ii

THE QUALITY OF LIFE AND COPING STRATEGIES OF HEMODIALYSIS PATIENTS AT ASIA RENAL CARE: BASIS FOR A PROPOSED COMPREHENSIVE RENAL MANAGEMENT PROGRAM

A Dissertation Presented to The Faculty of the Graduate School of Education University of Perpetual Help System DALTA Las Pias City

In Partial Fulfillment of the Requirements for the Degree Master of Arts in Nursing Major in Nursing Administration

MARIE ANTONETTE D.O. TAN March 2012

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APPROVAL SHEET

This thesis entitled, THE QUALITY OF LIFE AND COPING STRATEGIES OF HEMODIALYSIS PATIENTS AT ASIA RENAL CARE: BASIS FOR A PROPOSED COMPREHENSIVE RENAL MANAGEMENT PROGRAM prepared and submitted by MARIE ANTONETTE D.O. TAN in partial fulfilment for the degree of Master of Arts in Nursing Major in Nursing Administration, has been examined and recommended for acceptance and approval for oral examination.

HAZEL N. VILLAGRACIA, EdD Adviser ORAL EXAMINATION COMMITTEE Approved by the Committee on Oral Examination with a grade of _____________________.

ENJOLA KAYE S. ELMA, PhD Member

IMELDA O. JAVIER, MAN Member

NAOMI M. DE ARO, EdD Chairman

Accepted and approved in partial fulfilment of the requirements for the degree of Master of Arts in Nursing Major in Nursing Administration.

ATTY. IRINEO F. MARTINEZ, JR., PhD Dean, Graduate School

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ACKNOWLEDGMENT

The researcher would like to extend her utmost gratitude to the following people who contributed their significant parts in the realization of this humble piece of work:

ATTY. IRINEO F. MARTINEZ, JR., Dean, Graduate School of Education, University of Perpetual Help System-DALTA, who

encouraged and inspired the researcher by his sincerity and dedication to help all graduate students in their earnest desire to finish and attain their degrees; DR. HAZEL VILLAGRACIA, Chief Nurse, St. Dominic Medical Center, and the researchers adviser, for her intellectual guidance, brilliant suggestions and encouragement from the start until the end of her journey in writing which motivated her to accomplish this research. DR. NAOMI DE ARO, Dean, College of Nursing, De La Salle University, Dasmarinas, Cavite, the very knowledgeable chairman of the final defense panel, and the external member of the panel composed of Dr. Enjola Kaye Elma and Mrs. Imelda Javier for their encouraging recommendations to improve the study.

DR. JESUS GOLLAYAN, Full-Professional Lecturer of the Graduate School of Education, University of Perpetual Help SystemDALTA and the researchers thesis statistician, for his expertise in the statistical treatment of data that provided the researcher with substantial inputs and clear directions in the accomplishment of the thrust of the study. DRA. LYN GOMEZ, Medical Director, Asia Renal Care, Alabang Branch, for her approval to conduct the study involving hemodialysis patients. MR. KENNY LOU URMAZA, Head Nurse, University of Perpetual Help System Dalta Hemodialysis Section, for his approval to conduct the pilot study involving hemodialysis patients. TO ALL HER COLLEAGUES IN THE PROFESSION, and, most importantly, to the HEMODIALYSIS PATIENTS, for the active

participation tendered sincerely during the time of gathering information. TO HER PARENTS and SISTERS, for their endless moral support and great encouragement to finish this humble piece of work. TO HER PARTNER, for the unconditional love and support, who serves as an inspiration, making each day light and easy. Finally, TO GOD ALMIGHTY, for the strength bestowed on the researcher that made her accomplished her goals.

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ABSTRACT

Name of the Institution Address Title

: University of Perpetual Help System DALTA : Alabang-Zapote Road, Las Pias City : The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program

Author Degree Major Date of Completion

: Marie Antonette D.O. Tan : Master of Arts in Nursing : Nursing Administration : March 2012

STATEMENT OF THE PROBLEM: The study aimed to assess the Quality of Life of hemodialysis patients and to identify their coping strategies as basis for constructing a Comprehensive Renal Management Program to improve the patients Health-Related Quality of Life (HRQOL). Specifically, it provided answers to the following problems: 1. What is the demographic profile of the patient-respondents in terms of the following:

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1.1 Age; 1.2 Gender; 1.3 Civil Status; 1.4 Educational Attainment; 1.5 Employment Status; 1.6 Presence/Absence of Support System (Financial Capacity); and 1.7 Frequency of hemodialysis? 2. What is the Quality of Life (QOL) of hemodialysis patients in terms of the following domains: 2.1 General Health Perceptions; 2.2 Physical Health 2.2.1 Physical Functioning; 2.2.2 Ability to Work; 2.2.3 Role Limitation Due to Physical Function; 2.2.4 Pain Threshold; 2.2.5 Energy/Fatigue Tolerance; and 2.2.6 Sleep? 2.3 Mental Health; 2.3.1 Emotional Well-Being; 2.3.2 Social Health/Social Function/Social Support and 2.3.3 Expression of Sexuality?

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2.4 Kidney Disease Issues; 2.4.1 Appreciation/Understanding of the Nature of Disease and 2.4.2 Burden of Kidney Disease? 2.5 Patient Satisfaction; 2.5.1 Patient Satisfaction Regarding Treatment; 2.5.2 Efficiency of Staff in All Aspects; 2.5.3 Efficiency of the Machine; 2.5.4 Physical Environment; 2.5.5 General Systems; and 2.5.6 Cost of Treatment? 3. What are the Coping Strategies of hemodialysis patients? 4. Is there a significant difference in the Quality of Life (QOL) when grouped according to profile variables? 5. Based on the results of the study, what program can be proposed to improve the Quality of Life (QOL) of hemodialysis patients?

HYPOTHESIS: The null hypothesis is tested at the level of significance. There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to the profile data obtained.

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METHODOLOGY: The study employed the Descriptive and Quantitative Research Methods in gathering the data. The Descriptive Research Method

provided the data for the demographic profile of the patient-respondents and was enriched by the Quantitative Research Method via the survey questionnaire. The Quantitative Method used was a survey using the questionnaire as the instrument. A data interpretation scale which

summarizes the rating with the verbal and word description, together with corresponding statistical limits, were devised to facilitate data analysis. Patients with Chronic Kidney Disease Stage 4 and End-Stage Renal Disease were purposively chosen. Only patients undergoing

treatment at the center mentioned from December 2011 to February 2012 were included. A total of 50 respondents consisting of 27 male and 23 female patients participated in the study. The medical director Non-

allowed 50 patients only to become respondents of the study.

Random Sampling using Purposive Sampling was used as a sampling technique. Patients with Chronic Kidney Disease Stages 4 and 5, and

those present at the time of visit at the hemodialysis center, were the criteria for the selection of the subjects.

The Descriptive measures used in the treatment of data gathered from the study which included Frequency Count and Percentage, Weighted Mean, t-test, and the Analysis of Variance (ANOVA).

FINDINGS: The study produced the following findings: 1. The patient-respondents profile was vital in assessing and determining their Quality of Life (QOL). It is also important to know whether it affects their decision in choosing coping strategies. There are 27, or 54%, male and 23, or 46%, female respondents with age ranges of 30 and above. Majority of the patient-respondents are married or living-in with their partner. Most of them are also college graduates undergoing hemodialysis treatment twice a week and are retired without means to support their treatment (such as insurance or pension). 2. Data gathered from the patient-respondents responses on the following domains are as follows: 2.1 The response on General Health Perception showed an overall mean of 3.05, with a verbal description of a good quality of life. Most patients believed that their health is good despite having a chronic illness.

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2.2 The response on Physical Health showed an overall mean of 3.27 with a verbal description of a good quality of life. Patients believed that they can tolerate the needle insertion on their fistula or graft. 2.3 The response on Mental Health revealed an overall mean of 2.88 with a verbal description of a good quality of life. They said that they are satisfied with the support they receive from their family. 2.4 The response on Kidney Disease Issues registered an overall mean of 4.90 with a verbal description of an excellent quality of life. Patients complain of cramps as the usual

complication of hemodialysis; such had a mean of 2.72 with a verbal description of a good quality of life. 2.5 The response on Patient Satisfaction gave an overall mean of 4.997 with a verbal description of an excellent quality of life. Patients verbalize that the staff and machines are efficient however, some of them were not satisfied with the cost of treatment.

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3.

Determining the effectiveness of the coping strategies used is greatly influenced by the patients quality of life. The coping

strategies listed gave an overall mean of 4.36 with a verbal description of regularly manifested. The most common coping strategies of patients are keeping life as normal as possible, positive thinking, keeping a sense of humor, thinking about all the good things in life, keeping feelings under control, and venting feelings. 4. The profile of the patient-respondents like age, gender, educational attainment, financial security, and frequency of hemodialysis do not have a significant difference in the quality of life of patients except for the civil status which was found to have a significant difference in the quality of life of patients. 5. A wholistic renal program was developed for hemodialysis patients. Its primary focus is to significantly improve the patients Quality of Life (QOL) by focusing on the key areas of the domains of quality of life.

CONCLUSIONS: 1. Based on the results and findings of the study, it showed that majority of the patients are in the age bracket of 51-60 years old

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and most of them are males. Male persons are more prone to having this disease probably because of the sedentary lifestyle they adopted when they are still healthy. Majority of them are also married and college graduates. Most of the patients are

professional with a stable job not until them found out they have a kidney disease. They soon retire from work to be able to adhere completely to the treatment regimen. 2. The indicators of kidney disease greatly affect the quality of life of hemodialysis patient. The most commonly complained intraIt can be addressed by proper

dialytic symptom is cramps.

evaluation of treatment as included in the renal program proposed in the current study. Patient satisfaction indicators have a high score which means that patients who are satisfied with the care they are receiving have a high quality of life. Patients have a good quality of life despite their disease. This was proven by the effectiveness of their coping strategies. 3. The most common coping strategies of hemodialysis patients are the following: Keeping life as normal as possible; Positive thinking; Keeping a sense of humor; Thinking all the good things in life; Keeping feelings under control; and Venting feelings. Patients found the strategies they used to be effective.

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4. When it comes to the level of significance, the demographic profiles of the patients in general are not significant to the patients quality of life except for the civil status. The absence of a support system creates a significant impact on the quality of life of patients undergoing hemodialysis treatment. If patients have significant persons supporting them, they were able to adhere to the treatment regimen being prescribed to them which may result to a good quality of life. 5. Lastly, health education plays an integral role in the care of patients with chronic disease like End-Stage Renal Disease. Patients level of understanding should be carefully assessed so health care providers would know the techniques in initiating health education to patients.

RECOMMENDATIONS: 1. Based on the findings and conclusions drawn from the results of the study, the study is found to be highly recommended to health care providers. They should be aware of their role in uplifting the patients perception of their disease, particularly to patients with chronic disease like End-Stage Renal Disease. Nurses are in the

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front line of service and are usually the ones in first contact with the patients. Advocacy is the heart and soul of nursing practice. 2. The study is also recommended to the patients relatives as they should realize the importance of providing emotional support as it greatly affects the quality of life of patients. The patients relatives can be aware of the different domains in the quality of life affected by renal conditions for them to involve themselves in the patients plan of care. 3. The study is highly recommended to patients so they can actively participate in the implementation of their plan of care. Patients can be guided on several ways in coping with the renal condition. They should also develop self-management skills so they can manage the disruptions their illness may cause to their work, social, and family life. 4. The study is also recommended to other hemodialysis centers in the adoption of the renal program proposed by the researcher so they can also implement it in their center. 5. The study is also recommended to future researchers so they can also conduct a study and construct another renal program that can be used by other hemodialysis centers.

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TABLE OF CONTENTS PAGE TITLE PAGE APPROVAL SHEET ACKNOWLEDGEMENT ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES i ii iii v xv xviii xx

CHAPTER 1 THE PROBLEM AND ITS SETTING Introduction Theoretical/Conceptual Framework Statement of the Problem/Objectives Null Hypothesis Scope and Delimitation of the Study Significance of the Study Definition of Terms 2 REVIEW OF RELATED LITERATURE AND STUDIES Conceptual Literature 16 1 5 9 11 11 12 14

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General Health Perceptions Physical Health Mental Health Kidney Disease Issues Patient Satisfaction Coping Strategies of Hemodialysis Patients Related Studies Foreign Studies Local Studies Synthesis 3 METHODOLOGY Research Design Population and Sampling Respondents of the Study Research Instrument Validation of the Instrument Data Gathering Procedure Statistical Treatment of Data Gathered 4 PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

16 28 29 44 46 49 56 56 59 62

65 66 67 68 71 71 72 75

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SUMMARY OF FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS Summary Conclusions Recommendations

109

109 114 116

REFERENCES APPENDICES A B C D Proposed Renal Program for Asia Renal Care Letter of Request to Validate Questionnaire Letter of Request to Conduct a Pilot Study Letter of Request to Conduct a Study in the Research Locale E F G H Letter to Respondents Survey Questionnaire Certification of Statistical Treatment Certification of Editing

118

125 127 129 130

131 132 138 139

CURRICULUM VITAE

140

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LIST OF TABLES TABLE 1 Hemodialysis Patients Population and Respondents of the Study (December 2011-February 2012) Interpretation Scale for the English Questionnaire on the Patients QOL Profile of the Patient-Respondents According to Age Profile of the Patient-Respondents According to Gender Profile of the Patients According to Civil Status Profile of the Patient-Respondents According to Educational Attainment Profile of the Patient-Respondents According to Employment Status Profile of the Patient-Respondents According to Financial Security Profile of the Patient-Respondents According to Frequency of Hemodialysis Distribution of Mean Responses of Respondents on Quality of Life Domains Coping Strategies of Hemodialysis Patients Difference When Respondents Are Grouped According to Age PAGE 67

70

75

76

78

79

80

81

82

10

84

11

92

12

95

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13

Difference When Respondents Are Grouped According to Gender\ Difference When Respondents Are Grouped According to Civil Status Difference When Respondents Are Grouped According to Educational Attainment Difference When Respondents Are Grouped According to Employment Status Difference When Respondents Are Grouped According to Financial Security Difference When Respondents Are Grouped According to Frequency of Dialysis

97

14

99

15

100

16

102

17

104

18

105

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LIST OF FIGURE FIGURE 1 Conceptual Paradigm of the Study PAGE 8

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Chapter 1 THE PROBLEM AND ITS SETTING Introduction The worlds disease profile is changing and chronic diseases now account for the majority of global morbidity and mortality rather than infectious diseases. Chronic Kidney Disease is one of the most common debilitating conditions that greatly affect the quality of life of a person. It is increasingly recognized as a global public health problem. End Stage Renal Disease, the fifth and last stage of Chronic Kidney Disease, occurs when the kidneys are no longer able to function at a level needed for day-to-day life. In an article written by Gavin Becker at the Korean Academy of Medical Sciences (2009), he noted that Asian Pacific countries are included in those areas with the highest incidence of renal failure in the world. From this cone, many challenges, but also a strong basis for the introduction of strategies to combat renal disease. According to the World Health Organization (WHO) in their article entitled Health Situation and Trend in The Philippines, as of July 2010, the death rate in the country was estimated at 5.06 deaths per a population of 1,000; Kidney Failure ranked number nine in the leading causes of death. Romina Danguilan (2008) observed, as stated in ABS-

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CBN News.com that, sadly, in 2007, only 7,267 patients started dialysis or received kidney transplant directly. Only 73% received treatment

because they were able to get to a hospital providing dialysis or could afford the therapy. The acceptance rate of treatment for kidney failure in the Philippines is only 86 Per Million Population (PMP), compared to the 100 PMP in South Korea, and 300 PMP in the United States. Here, a quarter of Filipino patients probably just died without receiving any treatment. End-Stage Renal Disease patients require renal replacement therapy or dialysis. Unfortunately in the Philippines, only 50% maybe healthy enough to undergo kidney transplant and, of this number, only 20% can afford the costly life-saving operation. The therapy for a dysfunctional kidney can either be dialysis or kidney transplantation. Dialysis comes in two forms: Hemodialysis and Peritoneal Dialysis. This study will focus only on the process of hemodialysis. It is a process where the patients blood is made to run through a series of tubes which remove toxins and excess fluid that have accumulated in the blood, and is then returned to the patient. A hemodialysis session lasts for four hours and needs to be done two to three times a week depending on the doctors prescription to adequately replace sufficient kidney function for the patient to live. The patient needs to travel to a dialysis unit each time for treatment. Dialysis only provides

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about 15% of the kidney function. It is enough to sustain life, but needs to be performed regularly and for life. Most Filipinos pay for their treatment without any subsidy from insurance. According to a study done at the National Kidney and

Transplant Institute (NKTI), a tertiary government hospital providing services for kidney disease, showed that half the patients who start dialysis are dead within a year, presumably because they could not afford sufficient dialysis. Adequate dialysis costs from P10,500 to

P42,000 per month or P252,000 to P504,000 annually. If one is able to afford this lifelong treatment, then the patient will be well-enough to return to his normal way of life, and just apportion time for dialysis treatment. However, majority of Filipinos cannot afford this costly

treatment for more than a year. Even with the advances in dialysis treatment which have contributed to improved survival of patients with End-Stage Renal Disease (ESRD), the level of Health-Related Quality of Life (HRQOL) is much lower for these patients than for the general population. HRQOL encompasses domains of life directly affected by changes in health. The assessment of HRQOL helped identify ways to improve the well-being of ESRD patients and potentially identify strategies to prevent adverse

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outcomes. In addition, the evaluation of HRQOL may help identify an individuals risk of death and hospitalization. Having worked in a hemodialysis center, the researcher observed that patients undergoing hemodialysis have poor quality of life. Despite the efforts of the health care providers to provide the highest quality of life to every patient, the results were really not that effective. Could it be that the patients were not complying to the prescribed treatment? Or due to lack of education? Or could it be that the patient is experiencing severe depression that resulted to poor coping techniques? Is there

something that nurses can do to uplift hemodialysis patients for them to have an improved quality of life? With these questions, the researcher was motivated to know more about the quality of life and coping strategies of hemodialysis patients. In view of these reasons, there appears to be an imperative need to consider all possible factors to improve the patients outlook in life on the overall Health-Related Quality of Life. The result of this study will serve as a spring board for future interventional studies to address the issues concerning the quality of life of hemodialysis patients. The study also aims to determine the common coping strategies used by hemodialysis patients. Patients receiving hemodialysis use various strategies to cope with the stressors related to their disease and the treatment procedures.

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The data and researches gathered will serve as basis for constructing a Comprehensive Renal Program.

Theoretical/Conceptual Framework According to Fowler (2006), a goal in patients with Chronic Kidney Disease is maintenance of as optimal a life as possible. Functional ability and well-being of individuals can affect functioning and well-being in a negative manner. Furthermore, co-morbid conditions, such as diabetes mellitus,

hypertension, and cardiac disease, all of which are common in patients with chronic kidney disease may impact quality of life. According to Evans (2006), chronic illness has a significant impact on the quality of life of affected individuals. Individuals with chronic kidney disease who require dialysis have a greater decrease in quality of life and more psychological distress than those individuals with chronic kidney disease who do not yet require dialysis. Individuals with a chronic illness use a coping strategy which helps him or her to function better in a given situation. Dialysis patients know that their treatment is life-long and they are undergoing a certain phase in their life wherein they have to be strong not only for themselves, but also for their family. A severe chronic illness, such as End-Stage Renal Disease (ESRD) requiring hemodialysis, strains the coping capacities of patients and their families.

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Coping may be described as dealing with problems and situations, or contending with them successfully. According to Folkman and Lazarus (1991), coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. Patients undergoing hemodialysis experience many physical, social, and psychological changes. The physical changes involve problems with all body organ systems. Social changes include interference with ability to work, a decreased earning capacity, the increased expense of hemodialysis, and dietary restrictions. Responses to the physical and social problems result in psychological changes. The System Model theory of Betty Neuman (2012) greatly influences the study since Betty Neumans approach in nursing is comprehensive and wholistic. For this study, when it was concluded, the same enabled the

researcher to come up with a Comprehensive Renal Program to uplift patients perception of their quality of life. Indeed, renal nurses approach to

hemodialysis patients must be done in a unique way. Each patient has different needs and they must all be addressed equally. A response of one hemodialysis patient to stressors may be different from another hemodialysis patient. Wellness does not only mean that the patient has to be healthy physically. In hemodialysis patients, it can be a continuum of available energy to support the system in an optimal state stability. This will be manifested by responding to a

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stressor in a positive way.

To promote optimal wellness in hemodialysis

patients, health care providers should be constantly aware of their needs. Here, Neuman treats the process of reconstitution as a method of returning and maintaining system stability. Nurses should see patients as a whole and it is their task to address the person as a whole. The role of nurses is seen in terms of how he or she reacts to stressors. Therefore, if hemodialysis patients see the nurses as strong individuals, they will also attain stability. As a result, stressors will be reduced and patients will be able to cope effectively to their disease. Below is the Conceptual Paradigm of the study that discusses the steps taken that the researcher used to accomplish the aims and outcomes or results of the study. According to Harris and Taylor (1997), the Input-Process-Outcomes (IPO) Framework is used to elucidate the process of inclusive education. In the IPO Model, a process is viewed as a series of boxes (processing elements) connected by inputs and outputs. The IPO Model provided the general structure and guide for the direction of the study. Employing the variables of this study on the IPO Model, the researcher came up with the following model; thus:
INPUT Profile of PatientRespondents 1.1 Age 1.2 Gender 1.3 Civil Status 1.4 Educational Attainment 1.5 Employment Status 1.6 Financial Security 1.7 Frequency of Hemodialysis PROCESS Assessment of the quality of life and coping strategies in relation to the following factors & dimensions: 2.1 General Health Perceptions 2.2 Physical Health 2.3 Mental Health 2.4 Kidney Disease Issues 2.5 Patient Satisfaction OUTPUT

Construction of a comprehensive renal program aimed at improving the quality of life of hemodialysis patients

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Figure 1: The Conceptual Paradigm of the Study Based on the conceptual paradigm of the study, the Inputs were the profile of the patients in relation to the indicators of health-related quality of life; namely: General Health Perceptions, Physical Health, Mental Health, Kidney Disease Issues and Patient Satisfaction. The Process referred to the assessment of the quality of life and identification of coping strategies. Based on the assessment, the Output is aimed at construction of a Comprehensive Renal Program toward the improvement of the quality of life of hemodialysis patients. Assessing the quality of life of hemodialysis patients is very challenging. The researcher believed that the profile of the patient-respondents is vital in assessing the quality of life of hemodialysis patients. The quality of life of hemodialysis is then affected by the coping strategies they chose as a way of combating their disease.

Statement of the Problem/Objectives The study aimed to assess the quality of life of hemodialysis patients and identify their coping strategies as basis for constructing a Comprehensive Renal

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Management Program to improve patients Health-Related Quality of Life (HRQOL). Specifically, it provided answers to the following problems: 1. What is the demographic profile of the patient-respondents in terms of the following: 1.1 Age; 1.2 Gender; 1.3 Civil status; 1.4 Educational attainment; 1.5 Employment status; 1.6 Presence/absence of support system (financial capacity); and 1.7 Frequency of hemodialysis? 2. What is the Quality of Life (QOL) of hemodialysis patients at Asia Renal Care in terms of the following domains: 2.1 General Health Perceptions; 2.2 Physical Health; 2.2.1 Physical functioning; 2.2.2 Ability to work; 2.2.3 Role limitation due to physical function; 2.2.4 Pain threshold; 2.2.5 Energy/fatigue tolerance; and

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2.2.6 Sleep? 2.3 Mental Health; 2.3.1 Emotional well-being; 2.3.2 Social health/social function/social support; and 2.3.3 Expression of sexuality? 2.4 Kidney Disease Issues; 2.4.1 Appreciation/understanding of the nature of disease and 2.4.2 Burden of kidney disease? 2.5 Patient Satisfaction; 2.5.1 Patient satisfaction regarding treatment; 2.5.2 Efficiency of staff in all aspects; 2.5.3 Efficiency of the machine; 2.5.4 Physical environment; 2.5.5 General systems; and 2.5.6 Cost of treatment? 3. What are the Coping Strategies of hemodialysis patients at Asia Renal Care? 4. Is there a significant difference in the Quality of Life (QOL) when grouped according to profile variables? 5. Based on the results of the study, what program can be proposed to improve the Quality of Life (QOL) of hemodialysis patients?

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Null Hypothesis The Null Hypothesis is tested at the level of significance. There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients at Asia Renal Care when grouped according to the profile data obtained.

Scope and Delimitations of the Study This study focused on determining the quality of life and coping strategies of hemodialysis patients. The respondents of the study were limited to those patients having hemodialysis treatment at Asia Renal Care from December 2011 to February 2012. There were 50 subjects included in the study. They were patients who were diagnosed to have Chronic Kidney Disease Stages 4 and 5. The patients were categorized based on the degree of their illness so that it would be easier to determine their coping strategies. Patients with dementia, delirium or are psychologically incapacitated, and those who refuse to participate in the study were excluded from this work. The tool used for the study is a self-made questionnaire that describes the quality of life of hemodialysis patients and their coping strategies as basis for constructing a Comprehensive Renal Program.

Significance of the Study

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Quality of life is of paramount importance to all patients with chronic kidney disease, especially those with end-stage renal disease undergoing dialysis treatment. Numerous studies have shown that quality of life is intricately

associated with short and long term outcomes. However, patients are also acutely interested in how the ramifications of chronic kidney disease can affect their daily activities, and what they can do to maximize the physical, cognitive, psychological, and social aspects of their lives. Specifically, the study shall be highly significant to the following people: Patients and Their Families. The end-result of the study will benefit the patients so that they will have a positive outlook in life and, at the same time, their quality of life. Such will also be beneficial to their families so that they would be able to understand the condition of the patient and enable them to extend their deepest understanding to their relative. Staff Nurses of Asia Renal Care. They would be able to provide the highest quality of care that they can give to patients with ESRD as well as post-transplant patients. Nephrologists. The study will be of great importance to this

group of people for they will be able to not only treat the kidney disease

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but also identify the prevalence of depression and undertake suitable treatments for the same. Hemodialysis Centers. The end result of the study will benefit the hemodialysis centers in the country for them to determine the specific domain of life affected by kidney disease and consequently give the right care for their patients. They can also adopt the customized renal program as part of their implementation of the centers. All Nurses. The results of the study are significant to the nurses in honing their skills in the care of dialysis patients. This study will

inspire them to continue advancing their competencies in the field of renal or dialysis nursing.

Definition of Terms To ensure clarity in this study, the following terms were defined operationally and lexically: Coping Strategies. It refers to an innate or acquired way of

responding to a changing environment or specific problem or situation. It is measured by a self-made questionnaire which is divided into three parts. The coping strategies are seen on Part 3. The respondents rated the statements based on the most common coping strategies observed.

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Hemodialysis Patients. These are the patients with End-Stage Renal Disease (ESRD), specifically those with Chronic Kidney Disease Stages 4 and 5. Kidney Disease Issues. This term is a quality of life domain regarding the appreciation or understanding of patients on the nature of disease and the burden of kidney disease in their lives. Mental Health. Such is a domain of quality of life in the study used to describe the emotional well-being, social health, social function, social support and expression of sexuality of a patient. Patient Satisfaction. This term is a quality of life domain used in the study to describe the patients satisfaction regarding treatment, efficiency of staff in all aspects, efficiency of the machine, physical environment, general systems, and cost of treatment. Physical Health. It pertains to a quality of life domain utilized to describe patients physical functioning, ability to work, role limitation due to physical function, pain threshold, energy/fatigue tolerance, and sleep. Quality of Life. In general, this term is used to evaluate the

general well-being of an individual. For this study, it is used to identify the patients perception of their physical health, mental health, kidney disease issues, and patient satisfaction. It is measured by a

questionnaire that the researcher made. The questionnaire is comprised

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of 3 parts.

First part includes the demographic profile, second part

assessed the quality of life and the last part determined the most common coping strategies of the patient-respondents. Renal Program. This term refers to a customized, wholistic

treatment plan designed for hemodialysis patients, aimed primarily to improve the existing program in the center, and to improve the patients quality of life. This encompasses the assessment of their overall health status and coping strategies. (Please refer to Chapter 4 or Appendix for the Renal Program.) Chapter 2 REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the literature and studies reviewed by the researcher that have a significant bearing on the present study.

Conceptual Literature General Health Perceptions Quality of Life is of vital importance to patients with regard to dialysis and is often the gauge used to determine whether the treatments provided are successful. Nurses should be constantly aware of how several factors can negatively create an impact on the physical,

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cognitive, psychological, and social components of quality of life. Assessing health-related quality of life (HRQOL) can provide information on the types and degrees of burdens that afflict patients with chronic medical conditions, including end-stage renal disease (ESRD). There are numerous tools that can be used in assessing the quality of life of hemodialysis patients, but they all have a common goal and that is to gather information from patients so that appropriate measures can be done by the health care provider to change the perception of patients about Chronic Kidney Disease and End-Stage Renal Disease. The impact of Chronic Kidney Disease (CKD) on the body and individuals is significant and it ultimately affects every body system together with the chronicity of the disease contributing negatively to their perceived health related quality of life. The World Health Organization (WHO) defines Quality of Life as an individuals perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad-ranging concept affected in a complex way by the persons physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment (WHO, 2001). Measuring the Quality of Life (QOL) of hemodialysis patients has been the subject of various lines of research. Researches are being

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conducted to describe the quality of life of hemodialysis patients to be able to suggest ways of uplifting their outlook in life and how they could improve specific aspects of the individual patients quality of life. Although there are many studies addressing the quality of life of patients with end-stage kidney disease, there are very few studies that have specifically looked at patient symptoms directly attributable to the hemodialysis (HD) procedure. The study of Caplin (2010) affords a

significant input to this work because he revealed how dialysisassociated symptoms affected the quality of life of hemodialysis patients. Despite advances in hemodialysis (HD), intradialytic symptoms were frequently reported by the patients. There was substantial unexplained variation in symptoms suggesting that clinical practice or policies may play a role in preventing the adverse effects of dialysis. In his study, he suggests that these patients may benefit from a different approach to dialysis prescription. The study also revealed that older patients have lower expectations in terms of quality of life and accept their disease more and therefore report fewer symptoms. Indeed, Caplins study

proved to be beneficial to the researcher and it will likewise be so to renal nurses who take care of the patient while undergoing therapy because they will be able to value the importance of proper assessment

xxxix

of the patient, not only before the therapy starts, but also while therapy is ongoing. Understanding of the disease is vital for patients to have a high quality of life. Green (2011) discussed the importance of having knowledge of ones health. Health literacy, according to him, is an important public concern. There have been few studies examining this issue in patients with chronic kidney disease. His study sought to characterize the prevalence of and associations of demographic and clinical characteristics with limited health literacy in patients receiving maintenance hemodialysis. Lower educational level was

independently associated with limited health literacy. He concluded that limited health literacy is common among patients receving hemodialysis. Certain socioeconomic factors are strong independent predictors of limited health literacy. His work revealed that there was no association of limited health literacy with age, gender, overall symptom burden, and so does quality of life is not affected by the factors mentioned. Another factor commonly existing among hemodialysis patients is malnutrition. It is a common issue among patients with end-stage renal disease and is associated also with elevated mortality and morbidity. Lindsay and Kortas (2010) work had a significant bearing to this study because it deals with nutritional assessment as part of the treatment of patients undergoing hemodialysis. In their paper, it was found that quality of life is greatly affected

xl

by nutritional assessment.

Patients who were assessed regularly on their

nutritional status had a longer life than those patients who just came in to attend to their regular hemodialysis. Therefore, one can say that assessing the

nutritional status of renal patients posed a great responsibility on both the dieticians and nephrologist. They should collaborate with each other together with the renal nurses to ensure good nutrition of patients. Regular laboratory checks should also be done to detect problems that might cause a big problem or might trigger complications during hemodialysis session. The problems

detected can be used as baseline data in identifying the problems needed to be addressed. For example, a high phosphate level should alert the nurse that patients must be instructed to avoid foods high in phosphorus so that they can limit intake of those foods. Patients with high phosphate level are significantly known to have higher mortality rates than those patients with low phosphate levels. It is also the primary role of the nurse to give health teaching to patients. Indeed, regular nutritional assessment of end-stage renal disease (ESRD) patients is paramount to ensuring optimal well-being and evaluation of the adequacy of the renal replacement therapy; thus patients will develop high levels of health-related quality of life. Dialysis treatment results in prolongation of life for most patients. However, patients on dialysis face limited survival combined with considerable loss of health related quality of life. In addition, dialysis treatment itself

xli

generates considerable burden on daily life in terms of chores to be completed, time taken to obtain dialysis, expense of treatment, and hospitalization for surgical procedures and complications. Rocco (2009) presented some

suggestions for clinical care on the quality of life of dialysis patients which can be useful in the current undertaking for evaluating effective coping among older patients. He noted in one of his study that QOL was impaired in those with Chronic Kidney Disease (CKD). Age is strongly related to QOL in patients undergoing dialysis treatment. Most studies show that physical aspects of QOL deteriorate with advancing age. The study appears to suggest that older people may compensate for deteriorating function thru psychological adjustment. The researcher found Roccos study as

important in assessing the coping strategies of older people since it already mentioned that this group of patients compensate by psychological adjustment. Life in End-Stage Renal Disease (ESRD) is miserable. Food and fluid restrictions are mandatory for the patients due to hyperkalemia, high blood pressure, and fluid retention. Salt-free diet, low potassium containing foods and limited fluid intake are possible interventions, and even though protein adds up to uremia, ESRD patients have to consume a high protein diet so as to meet the extra needs for body repair functions and immunity. A research done in India by Francis, et al. (2009) focused on identifying the effect of patient counseling

xlii

and to discover the impact of it in Health-Related Quality of Life of hemodialysis patients. It is estimated that about 100,000 persons suffer from ESRD each year of which only about 20,000 get treated. Affordability is

hampered by low incomes, low reimbursement for chronic illnesses, and low penetration of insurance. This situation is unique to India as most other

countries in Asia specifically in the Philippines. Good hemodiaysis treatment requires a meticulously clean atmosphere, isolation of patients to prevent spread of infections, good water, trained technicians, and strict adherence to norms on dialyzer and consumable reuse. In reality, there is a large element of variation in hemodialysis practices from center to center. In the absence of strong

guidelines and legislations, several centers operate without even having a water purification system. In this study, they proposed the method of patient-

counseling as a means of providing medication information orally or in written form, to the patient or his/her representative on directions of use, advise on side effects, precautions, storage and diet, and lifestyle modification. They call it Medication Therapy Management. Due to poor economical aspects, most of the patients choose the twice a week hemodialysis category. Patient-counseling provided was mainly on food and fluid restrictions, lifestyle modifications, and correcting the misconceptions about diseases and medications. Counseling was given elusively. Results of this study concluded that most of the kidney patients are experiencing malnutrition. Medication dosage adjustment is another

xliii

important area in management of ESRD. Some patients knew very little and some knew nothing at all except for the color of the medication they were taking. Data from the study shows the impact of patient counseling as

promising in improving health related quality of life in ESRD. Awareness of patients on diet and medication through patient counseling was found to be very effective in improving the quality of life in hemodialysis patients. His study had a significant bearing to the current undertaking because the researcher thinks that the nurses have a great responsibility in making the patients feel less ill. They could sit for a while, listen to the patient, talk to them, and ask how they feel about their therapy so as to foster or establish good communication. This is already a form of patient counseling and, by this way, the patients may feel that the health care providers value them not only as a patient availing treatment at the clinic, but also as a person. Improving the quality of life of hemodialysis patients poses a challenging role to all health care providers. According to Chaudhury (2007), having a healthy kidney is worth a billion dollars, but an unhealthy kidney costs more about $16 billion more. In order to perform successful dialysis, it is critical to have a functioning vascular access. There are two main types of permanent dialysis access: an arteriovenous fistula, which connects the artery and the vein directly, and an arteriovenous graft, which connects the artery and the vein using a plastic tube or synthetic material.

xliv

Unfortunately, these connections may only last between six and 12 months due to stenosis, or narrowing of the veins. As a result, hemodialysis patients often have repeated hospital admissions and surgeries in order to keep their dialysis access open and functioning. Chaudhury said that problems associated with vascular access are probably the biggest factors that reduce the quality of life for hemodialysis patients. His study also had a significant relationship to the

current study because taking care of vascular access poses a great responsibility to renal nurses. Cincinnati Dialysis Access Research Program (CAP) was established by Chaudhury and his colleagues in 2007. The mission of the CAP is to improve the quality of life for dialysis patients by reducing the problems associated with dialysis vascular access. A journal written by Sathvik in 2008 illustrates how physical, psychological, social functioning, environmental, and general health were affected in end-stage renal disease patients. It is interesting to note that although majority of the study patients did not have adequate financial security and suffered a loss of income while being on hemodialysis, their environmental domain scores were not significantly lower than those of the healthy individuals in the study. Most of the study patients revealed that they had enough time for their recreation or leisure activities and a good home or physical environment. The patients were satisfied with

xlv

their access to health services, yet another contribution to the absence of any significant difference in the QOL scores. In addition, employment status also affects the quality of life of hemodialysis patients. The overall quality of life of employed hemodialysis patients was substantially better than that of the retired and the unemployed groups. Employed patients scored better in their physical, psychological, and environmental health domains. Financial independence, to some extent, might have

contributed to the higher quality of life scores in the employed group. In addition, better mobility, work capacity, and less restriction in daily activities are possible factors contributing to the better QOL scores in the aforementioned domains. Employment has been found to be a vital

factor in improving the QOL of end-stage renal disease patients. Moreover, the quality of life is also affected by higher income. An

employed patient has the ability to afford the prescribed treatment and, in turn, ensures a better quality of life. Patients who prematurely retire from work due to their illness have a significant deterioration in their quality of life. An article published by Mujais in 2009 investigated how chronic kidney disease affects the determinants of health-related quality of life in hemodialysis patients. Results revealed that health-related quality of life in patients with chronic kidney disease is reduced by a magnitude that is

xlvi

considered clinically significant.

Gender emerged as a powerful

predictor of low quality of life in concordance with other factors. The fact that women suffer more from chronic illnesses is not unique to nephrology and has not been adequately addressed in therapeutic approaches. The vulnerability of women to have low quality of life was manifested in many domains and was of a magnitude judged to be clinically significant. These observations suggest that particular attention to the impact of chronic kidney disease to quality of life should be exercised by all members of the health care team in female patients. According to Kanamori (2012), the number of dialysis patients along with the proportion of older patients is increasing in Japan. The Annual Statistics Survey by the Japanese Society for Dialysis Therapy from the end of 2003 to 2009, the mean age of the whole dialysis population rose from 61.5 to 65.8 years old, much older than in 1985 (50.3 years old). It is also reported that mental and physical health-

related quality of life in hemodialysis patients is lower than in the general population, and that depression is one of the most important predictors of patients prognosis. Therefore, paying more attention to the patients quality of life in addition to medical factors is vital. The study revealed that age does not have significant difference between elderly and nonelderly hemodialysis patients. However, better appetite, mood, and

xlvii

satisfaction in daily life were associated with better survival in non-elderly HD patients. It has been reported that the prevalence of depression is increasing with age in the general population. However, according to a patient survey performed by the Ministry of Health, Labor and Welfare in Japan in 2005, patients with depression were distributed widely between the ages of 30 to 70. This could account for the lack of difference in mood between elderly and non-elderly HD patients. These results

indicate more attention should be paid to appetite, depressive mood, and satisfaction in daily life to improve the survival especially in non-elderly HD patients. A study done by Andres, et al. (2003) in Manila tests the responsiveness of the Modified Quality of Life (QOL) questionnaire for End Stage Renal Disease (ESRD) patients which they adapted from the UP-DOH QOL Scale of Filipino Cancer patients developed by Ramiro (1997). It also has a significant relationship to this work since it

evaluates the effects of assessing laboratory parameters of a patient especially the hematocrit levels. The primary aim is to measure the

quality of life of patients with End-Stage Renal Disease (ESRD) using their Quality of Life (QOL) scores and to determine the relationship of Quality of Life (QOL) of chronic renal failure with the duration of kidney disease, socio-demographic factors, serum creatinine, albumin, and

xlviii

hematocrit at the start of dialytic therapy. The study concluded that the quality of lives of Filipino ESRD patients was high at the start of dialysis and it became moderate after one year. It is contrary to the common belief that their quality of life is poor if compared to the general population. Therefore, they can say that patients with high hematocrit and normal hemoglobin levels and those patients showing improvements on their hematologic and biochemical markers have a better quality of life.

Physical Health A study by Takhreem (2008) aimed at critically examining the effect of exercise prescription in reducing the physical and psychological limitations encountered by CKD patients. The result of the study

suggests a causal relationship between exercise intervention and Quality of Life (QOL) of CKD patients. It also shows a significant relationship to this study for most patients undergoing dialysis think that they could no longer exercise. Patients who exercise have shown improvements in physical fitness, psychological function, manual dexterity, reaction times, and lower-extremity muscle strength. All of these factors help improve Quality of Life (QOL). Evidence gathered from this study showed that exercise training has beneficial effects on the quality of life (QOL) of

xlix

chronic kidney disease (CKD) patients; however, exercise is still not routinely prescribed. Further research and robust evidence are needed to overcome the limitations encountered by previous studies to confirm the positive results of exercise prescription in management of chronic kidney disease (CKD).

Mental Health There have been various researches done in the past that stresses the importance of having a strong social support system that can help patients overcome the burden of hemodialysis. Untas, et al. in 2010 investigated the influence of social support on patient survival, adherence to medical recommendations, and quality of life. Their study is relevant to the current study because patients with strong social support system tend to cope effectively. Patients answered questions related to social activities, whether they felt isolated, considered themselves burdens, and what kinds of support they received from family and dialysis staff. Patients who said that their ill health had interfered with social activities, isolated them, or created a burden to family, and who lacked family support, were more likely to die during the study period. These patients were also less likely to follow their doctors' orders such as controlling weight, maintain, or possess physical quality of life. Surprisingly, staff encouragement and support did not help patients follow medical orders.

The investigators also noted some country-to-country differences. For example, Japanese patients had a particularly high risk of dying during the study if they felt dissatisfied with family support. Mortality was higher among patients

reporting that their health interfered with social activities, were isolated, felt like a burden, and were dissatisfied with family support. Poorer family support and several psychosocial were also associated with lower adherence to the prescribed hemodialysis length and the recommended weight gain between sessions. Some international differences were observed. Poorer self-reported social support and other psychosocial factors were associated with poor physical quality of life. In addition to this, patients with little social support are also more likely to ignore doctors orders, experience a poorer quality of life and die prematurely. The study concluded that poorer social support and other

psychosocial factors are associated with higher mortality risk, lower adherence to medical care, and poorer quality of life in hemodialysis patients. Combes study (2010) noted the presence of supportive people who can participate in care is an important source of strength for patients undergoing hemodialysis. His study is significant to the current study since Filipinos are known to have strong social support. In the absence of social support, patients will develop poor coping. The study raised the possibility that social

support interventions may improve patient care. Such interventions could strengthen other psychosocial factors, improve survival, and enhance

li

the quality of life. Social support could help improve the perception of a depressed patient. Although hemodialysis has a therapeutic effect on End-Stage Renal Disease, these patients encounter many physical, psychological, and social stressful factors that lead to a decrease in their Quality of Life (QOL). A study by Heidarzadeh (2009), published in the Iranian Journal of Nursing and Midwifery Research, states that one of the factors that are effective on increasing the quality of life is self-care ability. Review of literature demonstrated a few studies done on different aspects of quality of life in End-Stage Renal Disease patients under hemodialysis and their relationships with self-care ability. Results revealed that more than half of the patients had an undesirable quality of life. Patients

encounter many physical, psychological, and social problems that result in a decreasing quality of life in these patients. The result showed that hemodialysis patients had few problems in social dimension, but they had more problems in physical and psychological dimensions of quality of life. It is due to good and suitable communication between these patients and their families, and the effective and durable support of family. Social support was also desirable in most of the hemodialysis patients. It also showed that two thirds of hemodialysis patients had desirable self-care ability. It seems that patients with better self-care

lii

ability can observe diet and care of the vascular access and other requirements better, so they can control many physiological

complications. It results in improving physical, psychological and social situation. Therefore, it causes the improvement of the total quality of life. Depression plays a crucial role in the progression of chronic medical illnesses. People with depression feel so hopeless that they abandon the will to survive. Consequently, the person will fail to show compliance and the medical illness exacerbates due to lack of preventive measures. Moreover, loss of

appetite creates nutritional deficiencies to make things even worse. Deterioration of physical health would deepen the depression to create a vicious cycle. Chronic kidney disease is also a chronic medical illness. Independent of the cause of kidney disease physical fitness decreases with its progression until the development of End-Stage Renal Disease (ESRD). Patients on hemodialysis may manifest various psychiatric problems like affective disorders, dementia, and personality disorders. Amongst all psychiatric disorders, depression is the most important and common in patients with ESRD. Depression in dialysis patients not only affects mortality but also increased the rate of

hospitalizations wherein dialysis withdrawal is also very common. The World Health Organization in 2005 has predicted that depression will be the leading cause of death worldwide in the year 2020. Mortality related to major depression among the general population has

liii

been highlighted empirically in several studies, despite some methodological issues. Research has shown that depression increases the risk of mortality, particularly via cardiovascular disease. This association has an obvious severe implication for patients with End-Stage Renal Disease (ESRD), as cardiovascular disease remains the largest cause of death among this patient population. The psychological and somatic effects of depression can complicate chronic illness, reduce quality of life, reduce the motivation to maintain selfcare and increase hospitalization rates. The association between depression and immune function is well-recognized. In End-Stage Renal Disease (ESRD), significant associations have been reported regarding depression, immune parameters and mortality, although some of the data is limited and conflicting. Immune dysfunction has a great impact upon infection, which is the second largest cause of death among the ESRD population. Furthermore, research has shown significant associations between depression and nutritional status, which could mediate the relationship between depression and mortality in this population. Depression is the most frequent psychological complication of hemodialysis patients and has been associated with impaired quality of life (QOL). Cengic (2010) made a study aimed to investigate the prevalence of depression in hemodialysis patients in relation to socio-demographic factors and the relationship between depression and Quality of Life (QOL). His study

liv

shows a significant bearing to the current study because Quality of Life of patients undergoing hemodialysis procedure is greatly affected if a person is experiencing depression. Procedure of hemodialysis (HD) treatment

besides objective organic difficulties also causes bigger or less changes in psychological status and personality of hemodialysis patients. These changes are results of continuous stressful situation, to what patients are exposed three times per week, as well as numerous changes that they face on a personal, social, and professional sphere. However, the

psychological response of patients to hemodialysis will mostly depend on his or her pre-morbid personality, the extent of support by the family, and eventual co-morbid illness. Depression is the most common and

probably the most important, psychopathological complication of hemodialysis patients. Depression reduces patients Quality of Life

(QOL) and can progress to suicide or termination of HD if unrecognized or untreated. Patients often deny being depressed because they do not want to be stigmatized. Dialysis patients frequently exhibit a depressive affect, which contribute to marital, family, and occupational problems. He examined 200 patients aged 20-80 years. hemodialysis patients have shown depression. Depression and suicide are well-established as prevalent mental health problems for patients on hemodialysis. Chen (2010) examined Here, 51% of

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the demographic and psychological factors associated with depression among hemodialysis patients and elucidated the relationships between depression, anxiety, fatigue, poor health-related quality of life, and increased suicide risk. A cross-sectional study was done to 200

patients. Results revealed that 70 patients had depression symptoms and 43 patients had suicidal ideation in the previous month. Depression was significantly correlated with a low Body Mass Index (BMI) and a number of co-morbid physical illnesses. Depressed patients had greater levels of fatigue and anxiety, more common suicidal ideation, and poorer quality of life than non-depressed patients. Results revealed a significant direct effect for depression and anxiety on suicidal ideation. Watnick (2010) performed a clinical trial about morbidity and mortality among dialysis patients after treatment for depression. The study has two main objectives: to assess whether treatment and recovery from depression decreases adverse clinical events in chronic hemodialysis patients and to examine the rates of recovery from depression over a 6-month and 12-month period among prevalent dialysis patients. Baseline data collection includes patient

demographics, etiology of renal disease, nutritional status, past medical and psychiatric history and baseline health status. Social support and quality of life assessments were obtained from direct interviews. All

lvi

patients were assessed for depression by the Beck Depression Index, a depression scale particularly useful in those with chronic illness, and the Diagnostic Interview Scale, a gold standard for depression assessment. Those that are depressed underwent pharmacologic treatment with a Selective Serotonin Re-Uptake Inhibitor (SSRI), and was reassessed after 2 and 6 months of improvement. Patients who did not respond were referred for psychiatric therapy. Their study revealed that depression is a modifiable risk factor that warrants therapy for the well-being of dialysis patients. End Stage Renal Disease (ESRD) is a chronic illness that is very debilitating. Individuals with this disease are faced with having life sustaining hemodialysis treatments that are generally scheduled three times a week, lasting from 3 to 5 hours each session. A large proportion of people affected by this disease have limited lives as a result of the time constraints of treatments. According to Wells (2011), self-

management of chronic illnesses such as End-Stage Renal Disease, can be influenced by various biological, behavioral, and social factors which can influence health and adherence. In addition, social support is a

modifiable risk factor that can impact and improve medical adherence and health outcomes. Social support plays a key role in positive health outcomes. It includes resources offering emotional comfort, physical

lvii

assistance, and solutions to problems in order to preserve a patients sense of self-esteem and self-competency. The physical, psychological, and social well-being are directly enhanced for people who have supportive social networks. Patients who are diagnosed with End-Stage Renal Disease have many constraints related to their illness that they need strong and positive social ties to overcome them. Social support is defined as a composite concept including attachment or intimacy, social integration, nurturance, reassurance of worth, and availability of assistance. This study showed that there is a relationship between

social support and quality of life in hemodialysis patients in Western countries. Results indicated a positive correlation between social

support and quality of life. Furthermore, the most important life domains central to quality of life in order of importance were health, family and economics. Interestingly, participants in this study reported being most satisfied with their family and least satisfied with their health. Overall, perceived social support was positively correlated with QOL, and perceived social support was also associated with health-functioning and family in this study. Moreover, depression is the most widely-acknowledged

psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. A low

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quality of life (QOL) score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. In relation to that, they recommend to further study on the interrelationship between psychosocial factors and clinical outcome. Anees et al. in 2008 conducted a study on depression in hemodialysis patients in Pakistan. The main objective of their study is to measure the

frequency of depression and its risk factors in patients undergoing hemodialysis. They used a cross-sectional prospective study to obtain data from the research setting. All patients getting regular hemodialysis for more than three months were included. Becks Depression Inventory (BDI-II) was administered on all the patients who were able to read or understand it. Blood samples were drawn at the same time for routine hematological, biochemical parameters (urea, creatinine, sodium, potassium, calcium, phosphorus and albumin), and viral markers. Diagnosis was made as per Diagnostic and Statistical Manual of Mental Disorders (DSM IV). They concluded that majority of patients undergoing hemodialysis were depressed. Major risk factors for depression were illiteracy, marital status, number of children, socio-economic factors, financial support,

lix

and gender. In this study, education has a very strong association with psychological parameters of depression like insomnia, fatigue, and diminished interest. Due to education and misperceptions about the

disease, most people with kidney disease end up being sent to the hospital and endorsed to dialysis units in more miserable conditions. Therefore, one can say that education plays an integral role in the detection of kidney disease. People should be knowledgeable enough to report symptom(s) as early as stage I so that appropriate measures will be done. Marital Status and Number of Children had a statistical

significance as well and is also associated with the prevalence of depression of hemodialysis patients. As a sole bread winner and

guardian of 5-7 members of the family such poses a great responsibility. This debilitating disease not only affects their employment status but creates extra burden due to expensive treatment. This makes the

patient pensive and later on leads to depression. Socioeconomic factors such as depression also play an important role in depression. Dialysis is a costly treatment and most of the patients in this study are unemployed or not earning enough. People receiving any form of financial support from NGOs, hospitals, and/or organizations were found to be less depressed as compared to those who were not. Gender difference is also very important as noticed in various studies in the same country.

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The prevalence of depression is twice in female patients as compared to male patients. However in this study, this is not seen in renal patients. The major reason for this effect is that males are dominant and usually earn well; so, when they suffer from a kidney disease, they get more depressed than the adult female. Male patients feel loss of The

independence and authority and hence scored higher in BDI-II.

other reason is that patients with renal failure have increased uremic toxins in their body which inhibits testosterone secretion. Testosterone has an inverse relation with depression. Thus, low testosterone level is directly related to depression. New research suggests that patients with chronic hemodialysis, and diagnosed with depression, are twice as likely as their nondepressed counterparts to die or be hospitalized within a year. Busko (2008) in his recent study about the existence of depression in dialysis patients stated that physicians often misdiagnosed depression, therefore leading to poorer outcomes. Given the excessive rate of cardiovascular death in patients with End-Stage Renal Disease and the correlation of depression with increased cardiovascular events, it is important to investigate the link between depression and outcomes in dialysis patients. Busko examined whether there was an association between

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depression diagnosed in dialysis patients by physicians and subsequent patient death or hospitalization. Depression is common among dialysis patients, but behavioral therapy can significantly improve their quality of life. Dialysis exacts both a physical and mental toll on patients, and, not surprisingly, a significant proportion of patients. Depression in these patients is associated with hospitalizations, other diseases, and even mortality. Sesso et al. (2008) studied 85 patients with End-Stage Renal Disease who were on chronic hemodialysis and had been diagnosed with depression. Half of the

patients underwent three months of weekly 90-minute sessions of cognitive-behavioral therapy led by a trained psychologist. Sessions focused on issues related to kidney disease treatment and its effects on daily life, depression, and coping techniques, thinking and cognitive remodeling techniques, relaxation activities, and social behavior abilities. The other half of patients in the study received usual treatment offered in the dialysis clinic, without behavioral interventions. All patients filled out quality-of-life questionnaires at the start of the study and again after three and nine months of follow up. They found that, after three months of intervention, the group receiving cognitive-behavioral therapy had a significant improvement in depressive symptoms, cognitive function, and quality-of-life scores when compared to the control group. These

lxii

differences also persisted after six months of intervention. During this period, patients received once a month maintenance sessions. They concluded that cognitive-behavioral therapya relatively cheap,

harmless and practical interventionis an effective strategy to treat depression in patients with kidney disease. According to Johnson (2002), patients with terminal illnesses face grief and fear, not only for their own future, but also for their families future. There were three identified specific burdens: financial burden, provision of physical care, and inability to do their obligation to their family. These concerns over how their illness can affect their loved

ones. It may also influence on how they would seek care and what decisions they make about their health. Despite these burdens, patients related that their family has always been there to support them morally, financially, and emotionally. Filipino families are known to be closely knit because of the strong influence of tradition and sense of loyalty to family and community. Since depression can make the patient feel exhausted and helpless, he or she will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effect. Over the last 10-15 years, several studies have assessed healthrelated quality of life in different Chronic Kidney Disease populations.

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Mucsi (2008) in his article published in Primary Psychiatry journal revealed numerous socio-demographic factors that are associated with impaired health-related quality of life. It has been repeatedly

demonstrated that female patients consistently report worse quality of life than men. One potential explanation may be the more negative disease perception and the increased prevalence of depression in women. A lower social status, characterized by lower education, worse financial situation, or lack of employment, has also been consistently associated with impaired QOL. Patient employment status is far from being

satisfactory, even in kidney transplanted patients. This area should receive more attention than it currently does. The association of age with HRQOL is quite complex and illustrates the complexity of the QOLs concept. Obviously, the objective physical health status of most elderly patients is worse than the health status of younger CKD patients. The subjective QOL for elderly patients, however, varies depending on their expectations and beliefs. It could be surprisingly good compared to their younger counterparts In the Philippines, it has been said that patients who experience depression are those in the early start of hemodialysis. But in general, studies reviewed have shown that although patients are not manifesting physical and emotional signs of depression, they are still experiencing

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some episodes of it.

It is just a matter of how they cope with the

situation that makes them able to return to their normal way of life or well-being.

Kidney Disease Issues Aside from the symptoms that greatly affect the process of hemodialysis, there are also other factors that need to be taken into consideration in order to promote effective coping on patients. Gotch et al. (2010) were the originators of the formula for determining adequacy of dialysis. Dialysis Dose and Adequacy is attributed to cardiac morbidity and mortality risk. According to them, dialysis adequacy plays an integral role in predicting morbidity and mortality in hemodialysis setting. Patients will have a higher level of health-related quality of life if they are dialyzed regularly. If patients will be dialyzed on a regular basis, symptoms will be minimized and, therefore, incidence of mortality will be reduced. A journal published in the Journal of Behavioral Medicine in 2007 examined the relative effectiveness of three intervention strategies designed to increase compliance to diet and fluid restrictions in a group of ambulatory hemodialysis patients. Behavior modification approaches have been reported to be very effective in dealing with compliance problems to weight reduction and hypertension control. Several

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investigators have been interested in the effects on health-related behavior of attempts to modify beliefs. Belief change strategies are

based on the assumption that specific beliefs are the most important antecedents of decisions to act and the modification of such beliefs will result in desired alterations in behavior. On the other hand, several studies have been published with a primary aim of reviewing medications to treat muscle cramps. According to Raymond (2011), muscle cramps occur frequently in patients receiving hemodialysis. It is estimated that 33% to 86% of patients

receiving dialysis have experienced cramps (Holley, 2011). In a study from 2001, 25% of hemodialysis patients reported two or more interdialytic cramps weekly. Muscle cramps may have serious

consequences for patients who experience them. Muscle cramps can be painful and this may impact quality of life. Cramps may also limit a patient's ability to tolerate dialysis and, therefore, contribute to underdialysis or chronic fluid overload. Patients who experience cramps associated with dialysis have been reported to have higher serum creatine phosphokinase values suggesting muscle injury than patients who do not experience cramps. Quinine is approved not only for the treatment of malaria but has been used for many years for the treatment of cramps of both in the general population and in the dialysis

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population. Quinine reduces leg cramps by decreasing excitability of the nerve stimulations, which increases the muscle refractory period and, subsequently, prevents prolonged muscle contractions. According to

Roca (2010), three studies suggest that Vitamin E may be an alternative therapy for the management of leg cramps for patients receiving dialysis. Cramps have been frequently reported by patients and if addressed properly, it is as good as improving the quality life of patients.

Patient Satisfaction An article published by the National Kidney Foundation (2010) cites how the emotional health of a dialysis clinic affects the quality of life of hemodialysis patients. Patients often talk about clinical things like adequate dialysis, calcium and phosphorus management, and

hemoglobin count. Dialysis communities have also come a long way in improving the care of people with kidney failure. However, a very

important part of dialysis care has been overlooked emotional health. The emotional health of a dialysis clinic is the attitude either positive or negative that people in the dialysis clinic have toward each other. Keeping a dialysis clinic emotionally healthy takes a lot of hard work on everyones part. Patients and dialysis staff should trust and respect

each other. The clinic should have positive vibes. Patients should be

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able to discuss problems openly and honestly. Everyone in the dialysis clinic staff and people coming in for treatment has a responsibility to do their part. Dialysis clinics can be very emotionally charged places. There are a number of reasons why this is so and all of these reasons apply to dialysis staff, as well as to people on dialysis. Trying to consider other peoples feelings and emotions is one of the keys to an emotionally-balanced dialysis clinic. Unfortunately, during periods when we are having a hard time keeping our emotions and feelings balanced, it is difficult to consider other peoples feelings and emotions. This is true whether you are a person receiving treatment, a family member or friend, or dialysis staff member. The good news is that there are a lot of little things that a person can do to show consideration to people at the clinic that do not take a lot of effort or energy. If a dialysis clinic has a healthy environment, patients will not feel sickly as they really are. Over time, these little things can have a big impact on the emotional health of a dialysis clinic. Then, the quality of life of patients will then improve. Patient Satisfaction can be of great value to health care providers not only in recognizing and improving quality of care, but also in determining areas to improve in the aspects of the patients quality of life. An article published in Lippincott Williams and Wilkins by Al-Mailam

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(2005) mentioned the effects of nursing care in overall patientsatisfaction and its implications to the quality of life of patients. The study revealed that overall patient satisfaction is linked with quality nursing care, which, in turn, depends on the quality of leadership practiced at the institution. Transformational leadership behavior

promotes nursing satisfaction, which adds to the nurses work effectiveness and motivates them to provide quality patient care. If

patients feel that they are being cared in a compassionate way and if they feel that they are being treated well by health care providers, they will develop a good quality of life.

Coping Strategies of Hemodialysis Patients Coping strategies vary among individuals and are often related to the individuals perception of the stressful event. There are three

approaches to coping with stress namely: to alter the stressor, adapt to the stressor, or avoid the stressor. There is never only one way to cope. Some people choose avoidance; others confront a situation as a means of coping. There are two types of coping: Problem-Focused Coping and Emotion-Focused Coping (Kozier, 2004). Problem-Focused Coping

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refers to efforts to improve a situation by making changes or taking some action. Emotion-Focused Coping includes thoughts and actions that

relieve emotional distress. Emotion-Focused Coping does not improve the situation, but the person often feels better. Effective coping results in adaptation; ineffective coping results in maladaptation. Although the

coping behavior may not always seem appropriate, the nurse needs to remember that coping is always purposeful. Psychological stress is a relationship between the person and the environment appraised by the person as taxing or exceeding his or her resources, and endangering his or her well-being. Coping is the process through which the person manages the demands of the personenvironment relationship that are appraised as being stressful and which generate emotions. Psychosomatic Medicine (2010) conducted a study to determine the most common coping strategies of hemodialysis patients. The study aimed at investigating the root cause of stress in patients undergoing hemodialysis and its relationship to coping strategies used by patients with End-Stage Renal Disease. The hemodialysis stressor scale was used to measure the level of stress related to stressor subscales namely daily activity, physical condition, dependency on medical staff, fluid and food restriction, role ambiguity, blood vessel problems, and reproductive

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system functioning. Results show the daily activity subscale scores were positively associated with using emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Fluid and food restriction and role ambiguity subscales were found to be positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Reproductive system functioning was positively associated with emotionoriented, avoidance, and isolated thoughts coping strategies. The study concluded that the most commonly used coping strategies among hemodialysis patients were emotion-oriented, avoidance and isolated thoughts. Chou and Yeh (2007) investigated on the most common coping strategies and stressors in hemodialysis patients. They used the The

hemodialysis stressor scale and the Jalowiec Coping Scale.

Hemodialysis Stressor Scale measures the level of stress related to stressor subscales: daily activity, physical condition, dependency on medical staff, fluid and food restriction, role ambiguity, blood vessel problems, and reproductive system functioning. The Jalowiec Coping Scale identifies the use of the following coping strategies: problemoriented,emotion-oriented, support seeking, avoidance, and isolated thoughts.Results show that daily activity sub-scale scores were positively associatedwith using emotion-oriented, avoidance, and isolated thoughts

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as coping styles and negatively related to support seeking from professionals. The higher the perceived stress related to physical symptoms, dependency on medical staff, and blood vessel problems, the more the patients used emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Fluid and food restriction and role ambiguity subscales were found to be positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Reproductive system functioning was positively associated with emotionoriented, avoidance, and isolated thoughts coping strategies. Patients on hemodialysis seldom use problem-oriented strategy to ease their stresses. Support seeking was another in frequently used coping strategy. Therefore, they both agreed that the most commonly used

coping strategies in our patients were emotion-oriented, avoidance, and isolated thoughts. The choice of coping strategy depended on the types of stressor. While people with End-Stage Renal Disease face many physical and emotional changes related to their disease and its treatments, strategies for coping do exist. A study published in 2007 by Kidney

Times stresses the importance of emotional wellness as a key to renal rehabilitation. The basis for successful adjustment includes two key

elements: optimal clinical care to improve how patients feel, and

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rehabilitation management to improve their ability to function. This study shows significant relevance to the current study because without these elements, good long-term outcomes are not possible. In essence,

patients can live long, enjoy a high quality of life and live independently and productively if they are first able to function both physically and mentally. People on dialysis can significantly influence their own longterm outcomes. However, dialysis professionals can have a major

impact positive or negative on how patients deal with the life changes caused by kidney failure and its treatments. A study done by the Mayo Foundation for Medical Education and Research in 2011 discusses how positive thinking helps with stress management and how it can even improve a persons health. There are a lot of coping techniques or strategies that a person can use in dealing with chronic illness. Indeed, some studies show that personality traits like optimism and pessimism can affect many areas of a persons health and well-being. The positive thinking that typically comes with optimism is a key part off effective stress management. And effective stress Researchers

management is associated with many health benefits.

continue to explore the effects of positive thinking and optimism on health. Some of the benefits of positive thinking include the following: lower rates of depression, lower rates of distress, better psychological

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and physical well-being, reduced risk of death from cardiovascular disease and better coping skills during hardships and times of stress. In turn, patients will have a good quality of life when they practice positive thinking. A journal published in the American Journal of Kidney Diseases by Gillanders (2007) cites another way of approaching a chronic illness particularly end-stage renal disease. Results revealed that emotion

regulation is another psychological strategy that can be used to cope with the stressors of hemodialysis treatment. These strategies are

associated with a range of physical and psychological variation that may be related to kidney disease and its management. The study explores the associations of 2 emotion regulation strategies: reappraisal and suppression and will focus only on emotion regulation strategies and well-being rather than clinical parameters. It has been considered to have an impact on the patients well being and disease management. Reappraisal is the estimation again of the worth, value, or quality of a person or thing. Suppression in the other hand means to consciously and deliberately push down any thoughts that lead to feelings of anxiety. The study revealed that reappraisal has a more positive clinical and psychosocial associations than suppression.

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A study by Yanagida (2008) stated that denial has been documented as an important defense mechanism in helping the chronically ill cope with their disease. With respect to a dialysis Both

population, however, the role of denial has been ambiguous.

descriptive and predictive research with dialysis patients have confirmed that denial is a frequently used defense mechanism or coping strategy. Unfortunately, there is no systematic data on what exactly is being denied, nor is there consensus on how denial is to be operationally defined. Results revealed that patients with high levels of denial may be more difficult for the staff to treat. They are more likely to experience negative affects, and yet compliance may not be better. Patients also use denial to protect themselves from experiencing unpleasant, negative affect. According to Juneau (2007) in his study on adjustment and acceptance of ESRD, the role of the health care professional is to encourage and, where possible, to enable patients to accept responsibility for their health and well-being and to fulfill their obligations within the family and society. Prospects for renal rehabilitation increase if dialysis staff conveys a positive attitude and show a belief in patients potential to live long and well on dialysis. In addition, staff

encouragement toward rehabilitation goals helps patients form positive

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attitudes that will allow them to participate actively in life. Further, staff can provide valuable information on a wide range of topics - particularly things patients are able to control, like adherence, exercise, and selfcare. At the facility level, adjustment can be aided by offering flexible dialysis schedules, work-related goal-setting, and referral to vocational rehabilitation as well as opportunities for patient-to-patient

communication and meaningful staff interaction. This can be very useful to the current study to serve as an idea in constructing a successful renal program for hemodialysis patients at Asia Renal Care, Alabang.

Related Studies Foreign Studies Hemodialysis treatment results in many stresses and restrictions. In a number of studies, hemodialysis patients have reported a high degree of distress associated with a wide variety of psychosocial and physical problems. Interest in measuring health-related quality of life (HRQOL) has increased together with an awareness that such humanistic outcomes require valid and reliable measures. In the last decade, short, simple, and

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multidimensional generic and disease-specific questionnaires have been developed to aid in the easy assessment of the quality of life of hemodialysis patients. Health-related quality of life (HRQOL) predicts mortality in end-stage renal disease (ESRD), yet adoption of HRQOL monitoring is not widespread, and regulatory authorities remain predominantly concerned with monitoring traditional biologic parameters. To assist with future efforts of improving the outlook in life of hemodialysis patients, this study sought to establish which domains of HRQOL are mostly affected by ESRD at the same time identifying the causes of depression and their coping strategies. End-Stage Renal disease (ESRD) is a prevalent and expensive condition that affects more than 400,000 people in the United States at a cost of $20 billion annually. This health economic burden is amplified by the impact of ESRD on health-related quality of life (HRQOL) resulting from physical, psychological, and social stressors engendered by the disease and its treatment. The physical manifestations of ESRD span every organ system, range in severity from nuisance to life threatening, and negatively disrupt patients lifestyles without exception. Psychologically, patients with end-stage renal

disease (ESRD) have a disproportionately high incidence of depression, often experience anticipation anxiety of impending physical demise, and encounter difficulties in coping with their disease. Patients with end-stage renal disease

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(ESRD) are limited by dietary restrictions, time restrictions, and oftentimes overwhelming physical and psychological restrictions that can lead to disruptions in personal relations and social withdrawal. It was established that Quality of Life (QOL) is well-recognized as an important measure of treatment outcome. The study conducted by Bakewell and contemporaries in 2002 had a significant bearing to this work because it also aimed to determine which key factors affect QOL, which aspects of QOL change over time, and if measurements of QOL were associated with clinical outcome on their hemodialysis treatment. The most significant changes

were for the items general health symptoms/problems, burden of kidney disease, emotional well-being, and patient satisfaction. Increased hospital admissions were associated with a worse quality of life. Thus, they concluded that quality of life of patients on hemodialysis declined over time. As time passed, patients were more burdened by their kidney disease, feeling more frustrated by the time spent dealing with their disease, and the way it interfered with their life. Patient satisfaction with their care also declined over time. The availability of various renal replacement therapies (RRT) has reduced the severity of symptoms and resulted in longer survival of ESRD patients. One option people usually opted for is hemodialysis since this is the most reasonable treatment of choice of patients with

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chronic kidney disease (CKD). Hemodialysis therapy is time-intensive, expensive, and requires fluid and dietary restrictions. Long-term dialysis therapy itself often results in a loss of freedom, dependence on caregivers, disruption of marital, family, and social life, and reduced or loss of financial income. Due to these reasons, the physical,

psychological, socioeconomic, and environmental aspects of life are negatively affected, leading to compromised Quality of Life (QOL). A similar study in Washington conducted by Wright in 2008 said that Quality of Life is an important factor in decisions regarding hemodialysis in elderly patients. The study reveals that most elderly patients would elect dialysis if offered but that relief of symptoms was a major goal rather than survival alone. Overall, patients on hemodialysis rate their quality of life as poorer than age-matched controls.

Local Studies While the study of Lopes (2010) centered on depression, the researcher considered it also as relevant for it aimed to know the reasons for lower health-related quality of life scores in women compared to men on maintenance hemodialysis. They investigated

whether depression accounts for gender differences in health-related quality of life. Specifically, one of its conclusions expressed that women

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had higher depression scores than men. Women are more prone to depression than men. Lower health related quality of life among women was largely explained by depression symptoms. Results support greater emphasis on treating depression to improve health related quality of life in maintenance hemodialysis patients, particularly women. In the Philippines, a dialysis blogspot has been created especially for dialysis patients. It is primarily made to educate people about dialysis and chronic kidney disease. Patients and relatives share their thoughts about chronic kidney disease and hemodialysis experience. Danguilan (2010) in her study shows that End-Stage Renal Disease (ESRD) is already the 7th leading cause of death among Filipinos. It is said that a Filipino is having the disease hourly or 120 Filipinos per million population per year. This shows that about 10,000 Filipinos need to replace their kidneys. Unfortunately, though only 73% or about 7,267 patients received treatment, an estimate of about a quarter of the whole population probably just died without receiving any treatment. The study conducted by Minsuarez (2009) has a strong resemblance to this study as her work was on examining the quality of life of dialysis patients in 3 major dialysis units of Zamboanga City under a cross-sectional descriptive design. The results showed the QOL

domain on physical well-being, emotional and functional domains are

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interpreted as Moderate while their social status and cognitive ability is High. In turn, the sum of all the scores has a corresponding interpretation of moderate QOL. Thus, the Quality of life of the Dialysis patients is not Low, contrary to common belief. This finding is confirmed and supplemented by the result of the in-depth interview done to 10 selected participants who rated their QOL to be either Good or Okay, Moderate or Average, near Normal and Simple. The result can be attributed to the fact that Filipinos are closely-knit with good support system for they are strongly influenced by the traditions and have a sense of loyalty to family and the community. Hence, in times of misfortune like having a debilitating disease, they protect and help each other by rendering financial, emotional, and social support. Here, the researcher aimed to determine the Quality of Life of hemodialysis patients using a validated questionnaire to gauge the level of their Quality of Life based on their scores. The researcher likewise considered contributing factors to the prevalence of depression in hemodialysis patients and also determined the coping strategies they have been using to cope up with the burden of having Chronic Kidney Disease particularly those leading to End-Stage Renal Disease. Posttransplant patients having hemodialysis again after the kidneys have been rejected by their body are also considered as part of the study.

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Furthermore, it enables the readers to picture out and better understand the daily challenges experienced by patients with chronic kidney disease (CKD) and how it creates a significant impact on the quality of their lives. Subjective representations of what living with dialysis means can support the refinement of practice guidelines, individualized plans of care, and priorities in evaluating outcomes of care for these patients.

Synthesis Over the past few decades, quality of life research endpoints have emerged as a valuable research tool in assessing the outcome of therapeutic intervention in chronic diseases. End-Stage Renal Disease is one such chronic disease causing a high level of disability in different domains of the patients' lives, leading to an impaired quality of life. The concepts, ideas, and studies delineated hereto, contributed much to the current undertaking at hand. The consolidated account of all these thoughts and ideas allowed strengthening of the research and thus formed a more concrete structure of the fundamental and effective practices that will further help in the construction of a comprehensive renal program. No similar study was found to be parallel and suggestive

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to the study being done; however, there are several studies that were found to be related to if not contributory to the present study. The other literature and studies reviewed assisted in the scrutiny of the renal program that was being constructed. This aided in the

expansion of the scope of what was being studied thus catering to more concerns and enabling the study to address what is essentially involved, by attacking it in all areas of responsibility in all points that could be touched. The study by Caplin (2010), Green (2011), Lindsay (2004), and Kortas (2004) were able to assist the researcher on the importance of having knowledge about ones health. They were able to suggest ways of improving the quality of life of hemodialysis patients. The works of Rocco (2009), Sathvik (2008), Kanamori (2012), Untas (2010), Combe (2010), Heidarzadeh (2009), and Raymond (2011) emphasized how the domains of quality of life affect the patients in general thus, suggesting ways of improving it at the same time. The study by Al-Mailam (2007) made an impact on the study since it emphasized the effect of patient satisfaction to the quality of life. Chou (2007), Yeh (2007), Gillanders (2007), and Juneau (2007) specified how coping strategies helped hemodialysis patients to have a good quality of life.

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The current undertaking is similar to the rest of the studies reviewed because they have a common goal which is to evaluate the quality of life of a patient with chronic disease particularly End-Stage Renal Disease. The related literatures reviewed enriched knowledge

about the quality of life and coping strategies of hemodialysis patients. The researcher is in agreement with the other researchers because, generally speaking, the quality of life of a patient undergoing hemodialysis is greatly affected by the burden of kidney disease. The collated studies and literature that have been reviewed are significantly related to the study at hand. It is imperative to the

continuous propagation of knowledge needed to impart, not only to patients but to readers as well; thus, the formulation of a comprehensive renal management program suggested to be used by other hemodialysis centers to improve the quality of life of hemodialysis patients.

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Chapter 3 METHODOLOGY

This chapter presents a description of the method research used, the respondents of the study, description of the instruments utilized, the procedure of data gathering analysis adopted, and the statistical instrument applied.

Research Design To achieve the fundamental thrust of the study, the Descriptive Research Design was employed. Since this study is concerned in determining the quality of life and coping strategies of hemodialysis patients, the Descriptive Method is the most appropriate method for this type of study. However, Quantitative Research Method in the form of survey questionnaire, was likewise employed.

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This was done to get an in-depth analysis on the patient-respondents quality of life and coping strategies. The second broad class of non-experimental studies is Descriptive Research. According to Polit and Beck (2006), the purpose of Descriptive Research is to observe, describe, and document aspects of a situation as it naturally occurs and sometimes to serve as a starting point for hypothesis generation or theory development. Louis Cohen, Lawrence Manion, and Keith Morisson (2007), authors of Research Method in Education cited the best points of view about Descriptive Research. Descriptive Research is concerned with the conditions or relationship that exists, practices that prevail, beliefs, points of view, attitudes that are held, processes that are held, and trends that are developing. It also involves

description, analysis and interpretation of condition, and collection of data in order to answer questions concerning the current state of the subjects of the study. The present study is descriptive in nature because it attempted to determine the quality of life of hemodialysis patients and identify the most common coping strategies being used by the patient-respondents as a basis for constructing a Comprehensive Renal Program.

Population and Sampling

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The population of the study consisted of hemodialysis patients availing treatment at Asia Renal Care in Alabang from 2011-2012. There were one hundred thirty (130) hemodialysis patients at Asia Renal Care, Alabang. However, the medical director only allowed 50 patients to become respondents of the study. Non-Random Sampling using Purposive Sampling was used as a sampling technique. Patients with Chronic Kidney Disease Stages 4 and 5 and those present at the time of visit at the hemodialysis center are the criteria for the selection of subjects.

Table 1 Hemodialysis Patients Population and Respondents of the Study (December 2011- February 2012)
Gender Male Female Population at Asia Renal Care 86 44 Percentage 66 34 Respondents of the Study 27 23 Percentage 54 46

This table shows the total number of hemodialysis patients and the respondents of the study at Asia Renal Care. Male respondents were 86 and female respondents were 44, in number, for a total of 130 patients currently having hemodialysis treatment.

Respondents of the Study

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In this study, there were only fifty (50) patient-respondents who participated and answered the given questionnaires. Table 1 above shows the number of patients who participated in the study. There are 27 male patients who participated out of 86 male patients at the center, while 23 female patients out of 44 female patients, out of the 44 female patients, participated in the study.

Research Instrument The instrument used to collect data is a self-made questionnaire. In determining the research instrument, the researcher divided this part into three phases: Part 1 Obtaining the profile of hemodialysis patients; Part 2 Assessing the Quality of Life of each patient; and Part 3 Identification of the Coping Strategies and Its Effectiveness as used by the patients. The

questionnaire was patterned from Kidney Disease Quality of Life Instrument (KDQOL) by Hays, Kallich, Mapes, Coons, and Carter (1994). KDQOL is a multidimensional, reliable, and validated instrument specifically designed for dialysis patients. The questionnaire was evenly distributed to all respondents. This served as the primary data-gathering instrument. Modifications were made according to the variables of the study. The questionnaire was written in

English and Tagalog for the patients to easily understand it. . Part 1 of the questionnaire includes the demographic profile of the patient which includes the following: Age, Gender, Civil Status, Educational

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Attainment, Employment Status, Financial Security, and Frequency of Hemodialysis. Part 2 of the questionnaire consists of questions related to the patients quality of life in relation to the following factors: Physical Health, Mental Health, Kidney Disease Issues, and Patient Satisfaction. Statement

Numbers 1 to 13 pertains to the general health perceptions of the patient, physical health functioning, ability to work, role limitation due to physical function, pain threshold, energy/fatigue tolerance, and sleep. Statements

numbers 14 to 25 relate to the patients mental health in terms of emotional well-being, social health, and his/her expression of sexuality. Statement

Numbers 26 and 27 relate to the kidney disease issues particularly on the appreciation and understanding of the nature of disease and the burden of kidney disease on his or her life. Statement Numbers 28 to 34 pertain to the patient satisfaction regarding treatment, efficiency of staff and machines, physical environment, general systems and the cost of treatment. Negative statements include numbers 2, 3, 8, 9, 10, 13, 18, 19, 20, 21, 22, 23, 25, and 26. Part 3 contains the coping strategies of the patient-respondents. The questionnaire measured the quality of life of hemodialysis patients and their coping strategies which served as basis for constructing a wholistic renal program. The respondents were given the option as to whether to answer the English or Tagalog questionnaire. The researcher assessed the patients perception and rated their response based on the interpretation scale.

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Table 2 Interpretation Scale for the English Questionnaire on the Patients Quality of Life
Word Description for Positive/Negative Statement

Range or Interval

Scale

Verbal Description for Positive Statements Respondents believe that the indicator given is equivalent to an excellent quality of life Respondents believe that the indicator given is equivalent to a very good quality of life Respondents believe that the indicator given is equivalent to a good quality of life Respondents believe that the indicator given is equivalent to a fair quality of life Respondents believe that the indicator given is equivalent to a poor quality of life

Verbal Description for Negative Statements Respondents believe that the indicator given is equivalent to a poor quality of life Respondents believe that the indicator given is equivalent to a fair quality of life Respondents believe that the indicator given is equivalent to a good quality of life Respondents believe that the indicator given is equivalent to a very good quality of life Respondents believe that the indicator given is equivalent to an excellent quality of life

4.50-5.00

Excellent/Poor

3.50-4.49

Very Good/Fair

2.50-3.49

Good

1.50-2.49

Fair/Very Good

1.00-1.49

Poor/Excellent

Validation of the Instrument The contents of the questionnaire were validated by experts chosen by the Dean of the Graduate School. To test for its reliability, the items in the questionnaire were pre-tested by conducting a pilot study at the University of

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Perpetual Help Medical Center. Results of the pilot study revealed the r value is 0.531, whereas the critical r value is 0.381. It reveals significant reliability of the instrument.

Data Gathering Procedure The study was done at Asia Renal Care, Alabang Branch. Data

gathering started December 2011 and ended February 2012. There were three phases which was observed by the researcher in having the questionnaire. First: Preliminary Phase; Second: Actual Phase; and Third: Processing, Analyzing, and Interpretation. In the Preliminary Phase, the researcher studied the profile of the institution and sent a letter of intent to gain approval for the researcher to conduct a study at the center. Actual Phase started once the approval of the medical director was secured. The researcher collaborated with the members of the health care team to gather the profile of the patient-respondents (age, gender, civil status, educational attainment, financial security, and frequency of hemodialysis). The researcher asked permission from the patient-respondents and let them sign a consent form. Administration of the questionnaires followed once the copies were available. The patients were initially instructed to take the questionnaires at home for them to fill out. Majority of the patient-respondents opted to answer the questionnaire while they were having their treatment, rather than taking home the same.

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In the Processing, Analyzing, and Interpretation of data, the researcher grouped the questionnaires into categories connected with the sub-problems and presented it as tables.

Statistical Treatment of Data The researcher utilized Descriptive Statistics in this study. Descriptive Statistics describe the basic features of the data in a study. They provide sample summaries about the sample and the measures. Together with simple graphics analysis, they form the basis of virtually every quantitative analysis of data. It is typically distinguished with

Inferential Statistics. With Descriptive Statistics, it only describes what is or what the data shows. With inferential statistics, it means extending beyond the immediate data alone. The following statistical tools were used to treat and interpret the data obtained: Frequency Count and Percentage These statistical measures were used in presenting the population and sampling data of the respondents. Frequency distributions are

methods of imposing order on numeric data. A frequency distribution is a systematic arrangement of numeric values from the lowest to the highest, together with a count (percentage) of the number of times each

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value was obtained. This tool gave answers to the demographic profile of the patient-respondents in terms of age; gender; civil status; educational attainment; employment status; presence or absence of a support system, specifically the patients financial capacity, and frequency of hemodialysis.

Weighted Mean It was applied to the assessment of the survey. The second and third part of the questionnaire made use of a five-point Likert scale, where 5 is the highest and 1 is the lowest. It was adopted to measure the Quality of Life (QOL) of hemodialysis patients in terms of general health perceptions, physical health, mental health, kidney disease issues, and patient satisfaction. It also determined the most common coping strategies of patient-respondents.

t-test The t-test is the most commonly-used method to evaluate the differences in means between two groups. It can also be used even if the sample sizes are very small. This test was applied to determine significant difference between two mean groups. It was employed to test

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whether there is a significant difference in the quality of life in terms of the gender, civil status and presence or absence of a support system.

Analysis of Variance (ANOVA) Analysis of Variance is a parametric procedure used to test two or more mean group differences. ANOVA decomposes the variability of dependent variable into two components: variability attributable to the independent variable and variability due to all other sources. It is

employed to test whether there are significant differences in the assessment of the quality of life when grouped according to profile variables. This statistical tool specifically answered sub-problem number 4.

Chapter 4 PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

This chapter presents the results of the survey analysis and interpretation of data gathered based on the five problems answered by

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this study.

Results and discussions were organized in terms of the

sequence of the research problems stated in the previous chapter. Problem Number 1. The profile of patient-respondents according to age, gender, civil status, educational attainment, financial capacity, presence/absence of a support system, and frequency of hemodialysis.

Table 3 Profile of the Patients According to Age Age 30 & below 31-40 41-50 51 - 60 61 & above Total Frequency 3 9 6 18 14 50 Percentage 6 18 12 36 28 100

The table shows the population of patients wherein there were 18 patients whose age is 51 to 60, or 36%; for the 61 and above age group, there were 14 or 28%; the 31 to 40 age group had 9 or 18%; the 41 to 50 age group had 6 or 12%; and, lastly, with respect to the 30 and below age group, there were 3 patient-respondents or 6%. Majority of the population at Asia Renal Care is in the bracket of 51 to 60 yrs. old, while ages 30 and below was the age group with the smallest population.

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Age is strongly related to Quality of Life (QOL) in patients undergoing hemodialysis treatment. According to a study by Rocco

(2009), older people have higher expectations regarding quality of life since they compensate easily for deteriorating function rather than younger patients who may, sometimes, still be in the process of denial of having kidney disease. Several demographic factors influence the

quality of life of life of a patient, especially those having chronic illnesses; one of those is age. Older patients are more expectant of their disease. According to Heidarzadeh (2009), age does not directly affect the quality of life of hemodialysis patients. It is similar to the current study because results revealed the same information.

Table 4 Profile of the Patient-Respondents According to Gender Gender Male Female Total Frequency 27 23 50 Percentage 54 46 100

This table shows that there are 27 male patients or 54%, while for females, there are 23 or 46% of them. Majority of the patient-

respondents are male, but it only had a little difference in terms of the number of female respondents.

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Gender difference is also important in determining the quality of life of patients undergoing hemodialysis. In this case, there are more male patients than female patients. It could be because of the lifestyle they adopted when they were still healthy. During data gathering,

patients verbalized that they have a sedentary lifestyle before they were diagnosed of having kidney disease. According to Anees (2008), males are more dominant and they tend to lose independence and authority than female patients - that is why they suffer more from kidney disease than female patients. Therefore, male patients have a lower quality of life than female patients. Contrary to the previous study, Mucsi (2008)

revealed that gender directly affects the quality of life of a patient. Female patients consistently report a worse quality of life than male patients. This may be due to the fact that females have a more negative perception of disease than males that contributed to higher rates of depression affecting the quality of life of patients. The results of the current study revealed that gender does not affect the quality of life of patients. They may have different perceptions of their disease but what is important is that they know how to cope with the affliction of kidney disease.

Table 5 Profile of the Patient-Respondents

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According to Civil Status Civil Status Single/Separated/Widowed Live-in/Married Total Frequency 18 32 50 Percentage 36 64 100

The table showed that majority of the patient-respondents are living-in with their partner or married, with a frequency of 32 or 64%. On the other hand, single/separated/widowed had a frequency of 18 or 36%. Patients who are married or are living-in with their partner may have a high quality of life primarily because of the strong social support they are receiving from their loved ones. Single/Separated/Widowed

patients were still able to receive the emotional support they need. This may come from other significant persons in their life. According to Untas (2010), having a strong social support greatly influences the quality of life of hemodialysis patients. Patients tend to cope effectively when they are able to get the support they need from their loved ones. Poorer family support were also associated with lower adherence to the hemodialysis treatment and resulted to low quality of life.

Table 6 Profile of the Patient-Respondents

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According to Educational Attainment Educational Attainment Elementary/High School Graduate Vocational College Undergraduate College Graduate Post-Graduate Total Frequency 0 3 13 31 3 50 Percentage 0 6 26 62 6 100

The table showed that majority of the patient-respondents are college graduates with a frequency of 31 or 62%. undergraduate has a frequency of 13 or 26%. College

Vocational and post-

graduates both have a frequency of 3 or 6%. There are no identified elementary graduates among the participants of the study. According to Green (2011), lower educational level was independently associated with health literacy. Limited health literacy is common among patients receiving hemodialysis. Socio-economic

factors are strong independent predictors of limited health literacy. In this study, there was no association of limited health literacy with quality of life. The health care provider should be knowledgeable enough in assessing the level of understanding of patients about their disease. A patient does not have to be college graduate in order to understand his or her condition.

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Table 7 Profile of the Patient-Respondents According to Employment Status Current Occupation No Work Currently Working Retired Total Frequency 8 8 34 50 Percentage 16 16 68 100

The table showed that majority of the patient-respondents were already retired from their jobs, which had a frequency of 34 or 68%. However, patients who do not have work, and are currently working both have a frequency of 8 or 16%. Employment status also influences the Quality of Life (QOL) of a patient. According to Sathvik (2008), there was a significant difference between the quality of life scores in physical health, psychological health, and environmental dimensions of hemodialysis patients with different employment status. Analysis showed that hemodialysis subjects who were employed scored statistically higher in the physical, psychological, and environmental domains compared to hemodialysis subjects who were not employed. The results of the current study revealed that, as soon as patients discover that they have kidney impairments and will need hemodialysis, they soon retire from work. This could be due to the

demand in medical services like schedule of dialysis treatments per week, doctors check-ups, and laboratory requirements, as verbalized by the patients during data gathering.

Table 8 Profile of the Patient-Respondents According to Financial Security Financial Security None Yes Total Frequency 36 14 50 Percentage 72 28 100

The table showed that majority of the patient-respondents with a frequency of 36, or 72%, does not have insurance, pension, or any means to support their treatment. On the other hand, patients who have an insurance that they use for their hemodialysis have a frequency of 14 or 28%. Majority of the patients does not have means to support their treatment. Financial security may come in the form of an insurance or pension they receive after retiring from their job. The role of higher

income is reflected in the higher scores in all domains of quality of life except for the social relationship domain. This was proven by an article written and published in the Indian Journal of Nephrology (2008). The higher income of an individual improves the ability of the patient to afford

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the required treatment and ensures a better QOL. A secure income is a reassurance to the patients and contributes to their psychological wellbeing. Financial difficulties due to premature retirement or loss of employment due to the disease may result in deterioration of QOL.

Table 9 Profile of the Patient-Respondents According to Frequency of Hemodialysis Frequency of Dialysis Once Twice Thrice Total Frequency 5 33 12 50 Percentage 10 66 24 100

The table showed that majority of the patient-respondents have their hemodialysis treatment twice a week with a frequency of 33 or 66%; thrice a week is 12 or 24%; and once a week is 5 or 10%. According to Gotch (2010), dialysis adequacy plays an integral role in improving the quality of life of hemodialysis patients. Results revealed that dialysis dosing and determining adequacy is attributed to cardiac morbidity and mortality risk. If patients are dialyzed on a

prescribed basis, symptoms will be minimized and incidence of mortality will be reduced. Relating this to the current study, almost all patients are

cii

able to comply with the frequency of dialysis and these give patients a good quality of life.

Problem Number 2. The quality of life of hemodialysis patients in terms of the general health perceptions, physical health, mental health, kidney disease issues, kidney disease complications and patient satisfaction.

Table 10 Distribution of Mean Responses of Respondents on Quality of Life Domains

Indicators General Health Perception 1. In general, I feel my health is good. 2. I feel my health is poor. Overall Physical Health 3. I feel physical pain to the extent that it prevents me from what I need to do. 4. I have enough energy for my everyday life. Mean 4.00 2.10 3.05 2.04 3.80 Description* VG VG G VG VG

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5. 6. 7. 8. I have the opportunity for leisure activities. I am satisfied with my ability to perform my activities of daily living (ADL). I am satisfied with my capability to work. My physical health interferes with my normal social activities with family, friends, neighbors and groups. 9. I feel physical pain. 10. I feel that physical pain interferes with my normal work (including both outside the home and house work). 11. I can tolerate the pain of needle insertion on my fistula/graft. 12. I am able to sleep well at night. 13. I get tired easily. Overall Mental Health 14. I feel my life is meaningful. 15. I am satisfied with the amount of time I am able to spend with my family and friends. 16. I am satisfied with the support I receive from my family and friends. 17. I am still able to express my love to my family and friends despite of my disease. 18. I have negative feelings such as despair, anxiety and depression. 19. I feel that kidney disease interferes too much with my life. 20. I feel that too much of my time is spent dealing with my disease. 21. I act irritably to those around me. 22. I isolate myself from the people around me. 23. I have difficulty concentrating or thinking. 24. I am able to concentrate well. 25. I feel that I am a burden to my family. Overall Kidney Disease 26. I completely understand the nature of my disease. Kidney Disease Complications My kidney disease bothers me in each of the following areas: a. fluid restriction b. dietary restriction c. ability to travel d. sex life and becoming sexually aroused e. soreness in the muscle or edema f. cramps g. itchy skin h. dry skin i. lack of appetite Overall Patient Satisfaction 27. In terms of satisfaction of care I am receiving, I can say that the staffs are friendly. 28. I am satisfied with the general systems and overall implementations of protocols of the dialysis center. 29. The staff shows interest in me as a person/patient. 30. Dialysis staff support me in coping with my kidney disease. 31. The machines are efficient and provides adequate treatment. 32. The environment is clean and is a suitable place for treatment. 33. I am satisfied with the cost of treatment. Overall Grand Mean *Legend for Positive Statements E Excellent (4.50-5.00) VG Very Good (3.50-4.49) G- Good (2.50-3.49) F Fair (1.50-2.49) P Poor (1.0-1.49) 3.92 4.10 4.06 1.88 2.12 2.08 4.70 4.50 2.78 3.27 4.90 4.96 4.96 4.86 1.38 1.86 1.76 1.32 1.16 1.36 4.76 1.22 2.88 4.90 VG VG VG VG VG VG E E G G E E E E E VG VG E E E E E G E

2.26 2.26 2.38 1.20 2.48 2.72 2.48 2.10 2.10 2.22 5.00 5.00 5.00 5.00 5.00 5.00 4.98 4.997 3.55

VG VG VG E VG G VG VG VG VG E E E E E E E E VG

*Legend for Negative Statements P Poor (4.40-5.00) F Fair (3.50-4.49) G Good (2.50-3.49) VG Very Good (1.50-2.49) E Excellent (1.00-1.49)

The table showed that under general health perceptions, the indicator In general, I feel my health is good got a mean score of 4.00 which was verbally interpreted as Very Good. On the other hand, the indicator I feel my health is poor has a mean score of 2.10 and was

civ

verbally interpreted as Very Good. The overall mean score is 3.05 which has a verbal interpretation of Good quality of life in terms of general health perception. Despite all the burden of having chronic illness, patients still believe that their health is good and can function well despite having a kidney disease. This can be attributed to the fact that Filipinos are

known to be positive thinkers inspite of all the problems they are handling. A study done by the Mayo Foundation for Medical Education and Research (2011) stated that positive thinking helps with stress management and can even improve a persons health. It often starts with self-talk. Self-talk is the endless stream of unspoken thoughts that run through a persons head everyday. There are a lot of benefits of positive thinking. It is unclear why people who engage in positive One theory is having a

thinking experience these health benefits.

positive outlook enables a person to cope better with stressful situations. This shows why patients have a good quality of life because the coping strategies they chose are proven to be effective. The table also showed that under the physical health domain, indicators I can tolerate the pain of needle insertion on my fistula/graft and I am able to sleep well at night got mean scores of 4.70 and 4.50 and were verbally described as Excellent. It was followed by indicators

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I am satisfied with my ability to perform my activities of daily living (ADL), I am satisfied with my capability to work, I have the opportunity for leisure activities, and I have enough energy for everyday life have mean scores 4.10, 4.06, 3.92 and 3.80 respectively with a verbal description of Very Good. Indicator I get tired easily has a mean score of 2.78 and was verbally described as Good. Lastly, indicators I feel physical pain, I feel that physical pain interferes with my normal work (including both outside the home and house work), I feel physical pain to the extent that it prevents me from what I need to do , and My physical health interferes with my normal social activities with family, friends, neighbors and groups have mean scores 2.12, 2.08, 2.04 an 1.88 with a verbal description of Very Good. The overall mean score is 3.27 with a verbal interpretation of Good. Physical health is another important domain of the quality of life of hemodialysis patients. It is greatly affected by the burden of having

chronic illness. Majority of the patients are no longer able to do their normal work due to their condition. Patients do not let their disease interfere with their normal life. This is a good indicator of having a good quality of life. On the other hand, according to Heidarzadeh (2009),

many of the patients have a poor quality of life in the physical and mental dimensions. Patients encounter many physical, psychological, and

cvi

social problems that result in the decrease of the overall quality of life. In this study, however, physical dimensions do not affect the quality of life of patients. This may be due to their improved self-care ability. Results showed that if patient had desirable self-care ability, they will observe proper care of themselves and other requirements better. The incidence of having physiological complications will be reduced and it will therefore cause the improvement of the quality of life of patients. The results of the current study showed that most patients believed that their physical health interferes with their normal social activities. Patients are still able to do their normal work therefore their quality of life is not affected by their physical health. The table also showed that under the mental health domain, indicators I am satisfied with the amount of time I am able to spend with my family and friends, I am satisfied with the support I receive from my family and friends, I feel my life is meaningful, I am still able to express my love to my family and friends despite of my disease, and I am able to concentrate well have a mean scores of 4.96, 4.90, 4.86, and 4.76 respectively, and was verbally described as Excellent. It was followed by indicators I feel that kidney disease interferes too much with my life and I feel that too much of my time is spent dealing with my disease with mean scores of 1.86 and 1.76, with a verbal description of

cvii

Very Good.

Lastly, indicators I have negative feelings such as

despair, anxiety and depression, I have difficulty concentrating or thinking, I act irritably to those around me, I feel that I am a burden to my family, and I isolate myself from the people around me have mean scores of 1.38, 1.36, 1.32, 1.22 and 1.16 respectively and were verbally described as Excellent. The overall mean score is 2.88 with a verbal description of Good. According to Wells (2011), social support plays a key role in positive health outcomes of patients undergoing hemodialysis.

Research has shown that there is a relationship between social support and quality of life. Furthermore, the most important life domains central to quality of life were health, family, and economics. The results of the current study revealed that patients are still able to express their love to their families and friends despite their disease. Filipinos are known to have strong family knit which helps them cope easily with the difficulties of having chronic illness. The table also showed that under the kidney disease issues domain, the indicator I completely understand the nature of my disease has a mean score of 4.90 with a verbal description of Excellent. Under the kidney disease complications domain, indicator cramps got a mean score of 2.72 which was verbally described as Good. Indicators

cviii

soreness in the muscle or edema and itchy skin has mean scores of 2.48 with a verbal description of Very Good. It was followed by

indicator ability to travel with a mean score of 2.38 with a verbal description of Very Good. Indicators fluid restriction and dietary

restriction both have mean scores of 2.26, which were verbally described as Very Good. Lastly, indicators dry skin and lack of

appetite had mean scores of 2.10, with a verbal description of Very Good. The overall mean score is 2.22, with a verbal description of fair. Muscle cramps occur frequently in patients receiving dialysis. It can involve the legs, most commonly in the feet, but can also involve the arms and hands as well as abdominal muscles. According to Raymond (2011), it is estimated that 33% to 86% of patients receiving dialysis have experienced cramps. Muscle cramps may have serious

consequences for patients who experience them. It can be painful and this may impact the quality of life of patients. Cramps may also limit a patients ability to tolerate dialysis and, therefore contribute to under dialysis or chronic fluid overload. Quinine is a medication that has been used for many years for the treatment of cramps both in the general population and in the dialysis population. According to Roca (2010), vitamin E may be an alternative therapy for the management of leg cramps for patients receiving dialysis. Contrary to what patients said

cix

that they understand the nature of their disease, patients still manifest dialysis-associated/intra-dialytic symptoms. They often complain of

cramps based on the statistical result revealed by the study and it creates a big impact on the kidney disease complications. There are many dialysis-associated symptoms and it is the primary role of the nurse to address these symptoms to help them achieve optimal health. Having a kidney disease gives many restrictions to a patient. Maximizing the patients health is also vital. The table also showed that under the patient satisfaction domain, the indicators In terms of satisfaction with the care I am receiving , I can say that the staffs are friendly, I am satisfied with the general systems and overall implementations of protocols of the dialysis center, The staff show interest in me as a person/patient, Dialysis staff support me in coping with my kidney disease, The machines are efficient and provides adequate treatment, and The environment is clean and is a suitable place for treatment have mean scores of 5.00 and were verbally described as Excellent while the indicator I am satisfied with the cost of treatment has a mean score of 4.98 and was verbally described as Excellent. The patients in general are satisfied with the care they are receiving. Staffers are friendly and they helped them in coping with their

cx

kidney disease. They are satisfied with the overall implementations of the protocols of the clinic. The environment is clean and patients found it as a suitable place for treatment. These factors are important in helping patients achieve a high quality of life. In an article published by the National Kidney Foundation (2010), it was noted that an emotionallyhealthy dialysis clinic creates an impact on the quality of life of hemodialysis patients. The emotional health of a dialysis clinic means that the attitude is either positive or negative. This is an important aspect to health care providers. If they show interest in the care of patients, the patients will develop a positive attitude and, in turn, will have a good quality of life. In addition, patient satisfaction is of great importance, not only to patients, but also to health care providers. It determines areas to improve on the quality of life of patients and is linked with quality nursing care. Providing quality nursing care reflects the In this study, since

quality of leadership practiced at the institution.

patients are satisfied in the general systems of the dialysis clinic, it simply means that health care providers are giving the highest quality of care to patients for them to have a good quality of life. Relating this to the current study, patients develop a high quality of life if they feel that they are properly being taken care of by health care providers.

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Problem Number 3. What are the Coping Strategies of hemodialysis patients at Asia Renal Care?

Table 11 Coping Strategies of Hemodialysis Patients Indicators Participate in Religious Activities Acceptance Keeping life as normal as possible Positive thinking Keeping a sense of humor Thinking all the good things in life Keeping himself/herself busy Keeping feelings under control Drinking alcoholic beverage Denial Finding more about the problem Seeking social support Venting feelings OVERALL
*Legend: HE - Highly Effective (4.5-5) VE - Very Effective (3.5-4.49) ME - Moderately Effective (2.5-3.49) LE - Less Effective (1.5-2.49) NE - Not Effective (1-1.49)

Mean 4.86 4.96 5.00 5.00 5.00 5.00 4.92 5.00 1.00 1.22 4.98 4.72 5.00 4.36

Description* HE HE HE HE HE HE HE HE NE NE HE HE HE VE

The table revealed that the indicators keeping life as normal as possible, positive thinking, keeping a sense of humor, thinking all the good things in life, keeping feelings under control, and venting feelings are the most common coping strategies used by the patientrespondents which has a mean score of 5.00 (HE) followed by the

cxii

indicator finding more about the problem got a mean of 4.98 (HE), while the indicator acceptance has a mean score of 4.96 (HE). The indicator keeping himself/herself busy got a mean 4.92 (HE), followed by the indicator participate in religious activities with a mean 4.86 (HE), while indicator seeking social support had a mean of 4.72 (HE). The indicator denial got a mean of 1.22 (NE), while the indicator drinking alcoholic beverage being the least used coping strategy, had a mean of 1.00 (NE). Coping strategies vary among individuals and are often related to the individuals perception of the stressful event. In this case, emotion focused coping is commonly manifested by patients. This includes

thoughts and actions that relieve their emotional distress. It does not improve the situation, but the person often feels better. Emotion

regulation is another psychological strategy used by patients to cope with the stressors of hemodialysis treatment. According to Gillanders (2007), the strategies used by a patient have important implications for well-being and disease management. A person may have a different strategy in approaching a stress particularly brought by a disease. It would only be effective if his or her quality of life is not affected in a negative manner.

cxiii

According to Yanagida (2008), denial is a common coping strategy among hemodialysis patients. Patients with high levels of denial are difficult for the staff to treat because they are more likely to experience negative affects than patients with low levels of denial. They also use it to protect themselves from experiencing unpleasant, negative affect.

Problem Number 4. Is there a significant difference in the Quality of Life (QOL) when grouped according to profile variables (age, gender, civil status, educational attainment, employment status, financial capacity, and frequency of hemodialysis)?

Table 12 Difference When the Respondents Are Grouped According to Age

Computed F-value 0.356 Critical Fvalue* 2.579

Age 30 & below

Mean 3.69

Significance Not Significant

Decision** Ho; accepted

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31-40 41-50 51 60 61 & above 3.71 3.68 3.69 3.67

* = 0.05, 4 & 45 df ** There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to age

Table 12 presents the result of analysis of variance on comparing the quality of life of respondents grouped according to age. The mean ratings of the respondents grouped according to age range from 3.67 to 3.71. Age brackets 61 and above had the highest mean responses of 3.71, while the age bracket 31-40 had the lowest mean response of 3.67. Analysis revealed that the differences in the mean ratings were not significant since the computed F-value of 0.356 did not exceed the critical F-value of 2.579 at five percent level of significance. Hence, the Null Hypothesis that there is no significant difference in the quality of life of the respondents when grouped according to age is accepted. According to Rocco (2009), several demographic factors influence the quality of life of patients undergoing hemodialysis treatment. Older patients have higher expectations in their quality of life therefore they are more acceptant of their disease. This can be proven by the

effectiveness of their coping strategies. Kanamori (2012) also found out

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that age has no significant difference in quality of life in elderly and nonelderly patients. It has also been reported that the prevalence of

depression is increasing with age in the general population. However, according to a patient survey by the Ministry of Health, Labor and Welfare in Japan in 2005, patients with depression were distributed widely between the ages of 30 to 70. This could account for the lack of difference in mood between elderly and non-elderly hemodialysis patients. However, the results of the study revealed opposite

information. Age according to the current study does not directly affect the patients quality of life. This may be because each person has a different perception. Non-elderly patients compensate to their disease just as how much elderly patients would compensate to their disease as well.

Table 13 Difference When the Respondents Are Grouped According to Gender

Gender Male Female Mean 3.68 3.69 Computed t-value -0.342 Critical tvalue* 2.011 Significance Not Significant Decision** Ho; accepted

* = 0.05, 2 tailed, 48 df

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** There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to gender

Table 13 presents the result of t-test on comparing the quality of life of respondents grouped according to gender. The mean ratings of the male and female respondents are 3.68 and 3.69. Analysis revealed that the difference in the mean ratings programs is not significant since the computed t-value of -0.342 (negative indicates that male

respondents on the average rated lower than the female) did not exceed the critical value of 2.011 at five percent level of significance. Hence, the null hypothesis that there is no significant difference in the quality of life of the respondents when grouped according to gender is accepted. Gender is another important domain that should also be considered in assessing quality of life. A study by Mucsi (2008)

concluded that female patients report worse quality of life than male patients. This is because female patients have higher depression rates compared to male patients. According to Anees (2008), males suffer more from kidney disease than female patients because they are more dominant and tend to lose independence and authority. The results of the study revealed that gender does not have significant difference in the quality of life of hemodialysis patients. This could be because of the type of personality that a patient has that makes him or her acceptant of her

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disease. patient.

One patient may have different perception from another A study by Mujais (2009) investigated the determinants of The

health-related quality of life in chronic kidney disease patients.

observations made highlighted the profound impact that chronic kidney disease has on health-related quality of life. The results revealed that gender emerged as a powerful predictor of low health-related quality of life in concordance with other factors. This could possibly be because women are more vulnerable to experiencing depression than male patients. Therefore, they tend to experience a low quality of life.

Table 14 Difference When the Respondents Are Grouped According to Civil Status
Computed t-value 2.896 Critical tvalue* 2.011

Civil Status

Mean 3.73 3.66

Significance

Decision** Ho; rejected

Single/Separated/Widowed Live-in/Married

Significant

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* = 0.05, 2 tailed, 48 df ** There is a significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to civil status

Table 14 presents the result of the t-test on comparing the quality of life of respondents grouped according to civil status. The mean

ratings of those single/separated/widowed are 3.73, while patients who are living-in with their partner and married are 3.66. Analysis revealed that the difference in the mean ratings programs is found to be significant since the computed t-value of 2.896 exceeds the critical value of 2.011 at five percent level of significance. Hence, the null hypothesis that there is no significant difference in the quality of life of the respondents when grouped according to civil status is rejected. According to Untas (2010), having a strong social support is important to patients with chronic illness like chronic kidney disease. Patients with little social support are more likely to ignore doctors orders, experience a poorer quality of life, and die prematurely. Strong social networks are important for maintaining dialysis patients health. The

current study revealed that civil status has a significant difference to the quality of life of hemodialysis patients. This could be because patients who have a partner in life adhere more to the prescribed treatment than those without someone to support them emotionally, physically and mentally. Therefore, a significant partner is vital in the entire treatment regimen of the dialysis patients. Support system is necessary.

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Table 15 Difference When the Respondents Are Grouped According to Educational Attainment
Educational Attainment Vocational Undergraduate College Graduate Post-Graduate Mean 3.62 3.72 3.67 3.71 Computed F-value 1.505 Critical F-value* 2.807 Significance Not Significant Decision** Ho; accepted

* = 0.05, 3 & 46 df ** There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to educational attainment

Table 15 presents the result of analysis of variance on comparing the quality of life of respondents grouped according to employment status. The mean ratings of the respondents grouped according to

educational attainment ranges from 3.62 to 3.72. Undergraduate has the highest mean response of 3.72 while vocational had the lowest mean response of 3.62. Analysis revealed that the difference in the

mean ratings programs is not significant since the computed f-value of 1.505 does not exceed the critical value of 2.807 at five percent level of significance. Hence, the null hypothesis that there is no significant

difference in the quality of life of the respondents when grouped according to educational attainment is accepted.

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Understanding the nature of disease is important to know the approach a patient should use in combating with the disease. Indeed, it is also vital for patients to have a high quality of life. According to Green (2011), it is important that a person should have knowledge about his or her health. Lower educational level was independently associated with limited health literacy. The study revealed that educational attainment does not have significant difference in the quality of life of hemodialysis patient. A patient does not have to be a college graduate to be able to understand his or her disease. There are other significant persons that can help them further understand their disease.

Table 16 Difference When the Respondents Are Grouped According to Employment Status
Employment Status No Work Currently Working Computed F-value 0.328 Critical F-value* 3.195

Mean 3.68 3.71

Significance Not Significant

Decision** Ho; accepted

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Retired 3.68 * = 0.05, 2 & 47 df
** There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to employment status

Table 16 presents the analysis of variance on comparing the quality of life of respondents grouped according to employment status. The mean ratings of the respondents grouped according to financial capacity range from 3.68 to 3.71. Patient-respondents who are currently working got a mean response of 3.71 while those who already retired from their job and those who do not have work both got a mean response of 3.68. Analysis revealed that the differences in the mean ratings were not significant since the computed F-value of 0.328 did not exceed the critical F-value of 3.195 at five percent level of significance. Hence, the null hypothesis that there is no significant d ifference in the quality of life of the respondents when grouped according to employment status is accepted. Employment status is another important domain that affects the quality of life of a patient. According to Sathvik (2008), employed

patients have higher quality of life in the physical health, psychological health, and environmental health. The current study however revealed that employment status does not have a significant difference in the quality of life of hemodialysis patients. This could be because as soon as patients discover that they have kidney impairments, they soon retire

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from their work leaving them unemployed but still with other means to support treatment. During data gathering, patients verbalized that they are happier now after retiring to work because they have more time to spend with their family. According to Jofre (2008), the employment

status of working-age patients has a major influence on their quality of life. In a number of series, the number of patients who continue working is very low. However, it is more important to keep patients healthy and fit as possible right from the pre-dialysis stage so that, if they lose their jobs, it is not because of physical problems, which would make it much more difficult for them to re-enter the labor market.

Table 17 Difference When the Respondents Are Grouped According to Financial Security
Support System None Yes Mean 3.69 3.67 Computed t-value 0.788 Critical tvalue* 2.042 Significance Not Significant Decision** Ho; not rejected

* = 0.05, 2 tailed, 48 df ** There is no significant difference between the Quality of Life and

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Coping Strategies of hemodialysis patients when grouped according to financial security

Table 17 presents the result of t-test on comparing the quality of life of respondents grouped according to financial capacity. The mean rating of those without support system is 3.69, while patients with support system is 3.67. Analysis revealed that the difference in the

mean ratings programs is not significant since the computed t-value of 0.788 did not exceed the critical value of 2.042 at five percent level of significance. Hence, the null hypothesis that there is no significant

difference in the quality of life of the respondents when grouped according to support system is not rejected. Majority of the patients verbalized that kidney disease created a big impact on their financial status. Most of them suffered a loss of income while spending big money for their hemodialysis treatment. According to the Indian Journal of Nephrology (2008), patients who earn big have a good quality of life than patients who do not have other means to support their treatment. Patients who can pay for their

treatment will be dialyzed regularly and will be able to prevent complications and in turn will develop a good quality of life. The results of the current study revealed that financial security does not have a significant difference in the quality of life of hemodialysis patients. A patient does not have to have a life-saving insurance in order for him or

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her to be able to support the treatment. Patients may have other means to support their treatment. Financial help may come from other

members of the family. In the Philippines, patients were sometimes able to get financial assistance from the Philippine Charity Sweepstakes Office.

Table 18 Difference When the Respondents Are Grouped According to Frequency of Hemodialysis
Frequency of Dialysis Once Twice Thrice Mean 3.69 3.69 3.67 Computed F-value 0.149 Critical F-value* 3.195 Significance Not Significant Decision** Ho; not rejected

* = 0.05, 2 & 47 df ** There is no significant difference between the Quality of Life and Coping Strategies of hemodialysis patients when grouped according to frequency of hemodialysis

Table 18 presents the analysis of variance on comparing the quality of life of respondents grouped according to frequency of hemodialysis. The mean ratings of the respondents grouped according to frequency of hemodialysis range from 3.67 to 3.669. Patients having hemodialysis once and twice both have the highest mean response of 3.69, while thrice a week hemodialysis has a mean response of 3.67. Analysis revealed that the differences in the mean ratings were not significant since the computed F-value of 0.149 did not exceed the

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critical F-value of 3.195 at five percent level of significance. Hence, the null hypothesis that there is no significant difference in the quality of life of the respondents when grouped according to frequency of

hemodialysis is accepted. According to Gotch (2010), patients who were dialyzed regularly have good quality of life because symptoms are minimized. As a result, incidence of mortality will be reduced. The result of the study revealed that the frequency of hemodialysis does not have a significant difference on the quality of life of patients. Scheduling of dialysis is done by the patient together with the nephrologist. The usual schedule is twice or thrice a week hemodialysis treatment. During data gathering, patients were seen to be compliant with the treatment regimen being prescribed to them. Even without life-saving insurance to support their treatment, the patients have other means that is why they can still adhere to the schedule of hemodialysis treatment. This may be the primary reason why frequency of hemodialysis does not have a significant difference on the quality of life of patients.

Problem Number 5. A proposed wholistic renal program. Nephrology Nursing or Renal Nursing is a specialized area of nursing that is directed toward individuals with kidney failure and their

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families. Patient education is a very important role for the registered nurse in the health care setting. It is the primary role of the nurse as educator to give adequate information to patients so that they can care for themselves when they are at home. In renal failure, there is a

sudden loss in kidney function leading to complications which can affect their quality of life. Since majority of the profile of the patients do not have significant difference in the quality of life, a wholistic renal program is proposed. Rationale 1. To enhance the existing policy or program developed by the management; 2. To improve the health-related quality of life of hemodialysis patients; 3. To maximize the patients health; and 4. To provide safe hemodialysis therapy that is free of preventable complications to each patient. Specific Objectives 1. To inculcate knowledge on helping patients achieve their optimal health; 2. To be able to assess the patients learning needs; and

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3. To help patients develop better self-care and self-management skills to decrease the impact of disease and prevent future health complications.

Chapter 5 SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

This chapter presents the summary of findings, the interpretations and conclusions drawn from the analysis of the information and data

cxxviii

gathered, and the proposed recommendations of the researcher to address the problems and concerns revealed in the five problems stated in this study.

Summary The study sought to assess the quality of life and determine the coping strategies of hemodialysis patients at Asia Renal Care. Patients with Chronic Kidney Disease Stage 4 and End-Stage Renal Disease were the subjects of the study. Specifically, the study answered the following questions: 1. What is the demographic profile of the patient-respondents in terms of the following: 1.1 Age; 1.2 Gender; 1.3 Civil Status; 1.4 Educational Attainment; 1.5 Employment Status; 1.6 Presence/Absence of Support System (financial capacity); and 1.7 Frequency of Hemodialysis? 2. What is the Quality of Life (QOL) of hemodialysis patients at Asia Renal Care in Alabang in terms of the following domains:

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2.1 General Health Perceptions; 2.2 Physical Health; 2.2.1 Physical Functioning; 2.2.2 Ability to Work; 2.2.3 Role Limitation Due to Physical Function; 2.2.4 Pain Threshold; 2.2.5 Energy/Fatigue Tolerance; and 2.2.6 Sleep? 2.3 Mental Health; 2.3.1 Emotional Well-Being; 2.3.2 Social Health/Social Function/Social Support; and 2.3.3 Expression of Sexuality? 2.4 Kidney Disease Issues; 2.4.1 Appreciation/Understanding of the Nature of Disease and 2.4.2 Burden of Kidney Disease? 2.5 Patient Satisfaction; 2.5.1 Patient Satisfaction Regarding Treatment; 2.5.2 Efficiency of Staff in all aspects; 2.5.3 Efficiency of the Machine; 2.5.4 Physical Environment; 2.5.5 General Systems; and

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2.5.6 Cost of Treatment? 3. What are the Coping Strategies of hemodialysis patients at Asia Renal Care? 4. Is there a significant difference in the Quality of Life (QOL) when grouped according to profile variables? 5. Based on the result of the study, what holistic program can be proposed to improve the Quality of Life (QOL) of hemodialysis patients?

Methodology The study employed the Descriptive and Quantitative Research Methods in gathering the data. The Descriptive Research Method provided data for the demographic profile of the patient-respondents and was enriched by the Quantitative Research Methods thru the survey questionnaire. Patients with Chronic Kidney Disease Stage 4 and End-Stage Renal Disease were purposively chosen. Only patients undergoing treatment at the center mentioned from December 2011 to February 2012 were included. The survey questionnaire which was self-made was validated by experts assigned by the Dean of the Graduate School. Revisions were then made based on comments and suggestions received.

Findings The study produced the following findings:

cxxxi 1. The patient-respondents profile was vital in assessing and determining their

Quality of Life (QOL). It is also important to know whether it affects their decision in choosing coping strategies. There are 27, or 54%, male and 23, or 46%, female respondents with age ranges of 30 and above. Majority of the patient-respondents are married or living-in with their partner. Most of them are also college graduates undergoing hemodialysis treatment twice a week and are retired without means to support their treatment (such as insurance or pension). 2. Data gathered from the patient-respondents responses on the following domains are as follows: 2.1 The response on General Health Perception showed an overall mean of 3.05, with a verbal description of a good quality of life. Most patients believed that their health is good despite having a chronic illness. 2.2 The response on Physical Health showed an overall mean of 3.27 with a verbal description of a good quality of life. Patients believed that they can tolerate the needle insertion on their fistula or graft. 2.3 The response on Mental Health revealed an overall mean of 2.88 with a verbal description of a good quality of life. They said that they are satisfied with the support they receive from their family. 2.4 The response on Kidney Disease Issues registered an overall mean of 4.90 with a verbal description of an excellent quality of life. Patients complain of cramps as the usual complication of hemodialysis; such had a mean of 2.72 with a verbal description of a good quality of life.

cxxxii 2.5 The response on Patient Satisfaction gave an overall mean of 4.997 with a verbal description of an excellent quality of life. Patients verbalize that the staff and machines are efficient however, some of them were not satisfied with the cost of treatment. 3. Determining the effectiveness of the coping strategies used is greatly influenced

by the patients quality of life. The coping strategies listed gave an overall mean of 4.36 with a verbal description of regularly manifested. The most common coping strategies of patients are keeping life as normal as possible, positive thinking, keeping a sense of humor, thinking about all the good things in life, keeping feelings under control, and venting feelings. 4. The profile of the patient respondents like age, gender, educational attainment,

financial security, and frequency of hemodialysis do not have a significant difference in the quality of life of patients except for the civil status which was found to have a significant difference in the quality of life of patients. 5. A wholistic renal program was developed for hemodialysis patients. Its primary

focus is to significantly improve the patients Quality of Life (QOL) by focusing on the key areas of the domains of quality of life.

Conclusions
1. Based on the results and findings of the study, it showed that majority of the

patients are in the age bracket of 51-60 years old and most of them are males. Male persons are more prone to having this disease probably because of the sedentary lifestyle they adopted when they are still healthy. Majority of them are also married

cxxxiii and college graduates. Most of the patients are professional with a stable job not until them found out they have a kidney disease. They soon retire from work to be able to adhere completely to the treatment regimen. 2. The indicators of kidney disease issues greatly affect the quality of life of The most commonly complained intra-dialytic symptom is

hemodialysis patient.

cramps. It can be addressed by proper evaluation of treatment as included in the renal program proposed in the current study. Patient satisfaction indicators have a high score which means that patients who are satisfied with the care they are receiving have a high quality of life. Patients have a good quality of life despite their disease. This was proven by the effectiveness of their coping strategies. 3. The most common coping strategies of hemodialysis patients are the following:

Keeping life as normal as possible; Positive thinking; Keeping a sense of humor; Thinking all the good things in life; Keeping feelings under control; and Venting feelings. Patients found the strategies they used to be effective. 4. When it comes to the level of significance, the demographic profiles of the

patients in general are not significant to the patients quality of life except for the civil status. The absence of a support system creates a significant impact on the quality of life of patients undergoing hemodialysis treatment. If patients have significant

persons supporting them, they were able to adhere to the treatment regimen being prescribed to them which may result to a good quality of life. 5. Lastly, health education plays an integral role in the care of patients with chronic

disease like End-Stage Renal Disease. Patients level of understanding should be

cxxxiv carefully assessed so health care providers would know the techniques in initiating health education to patients.

Recommendations 1. Based on the findings and conclusions drawn from the results of

the study, the study is found to be highly recommended to health care providers. They should be aware of their role in uplifting the patients perception of their disease, particularly to patients with chronic disease like End-Stage Renal Disease. Nurses are in the front line of service and are usually the ones in first contact with the patients. Advocacy is the heart and soul of nursing practice. 2. The study is also recommended to the patients relatives as they

should realize the importance of providing emotional support as it greatly affects the quality of life of patients. The patients relatives can be aware of the different domains in the quality of life affected by renal conditions for them to involve themselves in the patients plan of care. 3. The study is highly recommended to patients so they can actively

participate in the implementation of their plan of care. Patients can be guided on several ways in coping with the renal condition. They should also develop self-management skills so they can manage the disruptions their illness may cause to their work, social, and family life.

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4.

The study is also recommended to other hemodialysis centers in

the adoption of the renal program proposed by the researcher so they can also implement it in their center. 5. The study is also recommended to future researchers so they can

also conduct a study and construct another renal program that can be used by other hemodialysis centers.

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Critical to Dialysis Patients' Health. Retrieved October 21, 2010 from http://www. eurekalert.org/pub_releases/2010-10/asonlom101910.php Cohen, L., Manion, L., Morrison, K. (2007). Research Methods in th Education. 6 ed. Taylor and Francis e-Library. Danguilan, R. (2010). The Burden of Kidney Disease in the Philippines. Retrieved July 29, 2008 from http://www.abscbnnews.com/views-and-analysis/07/29/08/burden-kidneydisease-philippines Delaun, SC., Ladner, PK. Fundamentals of Nursing, Standard and Practice. 2nd Edition, Thomson, NY, 2002. Retrieved June 20, 2011 from http://currentnursing.com/nursing_theory/Neuman.html Elma, E.K. (2011). Ecological Development of Selected Centers of Excellence in Nursing Schools in the Philippines; Benchmarking for a Model Plan. Folkman, S., Lazarus, R.S. (1991). "Stress and Coping". York: Columbia University Press. 3rd ed. New

Fowler, C. (2006). Illness Representations in Patients with Chronic Kidney Disease on Maintenance Hemodialysis. Nephrology Nursing Journal. Retrieved from http://findarticles.com/p/articles/mi_m0ICF/is_2_33/ ai_n17212640/ Francis, B., Joseph, J., Mohanta, G., Thomas, D. (2009). Effect of Patient Counseling on Quality of Life of Hemodialysis Patients in India. Retrieved May 22, 2009 from http:www.pharmacypractice.org/vol07/pdf/181-184.pdf Gillanders, S. (2007). Emotion Regulation, Psychosocial Functioning, and WellBeing in Hemodialysis Patients. Retrieved December 17, 2007
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Green, J. (2011). Prevalence and Clinical Associations of Health Literacy in Patients on Maintenance Hemodialysis. Retrieved April 2011 from
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Heidarzadeh, M. (2009). Relationship Between Quality of Life and Self-Care Ability in Patients Receiving Hemodialysis. Retrieved January 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093176/ Jofre, R. (2008). Quality of Life for Patient Groups. Retrieved from http://www.nature.com/ki/journal/v57/n74s/full/4491633a.html Johnson, M. (2002). Facing Grief and Fear During Terminal Illnesses. Philippine Journal of Internal Medicine. Journal of Behavioral Medicine. (2007). Intervention Strategies to Improve Compliance With Medical Regimens by Ambulatory Hemodialysis Patients. Retrieved 2007 from http://deepblue.lib.umich.edu/bitstream Juneau, B. (2007). Psychologic and Psychosocial Aspects of Renal Rehabilitation. Critical Care Nursing Quarterly. Vol 17 pp 62-66. Kanamori, H. (2012). Comparison of the psychosocial quality of life in hemodialysis patients between the elderly and nonelderly using a visual analogue scale: The importance of appetite and depressive mood. Retrieved 2011 from http://onlinelibrary.wiley.com/doi/10.1111/j.14470594.2011.00731.x/full Kidney Times. (2007). Adapting to ESRD and Dialysis: Emotional Wellness is a Key to Renal Rehabilitation. Retrieved October 2007 from http://www.kidneytimes.com/article.php?id=20071015183318 King, K. (2009). Tips to Coping. Retrieved 2009 from http://www.kidney.org/patients/pdf/ff_su05.pdf Kortas, C., Lindsay, R. (2004). Daily and Nocturnal Hemodialysis:

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Contributions to Nephrology. Retrieved from http://books.google.com.ph/ books?id=no3pSWjijZYC&pg=PA97&lpg=PA97&dq=lindsay+ and+kortas+nutritional+assessment&source= bl&ots=E9bjZn736I&sig=ycdaLuV3PXjw5zlflurPLL_nl0Q&hl=en&e i=r34tTouUGsLImAW4rNTlBg&sa=X&oi=book_result&ct=result&r esnum=1&ved=0CBUQ6AEwAA#v=onepage&q=lindsay%20and %20kortas%20nutritional%20assessment&f=false Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). "Fundamentals of Nursing: Concepts, Process and Practice". 7th ed. Pearson Education South Asia Pte. Ltd. Lippincott Williams and Wilkins (2007). Understanding and Measuring Patients Assessment of the Quality of Nursing Care. Retrieved from http://blog.tcu.edu.tw/gallery/127/%E6%98%A5%E6%BB%BF65. pdf Lopes, O. (2010). Depression: A Prevalent Case Among Dialysis Patients. Philippines Journal of Internal Medicine. Mapes, D. (2010). Health-related quality of life as a predictor of mortality and hospitalization: The dialysis outcomes and practice patterns study (DOPPS). Retrieved 2010 from http://www.nature.com/ki/journal/v64/n1/full/4493877a.html Mayo Foundation for Medical Education and Research (2011). Positive Thinking: Reduce Stress by Eliminating Negative SelfTalk. Retrieved 2012 from http://www.mayoclinic.com/health/positive-thinking/SR00009/ NSECTIONGROUP=2 Minsuarez, R. (2009). The Quality of Life of Dialysis Patients in Selected Dialysis Units in Zamboanga City . Retrieved from 090707MINSUAREZ,RIENNE_Q..pdf Mucsi, A. (2008). Health-Related Quality of Life in Chronic Kidney Disease Patients. Retrieved 2008 from http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid =1408

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Mujais, S. (2009). Health-Related Quality of Life in CKD Patients: Correlates and Evolution Over Time. Retrieved http://cjasn.asnjournals.org/content/4/8/1293.full

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Philippine Society of Nephrology. (2004). Chronic Kidney Disease: The Philippine Situation National Nutrition and Health Survey. Pinoy Dialysis (2009). Dialysis Club of the Philippines. Retrieved from http://pinoydialysis/blogspot.com Polit D.F., Beck C.T. (2006). Essentials of Nursing Research: Methods, Appraisal and Utilization Sixth Ed. Lippincott Williams and Wilkins. Potter, P. and Perry, A. (2009). Fundamentals of Nursing. Retrieved 2007 fromhttp://www.ehow.com/way_5525405_nursing-teachingplan-renal.html Psychosomatic Medicine (2010). Coping Strategies and Stressors in Patients With Hemodialysis Retrieved from http://www.psychosomaticmedicine.org/content/69/2/182.full.pdf Raymond, C. (2011). Treatment of Leg Cramps in Patients With Chronic Kidney Disease Receiving Hemodialysis. Read Periodicals. Retrieved from http://readperiodicals.com/201107/2457345241.html#b Roca, A. (2010). Dialysis Leg Cramps: Efficacy of Quinine Versus Vitamin E. American Society for Artificial Internal Organs Journal. Retrieved from http://readperiodicals.com/201107/2457345241.html#b Rocco, M. (2009). Peritoneal Dialysis Adequacy and Risk of Death. International Society of Nephrology Vol. 58 Pp 446-457. Sathvik, B. (2008). An Assessment of the Quality of Life in Hemodialysis Patients using the WHOQOL-BREF Questionnaire. Retrieved 2008 from http://www.indianjnephrol.org/article.asp?issn=0971-4065;year= 2008;volume=18;issue=4;spage=141;epage=149;aulast=Sathvik

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Sesso, R. (2008). Behavioral Therapy helps Overcome Depression in Kidney Disease Patients on Dialysis. Retrieved November 2008. Takhreem, M. (2008) The Effectiveness of Intradialytic Exercise Prescription on Quality of Life in Patients With Chronic Kidney Disease. Medscape Journal of Medicine Vol 10. Retrieved October 1, 2008 from http://www. ncbi.nlm.nih.gov/pmc/articles/PMC2605133/ Untas, A. (2010). Lean on me: Social Support is Critical to Dialysis Patients Health. American Society of Nephrology. Retrieved October 2010 from http://www.eurekalert.org/pub_releases/2010-10/asonlom101910.php Watnick, S. (2005). Validation of 2 Depression Screening Tools in Dialysis Patients. American Journal of Kidney Disease. Retrieved from http://www.sciencedirect.com/science/article/pii/S0272638605011 091

Wells, J. (2011). Self-Efficacy and Social Support in African Americans Diagnosed With End-Stage Renal Disease. Read Periodicals. Retrieved from http://readperiodicals.com/201101/2355412921.html#b World Health Organization (1997). Measuring Quality of Life. Retrieved from http://www. who.int/mental_health/media/68.pdf Yanagida, E. (2008). Denial in Dialysis Patients: Relationship to Compliance and Other Variables. Retrieved from http://www.psychosomaticmedicine. org/content/43/3/271.full.pdf

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APPENDIX-A Proposed Renal Program for Asia Renal Care Rationale 1. To enhance the existing policy or program developed by the management; 2. To improve the health-related quality of life of hemodialysis patients; 3. To maximize the patients health; and 4. To provide safe hemodialysis therapy that is free of preventable complications to each patient.

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Specific Objectives 1. To inculcate knowledge on helping patients achieve their optimal health; 2. To be able to assess the patients learning needs; and 3. To help patients develop better self-care and self-management skills to decrease the impact of disease and prevent future health complications.

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APPENDIX-B Letter of Request to Validate Questionnaire

MR. CARLO BALDERAMA, RN, MSN Charge Nurse, Hemodialysis Unit San Juan De Dios Educational Foundation Hospital, Pasay City

Dear Mr. Balderama,

Please be informed that you are requested to be one of the evaluators of the self-made questionnaire of the Thesis entitled The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program of Ms. Marie Antonette D.O. Tan a Master of Arts in Nursing major in Nursing Administration (MAN-Nursing Admin) candidate.

In this regard, please look into the statement of the problem and the specific objectives if the proposed questionnaire will attain the objectives set-forth by the paper.

Thank You.

Sincerely Yours,

cxlv
(Sgd) DR. ALFONSO H. LORETO Acting Dean

CONFORME

(Sgd) Mr. CARLO BALDERAMA

MR. GYDION NICOLIE BATUIGAS, RN, MSN Faculty, College of Nursing St. Dominic College of Asia, Bacoor, Cavite

Dear Mr. Batuigas, Please be informed that you are requested to be one of the evaluators of the self-made questionnaire of the Thesis entitled The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program of Ms. Marie Antonette D.O. Tan a Master of Arts in Nursing major in Nursing Administration (MAN-Nursing Admin) candidate.

In this regard, please look into the statement of the problem and the specific objectives if the proposed questionnaire will attain the objectives set-forth by the paper.

Thank You.

Sincerely Yours,

(Sgd) DR. ALFONSO H. LORETO Acting Dean

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CONFORME

(Sgd) Mr. GYDION NICOLIE BATUIGAS

APPENDIX-C Letter of Request to Conduct a Pilot Study

Letter of Request Kenny Lou Urmaza Head Nurse, Hemodialysis Section Greetings! I hope this letter reaches you in high spirits and good health.

I, Marie Antonette D.O. Tan, candidate of Master of Arts in Nursing major in Nursing Administration is conducting a research on the topic: The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program. In this view, I would like to seek your permission to allow me to conduct my pilot study at the Hemodialysis Section of the University of Perpetual Help Medical Center that the current research will help me obtain Master of Arts in Nursing major in Nursing Administration. Your favorable response will be highly appreciated.

Thank You.

cxlvii
Very respectfully yours,

(Sgd) MARIE ANTONETTE O. TAN, RN Candidate, MAN

Recommending Approval:

(Sgd) ATTY. IRINEO F. MARTINEZ JR., Ph.D. Dean, Graduate School

APPENDIX-D Letter of Request to Conduct a Study in the Research Locale

Letter of Request

To: DRA. LYN GOMEZ Medical Director Asia Renal Care, Alabang, Muntinlupa City Thru: MR. ALERT P. GAUTANI Charge Nurse Asia Renal Care, Alabang, Muntinlupa City Dear Dra. Gomez; Greetings! I am currently enrolled in thesis writing as a final requirement for the degree Master of Arts in Nursing major in Nursing Administration in the University of Perpetual Help System DALTA - Las Pias. My research problem is entitled The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Program. The focus of the study is to assess the quality of life of hemodialysis pa tients and identify their coping strategies to serve as a basis for constructing a comprehensive renal program. I have been a trainee in your clinic from July 26, 2010 to October 2, 2010 and has been a witness to the protocol of the unit and how you handle hemodialysis patients. In this regard, may I request your earnest approval that I be allowed to conduct my study in your unit so that I can gather information on the quality of life and coping strategies of hemodialysis patients.

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Rest assured that all information will be kept in strict confidentiality. Your favorable response will help me finish my study at the soonest time possible. Thank You.

Respectfully Yours,

(Sgd) MARIE ANTONETTE O. TAN, RN MAN Candidate

Recommending Approval:

Approved:

(Sgd) ATTY. IRINEO F. MARTINEZ JR., Ph.D. Dean Graduate School

(Sgd) DRA. LYN GOMEZ Medical Director Asia Renal Care

APPENDIX-E Letter to Respondents Letter of Permission

Dear Patients;

Greetings!

I am currently enrolled in thesis writing as a final requirement for the degree Master of Arts in Nursing major in Nursing Administration in the University of Perpetual Help System DALTA - Las Pias. My research problem is entitled The Qualit y of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program. The focus of the study is to assess the quality of life of hemodialysis patients and identify their coping strategies to serve as a basis for constructing a comprehensive renal program.

In this regard, may I request your earnest approval that I be allowed to solicit your opinions and gather information regarding your quality of life and coping strategies.

Rest assured that all information you will give me will be kept in strict confidentiality. Your favorable response will help me finish my study at the soonest time possible. Thank You.

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Respectfully Yours,

(Sgd) MARIE ANTONETTE D.O. TAN, RN Candidate, MAN

Recommending Approval:

(Sgd) ATTY. IRINEO F. MARTINEZ JR., Ph.D. Dean, Graduate School

APPENDIX-F Survey Questionnaire

SURVEY ON THE QUALITY OF LIFE AND COPING STRATEGIES OF HEMODIALYSIS PATIENTS AT ASIA RENAL CARE IN ALABANG
Part I Demographic Profile Direction: Please read and fill out the following as honest as possible. Name (optional): Age: Gender: Civil Status: ___ Single ___ Married ___ Living-In ___ Separated ___ Widowed Educational Attainment: ___ Post Graduate ___ College Graduate ___ Vocational ___ High School ___ Elementary Others, please specify: ____________________ Occupation Before Diagnosis: ___________________________________________________ Current Occupation: ____________________________________________________ Is there a life insurance or savings to support treatment? ___ Yes ___ None ___ Sometimes

cl
Frequency of Dialysis: ___ Once a week ___ Twice a week ___ Thrice a week Part II Assessment of Quality of Life Direction: Please read each question, assess your own health, and rate your quality of life as 5 being the highest and 1 being the lowest. Assessment of the Quality of Life 1. In general, I feel my health is good. 2. I feel my health is poor. 3. I feel physical pain to the extent that it prevents me from what I need to do. 4. I have enough energy for my everyday life. 5. I have the opportunity for leisure activities. 6. I am satisfied with my ability to perform my activities of daily living (ADL). 7. I am satisfied with my capability to work. 8. My physical health interferes with my normal social activities with family, friends, neighbors and groups. 9. I feel physical pain. 10. I feel that physical pain interferes with my normal work (including both outside the home and house work). 11. I can tolerate the pain of needle insertion on my fistula/graft. 12. I am able to sleep well at night. 13. I get tired easily. 14. I feel my life is meaningful. 15. I am satisfied with the amount of time I am able to spend with my family and friends. 16. I am satisfied with the support I receive from my family and friends. 17. I am still able to express my love to my family and friends despite of my disease. 18. I have negative feelings such as despair, anxiety and depression. 19. I feel that kidney disease interferes too much with my life. 20. I feel that too much of my time is spent dealing with my disease. 21. I act irritably toward those around me. 22. I isolate myself from people around me. 23. I have difficulty concentrating or thinking. 24. I am able to concentrate well. 25. I feel that I am a burden to my family. 26. I completely understand the nature of my disease. 27. My kidney disease bothers me in each of the following areas: a. fluid restriction 5 4 3 2 1

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b. dietary restriction c. ability to travel d. sex life and becoming sexually aroused e. soreness in muscles/edema f. cramps g. itchy skin h. dry skin i. lack of appetite 28. In terms of satisfaction with the care I am receiving, I can say that the staff are friendly. 29. I am satisfied with the general systems and overall implementations of protocols of the dialysis center. 30. The staff shows interest in me as a person/patient. 31. Dialysis staff support me in coping with my kidney disease. 32. The machines are efficient and provides adequate treatment. 33. The environment is clean and is a suitable place for treatment. 34. I am satisfied with the cost of the treatment. Part II: Coping Strategies Please check the appropriate coping strategy that you commonly use as a patient. Coping Strategies 35. I participate in religious activities to overcome depression. 36. I accept my disease. 37. I try to keep my life as normal as possible. 38. I think positively. 39. I keep a sense of humor. 40. I think about the good things in my life. 41. I keep myself busy. 42. I keep my feelings under my control. 43. I drink alcoholic beverage to divert my attention of having kidney disease. 44. I am on the process of denial of having a kidney disease. 45. I find out more about the problem. 46. I seek social support. 47. I focus on myself and vent out my feelings or emotions. 48. The coping strategy/ies I chose is effective. Others: 5 4 3 2 1

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PAGSISIYASAT SA KALIDAD NG BUHAYAT STRATEHIYA SA PAGHARAP SA MGA BALAKID NG MGA PASYENTE NGHEMODIALYSIS SA ASIA RENAL CARE, ALABANG
Part I Demograpiya Direksyon: Basahin at sagutan ang mga sumusunod nang tapat sa iyong kalooban. Pangalan (pwedeng hindi isulat): Edad: Kasarian: Estado: ___ Dalaga/Binata ___ May Asawa ___ Hiwalay sa Asawa ___ Byuda/Balo Kasalukuyang Natapos sa Pag-aaral: ___ Tapos ng Masters Degree ___ Tapos ng Kolehiyo ___ Tapos ng Vocational ___ Hayskul ___ Elementarya At iba pa, pakisulat: ____________________ Trabaho Bago Magka-sakit: ______________________________________________ Kasalukuyang Trabaho: _________________________________________________ May kasalukuyan bang kasiguruhan na sumusuporta sa pagpapa-gamot? ___ Meron ___ Wala Dalas ng pagpapa-dialysis: ___ Isang Beses ___ Dalawang Beses ___ Tatlong Beses Part II: Pagsisiyasat sa Kalidad ng Buhay

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Direksyon: Basahin ng mabuti ang mga tanong, suriin mabuti ang kalusugan

Pagsisiyasat sa Kalidad ng Buhay 1. Sa kabuuan, pakiramdam ko ang aking kalusugan ay maayos. 2. Pakiramdam ko ay mahina ang aking katawan. 3. Nakakaramdam ako ng pisikal na sakit sa katawan at umaabot sa puntong hindi ko na magawa ang mga dapat kong gawin. 4. Meron akong sapat na lakas para sa aking pang araw-araw na gawain. 5. May pagkakataon ako para mag-libang. 6. Kuntento ako sa aking kakayahang gawin ang aking mga pang araw-araw na gawain. 7. Kuntento ako sa aking kakayahang mag-trabaho. 8. Ang aking pisikal na pangangatawan ay Nakakasagabal sa aking pakikisalamuha sa aking pamilya at mga kaibigan. 9. Nakakaramdam ako ng pisikal na sakit sa aking katawan. 10. Ang pisikal na nararamdaman kong sakit ng aking katawan ay nakakaapekto sa aking normal na trabaho sa pang araw-araw. 11. Natitiis ko ang tusok ng karayom sa aking fistula/graft. 12. Nakakatulog ako ng maayos at mahimbing sa gabi. 13. Mabilis akong mapagod.. 14. Pakiramdam ko ang buhay ko ay makabuluhan. 15. Kuntento ako sa oras na naibibigay ko sa aking pamilya at mga kaibigan. 16. Kuntento ako sa suportang natatanggap ko mula sa aking pamilya at mga kaibigan. 17. Napaparamdam ko pa rin sa aking pamilya at mga kaibigan ang aking pagmamahal sa kabila ng aking karamdaman. 18. Nakakaramdam ako ng lungkot at kawalang pag-asa sa aking buhay. 19. Pakiramdam ko ay nakakasagabal sa aking buhay ang aking sakit. 20. Nararamdaman ko na buong oras at panahon ko ay aking ginugugol sa aking pagkakasakit. 21. Irritable sa mga nakapaligid sa akin. 22. Hinihiwalay ang aking sarili sa mga taong nakapaligid sa akin. 23. Nahihirapan ako na mag-pokus at mag-isip. 24. Nakakapag-isip ako ng maayos. 25. Nararamdaman kong pabigat ako sa aking pamilya. 26. Nauunawaan ko ang dahilan ng aking pagkaka-sakit. 27. Ako ay nahihirapan sa aking sakit sa mga sumusunod na aspeto:

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a. pag-kontrol sa tubig na iniinom b. pag-kontrol sa mga bawal na pagkain c. kakayahang bumiyahe d. kakayahang makipagtalik e. pamamanas f. kirot ng kalamnan g. pangangati ng balat h. panunuyo ng balat i. kawalan ng ganang kumain 28. Masasabi kong pala-kaibigan ang mga empleyado ng dialysis clinic na ito. 29. Kuntento ako sa pangkabuuang pamamalakad at patakaran sa dialysis clinic na ito. 30. Nagpapakita ng interes sa akin ang mga empleyado ng dialysis clinic na ito. 31. Sinusuportahan ako ng mga staff sa pakikipaglaban sa aking sakit. 32. Ang mga makina para sa dialysis ay umaandar ng maayos at epektibo sa pagsasa-ayos ng pakiramdam ko. 33. Malinis ang kapaligiran at kaaya-aya sa aking pagpapagamot. 34. Kuntento ako sa aking binabayad sa aking pagpapagamot. Part II: Stratehiya sa Pag-harap sa mga balakid Tsekan ang pinaka-angkop na ginagamit na stratehiya sa pagharap sa mga balakid bilang isang pasyente. Stratehiya sa Pag-harap sa mga balakid 5 4 3 2 1 35. Nakikisalamuha ako sa mga relihiyosong gawain para kayanin ang lungkot na nararamdaman. 36. Tanggap ko ang aking pagkakasakit. 37. Ginagawa kong simple ang aking buhay hanggang maaari. 38. Nag-iisip ako ng maganda. 39. Pinapanatili kong magkaroon ng saya sa aking sarili. 40. Iniisip ko ang mga magagandang pangyayari sa aking buhay. 41. Pinapanatili kong madaming gawain sa aking buhay. 42. Kino-kontrol ko ang aking nararamdaman. 43. Umiinom ako ng alak para maibaling ang aking atensyon sa aking pagkakasakit. 44. Kasalukuyang hindi ko pa rin matanggap ang aking pagkakasakit. 45. Hinahanapan ko ng lunas ang mga problema kong nararamdaman. 46. Humahanap ako ng tulong mula sa ibang tao. 47. Ibinabaling ko ang aking atensyon sa aking sarili upang mailabas ang aking emosyon at nararamdaman.

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48. Masasabi kong epektibo ang napili kong stratehiya. At Iba Pa:

APPENDIX-G Certification of Statistical Treatment

May 2, 2012 This is to certify that the thesis / Dissertation entitled The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program of Ms. Marie Antonette D.O. Tan was statistically analyzed by the undersigned.

____Jesus B. Gollayan_____ Statistician

Noted:

Atty. Irineo F. Martinez, Jr., PhD Dean

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APPENDIX-H Certification of Editing

May 2, 2012 This is to certify that the thesis / Dissertation entitled The Quality of Life and Coping Strategies of Hemodialysis Patients at Asia Renal Care: Basis for a Proposed Comprehensive Renal Management Program of Ms. Marie Antonette D.O. Tan was edited / read / by the undersigned.

______Francisco Rivas______ Editor

Noted:

Atty. Irineo F. Martinez, Jr., Ph.D. Dean

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CURRICULUM VITAE

Name Address Gender Date of Birth Place of Birth Civil Status Religion Present Position Office Address

Marie Antonette D.O. Tan 75 Gloria Diaz St. BF Resort Village, Las Pias City Female November 22, 1987 Lucena City, Quezon Single Roman Catholic Executive Assistant to the Medical DIrector 8th Floor ACCRA Law Tower, 2nd Avenue cor 30th St., Bonifacio Global City, Taguig City

EDUCATIONAL BACKGROUND Graduate Studies Master of Arts in Nursing major in Nursing Management University of Perpetual Help System DALTA, Las Pias City Bachelor of Arts in Nursing

Tertiary

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University of Perpetual Help System DALTA, Las Pias City March 2008 Secondary Maryhill College Lucena City, Quezon March 2004 Maryhill College Lucena City, Quezon March 2000

Elementary

TRAININGS ATTENDED o ICD-10 Training for Coders Balay-Kalinaw, UP Diliman Campus, Quezon City February 20-24, 2012 o IV Preceptorship Training St. Dominic Medical Center, Bacoor, Cavite October 4-6, 2011 o Basic Life Support Training Cardinal Santos Medical Center, Greenhills West, San Juan City August 15, 2011 o Salvaging Vascular Access: The Future and Beyond Philippine Heart Center, East Avenue, Quezon City January 30, 2011 o The Anatomy of Nursing Malpractice Acts University of Perpetual Help System DALTA Health Tower Las Pias October 12, 2010 o Dialysis Nursing University of Perpetual Help System DALTA, Las Pias September 28, 2010 o Nurse Entrepreneurship: Alternative Road to Success University of Perpetual Help System DALTA, Las Pias September 28, 2010 o Hemodialysis Nurse Training Asia Renal Care Philippines, Alabang Branch July 26, 2010 to October 2, 2010

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o Values Integration in Different Learning Areas Towards Human Capital Development University of Perpetual Help System DALTA Health Tower, Las Pias July 24, 2010 o Coping with the Unexpected: Care for Those with Chronic and Life Threatening Ilnesses Asian Hospital and Medical Center March 25, 2010 o Graduate School of Education: The Core of Excellence University of Perpetual Help System DALTA Health Tower Las Pias February 20, 2010 o Cardiac Disorders Affecting the Young University of Perpetual Help Dalta Medical Center, Las Pias City August 6, 2009 o Intravenous Therapy Training Las Pias City Medical Center March 16-18, 2009 EXAMINATIONS PASSED o Registered Nurse, Philippines o Passed the Hemodialysis/ Renal Nurse Certification, conducted by the Renal Nurses Association of the Philippines (January 2011 accreditation) WORK EXPERIENCES Executive Assistant to the Medical Director LifeScience Center for Wellness and Preventive Medicine Fort Bonifacio, Global City October 27, 2011 to Present Staff Nurse LifeScience Center for Wellness and Preventive Medicine Fort Bonifacio, Global City March 1, 2011 to October 27, 2011 Hemodialysis Nurse Asia Renal Care Philippines Alabang Town Center, Alabang, Muntinlupa City

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July 26, 2010 to October 2, 2010 Customer Service Representative APAC Customer Services, Inc. Alabang, Muntinlupa City July 28, 2008 to July 7, 2010