialysis to determine what strategies can be implemented
to improve quality of life. The purpose of this study was to examine the quality
of life in patients with End-Stage Renal Disease (ESRD) on hemodialysis.
Data collection took place at West Georgia Dialysis in LaGrange, Georgia.
A convenience sample of 63 patients was used in the study. The mean
age was 57 years, 57.1% were female and 74.6% were African American.
Approximately 69.8 % had a high school diploma or higher education, 95.2%
were unemployed, disabled or retired and 42.9% were married. Participants
completed Ferrans & Powers Quality of Life Index Dialysis Version III in
which they were asked to rate satisfaction and importance of 68 items that
measure overall quality of life. Participants also completed a demographic
survey which ascertained age, race/ ethnicity, education, employment, marital
status and number of chronic illnesses. Five scores were produced by Ferrans
& Powers Quality of Life Index Dialysis Version III that measured quality of life
overall and quality of life in four domains: health and functioning, social and
economic, psychological/ spiritual, and family. The possible range of scores
for each subscale was 0 to 30. Results showed a mean overall quality of life
score of 23.2 (SD 4.0). Findings suggest that patients receiving hemodialysis
as treatment for End Stage Renal Disease have a fair perception of their
quality of life. This study provides healthcare providers with ways to identify
the patients quality of life as well as to plan and implement strategies to help
enhance it.
Introduction
Before dialysis was available, patients with renal disease faced imminent
death. However, since the development of treatment modalities such as
dialysis and renal transplant, the life of renal patients have been improved
and prolonged. Hemodialysis is a treatment option available for patients
experiencing renal insufficiency, in which a machine is used to act out the
function of the kidney such as filtering the blood and excretion of by-products.
Considering the risks that may occur with the treatment options available,

many choose to be placed on dialysis. However, hemodialysis treatment may

be debilitating. Patients with renal failure face many challenges due to their
condition which may leave them feeling fatigued and depressed. Body image
may be affected by fistula or grafting for dialysis access. Finances may be
affected by the high cost of weekly treatments for dialysis and occasional
admission to the emergency department due to complications. Relationships
and independency are also threatened. Studies have been conducted to
identify the factors that contribute to the quality of life in patients who are on
dialysis to determine what strategies can be implemented to improve quality
of life. The purpose of this study was to examine the quality of life in patients
with End-Stage Renal Disease (ESRD) on hemodialysis. Researchers want to
increase knowledge that will improve nursing practice, ultimately enhancing
quality of life for these patients.
A literature review was commenced to identify the quality of life in
patients experiencing renal failure. The literature search was performed
using the Cumulative Index of Allied Health Literature (CINAHL), an electronic
database from 1995 through 2010. The search terms included: quantitative
studies, renal failure, quality of life, ferrans & powers, hemodialysis. The
tools used in the studies included the Jaloweic Coping Scale, Chronic
Kidney Disease (CKD) Stress Inventory (Harwood, Wilson, Locking-Cusolito,
Sontrop & Spittal, 2009), Ferrans and Powers Quality of Life Index Dialysis
Version III (Greene, 2005), a Dialysis Demographic Form, Dialysis Symptom
Index, Hospital Anxiety and Depression Scale, Fatigue Visual Analog Scale
Inventory of Functional Status- Dialysis, Palliative Performance Scale (Kring
& Crane, 2009). Participants in these studies were mostly in large groups
who were patients at dialysis centers across the globe. Harwood et al (2009)
measured stressors and identified coping methods used by 226 patients with
chronic kidney disease who are not on dialysis. Greene (2005) explored the
perceptions of 98 African American patients with ESRD who were receiving
hemodialysis and compared those perceptions by age. Kring & Crane (2009)
performed a study using 73 patients with ESRD to describe the quality of life
and examine the factors that influence it.
In the Harwood et al (2009) study, 226 patients with chronic kidney
disease who were not on dialysis were evaluated using the Jaloweic Coping
Scale and the CKD Stress Inventory. The Jaloweic Coping Scale is a 60
item questionnaire that is used to identify coping methods and their effect
on the specific situation. The items are classified into eight coping styles:
confrontation, evasive, optimistic, fatalistic, emotive, palliative, supportant,
and self- reliant. The CKD Stress Inventory was developed specifically for
the purpose of this study to identify stressors and evaluate their intensity.
The results indentified six stressors that had high intensity: fatigue, sleep
problems, peripheral neuropathy, muscle cramps, restless legs, and shortness

of breath. The Jaloweic Coping Scale indentified that the optimistic coping
styles was the most likely used and effective coping strategy overall. Next
were confrontive, supportant, self- reliant, palliative, evasive, fatalistic and
emotive, in that order.
Data collection for the Kring and Crane (2009) study took place at
an outpatient dialysis clinic. The study used a Dialysis Demographic
Form which included age, gender, race, employment, time on dialysis,
marital status, socioeconomic status as well as recent serum albumin and
hemoglobin levels. The Dialysis Symptom Index was used to measure 30
of the most common physical and emotional symptoms experienced by
patients on dialysis and the severity and frequency of those symptoms.
Each patient was asked if the symptom had been experienced within the
past week. If yes, to what degree was the symptom bothersome on a
5-point likert scale (1=not at all and 5=very much). The Hospital Anxiety
and Depression Scale was developed to identify patients at risk for anxiety
and depression on a 14-item questionnaire. The Fatigue Visual Analog
Scale was used to measure fatigue. The Inventory of Functional StatusDialysis was developed for patients to identify and evaluate the activities
patients engage in. The participants were asked to rate the degree of
participation in a typical week in the past month on a 4-point scale. The
Palliative Performance Scale was used to measure the decline in function
that is experienced by patients who are terminally ill. The patients classified
according to ambulation, activity/ evidence of disease, self-care, intake and
level of consciousness. The General Perception of Health was measured
by asking the question How would you rate your health on a scale of 1 to
10, with 1= poor and 10=excellent? The Ferrans & Powers Quality of Life
Index Version III was also used in this study. The results of the study (Kring
& Crane, 2009) suggest that persons with ESRD experience a relatively
comparable quality of life given their symptom burden and intensive therapy.
Participants in the Greene (2005) study were drawn from a convenience
sample of African American patients on dialysis in Washington, DC. The
sample was sub grouped according to age into 4 categories: 26 to 45 years
(n=23); 46 to 55 years (n=23); 56 to 65 years (n=28); and 66 and older (n=24).
Participants were interviewed using Ferrans & Powers Quality of Life Index
of Dialysis Version III. Five quality of life subscales were analyzed using
age as the research variable: health and functioning, social and economic,
psychological and spiritual, family and total quality of life. Greene (2005)
found that the quality of life of African Americans with ESRD increased as
they aged for all subscales except psychological and spiritual. The results
suggested that younger patients with ESRD had a lower perception of
quality of life than the older individuals.
All studies suggested that determination of quality of life in

renal failure patients can be used to measure the outcomes of therapy.

Understanding the factors that influence well being will allow nurses to focus
on specific interventions for enhancing quality of life (Kring & Crane, 2009).
Knowledge gained from these studies can be applied to education and
supportive interventions for patients with chronic kidney disease (Harwood et
al, 2009)
The conceptual framework that was used to guide this study was
the revised version of Wilson and Clearys (1995) Model for Health-Related
Quality of Life (Ferrans et al., 2005). This framework encompasses four
main determinants to overall quality of life: biological function, symptoms,
functional status and general health perceptions (Kring, 2008, p. 13). These
determinants, as well as overall quality of life, are ultimately affected by the
characteristics of the individual and the environment (Ferrans et al., 2005,
Kring, 2008)
The revised model clearly indicates the association between the
determinants (Figure 1.1). The first determinant is the biological function,
which is the cell functions supporting life. These are easily accessed through
laboratory test, physical assessment and medical diagnoses. The second
determinant is symptoms, which refers to physical, emotional, and cognitive
symptoms that the patient expresses. The third determinant, functional
status, consists of physical, psychological, social, and role function. The
fourth determinant, general health perceptions, includes subjective ratings of
the valued determinants. Overall quality of life is the concept of how satisfied
someone is with their life in general (Ferrans et al., 2005). Ferrans et al (2005)
revised model focuses more on the effects of the deficits in functioning and
how it impacts a persons daily life while continuing to measure the four
domains of functioning (Kring, 2008). The arrows represent the relationships of
these concepts and effect they have on one another that reflects the patients
perception of their quality of life.
Research Questions
1. What are hemodialysis patients perceptions of their quality of life?
2. What factors do ESRD patients perceive as important with regards
to helping them cope with the life style changes and hardships caused by
hemodialysis?
3. Does hemodialysis have a positive or negative impact on quality of
life?
Methods
The study was reviewed and approved by the Lagrange College
Institutional Review Board and Nursing Faculty prior to data collection. In
addition, permission was granted from the director of West Georgia Dialysis
Center. Patients were approached by a researcher to ascertain interest and
receive verbal and written explanation of the purpose, benefits and risks

associated with the study. Those who were interested in participating in the
study were asked to review and sign the consent form. Each participant
received a copy of the signed consent form for their records. Participation
in this study was voluntary. Subjects were fully informed of their rights to
decline or withdraw from participation in the study if desired. Confidentiality
was maintained on all data collection forms by using codes to identify each
participant. A master list of patients was kept separate from data collection
forms. All information was kept in a locked file cabinet and shredded after data
analysis.
Participants
A descriptive design was used to examine the quality of life in patients
with ESRD. Data collection took place at West Georgia Dialysis in Lagrange,
Georgia. Participants were selected from a convenience sample. A total of 63
patients were used in the study. Inclusion criteria of 18 years of age or older,
able to read, write and speak English, and have the cognitive ability to answer
survey questions and give consent.
Materials and Procedure
The instruments used for data collection included a general
demographic survey as well as Ferrans and Powers Quality of Life Index
Dialysis Version III. The demographic survey, developed by researchers,
ascertained age, gender, ethnic origin (race), education, marital status,
employment status, and any comorbidity.
Researchers received permission from Dr. Carol Estwing Ferrans for
the use of the Quality of Life Index (QLI) Dialysis Version III. This instrument
was developed by Ferrans and Powers to measure quality of life in terms of
satisfaction with life (1985). This instrument measures both satisfaction as well
as the importance of certain aspects of their life. Importance ratings are used
to weight the satisfaction responses, so that scores reflect the respondents
satisfaction with the aspects of life they value. The items rated most important
have a larger impact on the scores than those of less importance. The
instrument contains two parts, each containing thirty-four items: the first
measuring satisfaction with certain aspects of life and the second measuring
the importance of those same aspects. There are four domains: health
and functioning (HFSUBa), psychological/ spiritual (PSPSUBc), social and
economic (SOCSUBb) and family (FAMSUBd) as well as overall quality of life
are scored (Ferrans, 1996; Ferrans &; Powers, 1985; Ferrans & Powers, 1992;
Ferrans, 1990; Warnecke, Ferrans, Johnson, &et al., 1996).
The Quality of Life Index is a self-administered questionnaire
containing 68 questions that are answered on a scale of 1-6. 1 indicates very
dissatisfied and 6 indicates very satisfied. This instrument has an internal
consistency reliability that ranges from .73 to .99, using the Cronbachs alpha,
across 48 studies. The QLI was tested for sensitivity to change in ESRD and

hemodialysis patients using Cronbachs alpha scoring between .88 to .93

(Ferrans & Powers, 1992). Researchers set up appointments at West Georgia
Dialysis on two different weekly sessions. The participants were asked to
complete the demographic survey as well as the QLI questionnaire.
Results
Statistical analyses were performed using the Statistical Package for
the Social Science (SPSS) as well as Microsoft Excel 2010. Demographic
characteristics of the sample are presented in Table 1.1. The mean age
was 57 years, 57.1% were female and 74.6% were African American.
Approximately 69.8 % had a high school diploma or higher education, 95.2%
were unemployed, disabled or retired and 42.9% were married. Five scores
were produced by Ferrans & Powers Quality of Life Index Dialysis Version III
that measured quality of life overall and quality of life in four domains: health
and functioning, social and economic, psychological/ spiritual, and family. The
possible range of scores for each subscale was 0 to 30.
The mean score for the overall quality of life was 23.2 (SD 4.0)(Table
1.2). Scores in this category ranged from 4.16 to 28.50. Scores were highest in
the psychological/spiritual (PSPSUBc) subscale ranging from 1.71 to 30, with
a mean score of 26.1 (SD 4.7). This subscale included items pertaining to faith,
achieving personal goals, happiness, peace of mind, and satisfaction with life
in general. Considering ages by decade, there were no significant differences
between QOL scores. However, when comparing male and female scores
in the health and functioning subscale (HFSUBa), a significant difference
was noted (p=0.042) (Table 1.3). Males had a mean score of 23 and females
had a mean score of 20.5 (Table 1.4). The remaining subscales showed no
significant differences.
Discussion
The results of this study concluded that patients with end-stage renal
disease on hemodialysis generally have a fair perception of their quality of
life. This information may correlate with the length of time these patients
have been receiving dialysis treatments. The health and functioning subscale
included factors such as health, healthcare, fatigue, worries, ability to take
care of family responsibilities and changes made in life because of kidney
failure. Men viewed their health and functioning substantially higher than the
women. However, considering the age range of the patients who participated
in this study, many of the female patients may be experiencing menopause.
This factor may contribute to their perceptions of quality of life at this time.
For future studies it will be essential for researchers to consider the
length of time that the patients have been receiving dialysis treatments. This
variable may greatly affect the quality of life in these individuals. In this attempt
to examine the quality of life in patients with end stage renal disease on
hemodialysis, we did not address the length of time these patients have been

on dialysis. A larger and more diverse population can be utilized to generalize

study findings more appropriately.
Studying these phenomena can be beneficial to both the patient
and the healthcare professional through the knowledge gained. This study
provides healthcare providers with ways to identify the patients quality of life
as well as to plan and implement strategies to help enhance it. It can also be
educating for the patient by increasing their awareness that may affect their
quality of life.
References
Burns, N., Grove, S. (2003). Understanding Nursing Research.

Philadelphia: W.B. Sanders Co.
Ferrans, C., & Powers, M. (1985). Quality of Life Index: Development and

psychometric properties. Advances in Nursing Science, 8, 15-24.
Ferrans, C. E. (1990). Development of a quality of life index for patients

with cancer. Oncology Nursing Forum, 17(3), 15-19.
Ferrans, C., & Powers, M. (1992). Psychometric assessment of the Quality

of Life Index. Research in Nursing and Health, 15, 29-38.
Ferrans, C. (1996). Development of a conceptual model of quality of life.

Scholarly Inquiry for Nursing Practice: An International Journal,

10(3), 293-304.
Greene, R.A (2005). Using the Ferrans and Powers Quality of Life Index

of Dialysis: A Comparison of Quality of Life in Older and

Younger African Americans Receiving Hemodialysis. Topics in

Geriatric Rehabilitation. Vol.21, No. 3,pp 230-232
Harwood, L., Wilson, B., Locking-Cusolito, H., Sontrop, J., & Spittal, J.

2009). Stressors and Coping in individuals with Chronic Kidnely

Disease. Nephrology Nursing Journal , 265-275, 301.
Jablonski, A. (2007). The Multidimensional Characteristics of symptoms

Reported by patients on Hemodialysis. Nephrology Nursing

Journal , 29-38.
Kring, D., (2008). Using the revised Wilson and Cleary model to explore

factors effecting quality of life in persons on hemodialysis.
Kring, D., & Crane, P. (2009). Factor affecting Quality of life In Persons on

Hemodialysis. Nephrology Nursing Journal , 15-24, 55.
Warnecke, R., Ferrans, C., Johnson, T., et. al. (1996). Measuring quality

of life in culturally diverse populations. Journal of the National

Cancer Institute Monographs, 20, 29-38.

Figure 1.1

Figure 1.1 Revised Wilson and Cleary model for health-related quality
of life. Adapted from Linking Clinical Variables with Health-Related Quality
of Life: A Conceptual Model of Patient Outcomes, by I.B. Wilson and P.D.
Clearly, 1995.

Figure 1.2

Table1.1
DescriptionofSample
Age(Years)
2938
3948
4958
5968
>69

Gender
Male
Female

Ethnicity
AfricanAmerican
Caucasian
Other

MaritalStatus
NotApplicable
Married
Single
Divorced
Widowed

Education
NotApplicable
<HighSchool
HighSchoolGraduate/GED
SomeCollege
CollegeDegree

Employment
NotApplicable
Employed
Unemployed/Disabled
Retired
NumberofComorbidConditions
None
One
Two
Threeormore

n
%
5
8
12 19.2
15 24
18 28.6
13 20.8

27 42.9
36 57.1

47 74.6
16 25.4
0
0

1 1.6
27 42.9
15 23.8
14 22.2
6 9.5

5 7.9
14 22.2
30 47.6
6 9.5
8 12.7

1 1.6
2 3.2
39 61.9
21 33.3
8 12.7
16 28.6
26 41.3
10 16

Table 1.2
Ferrans & Powers Quality of Life Index Dialysis

Overall QOL
HFSUBa
SOCSUBb
PSPSUBc
FAMSUBd

Mean

Std.
Deviation

63
63
63
63
63

23.1902
21.5958
22.0813
26.0850
25.3762

3.97524
5.03400
4.14805
4.71605
4.93463

Table 1.3
ANOVA Summaries for Male Versus Female Quality of Life
Sum of
Squares

df

Mean Square

Sig.

1.353

.249

4.307

.042

1.492

.227

.218

.642

2.580

.113

Overall

Between Groups

21.266

21.266

Quality of

Within Groups

958.490

61

15.713

Life

Total

979.756

62

HFSUBa

Between Groups

103.624

103.624

Within Groups

1467.526

61

24.058

62

SOCSUBb

PSPSUBc

FAMSUBd

Total

1571.150

Between Groups

25.465

25.465

Within Groups

1041.329

61

17.071

Total

1066.794

62

Between Groups

4.910

4.910

Within Groups

1374.037

61

22.525

62

Total

1378.948

Between Groups

61.258

61.258

Within Groups

1448.476

61

23.746

Total

1509.734

62

Table 1.4
Males

Valid
Mean

QLI

HFSUBa

SOCSUBb

PSPSUBc

FAMSUBd

27

27

27

27

27

23.8611

23.0767

21.3472

26.4074

26.5148

Females

Valid
Mean

QLI

HFSUBa

SOCSUBb

PSPSUBc

FAMSUBd

36

36

36

36

36

22.6871

20.4851

22.6319

25.8433

24.5222