Comfort and Fluid Retention in Adult
Patients Receiving Hemodialysis
Karen M. Estridge
Diana L. Morris
idney failure with subsequent
K
hemodialysis (HD) is not only
disruptive to lifestyles of
patients and families, but also
has concerning financial implications.
Decreasing the burden of treatments,
such as fluid restrictions for patients
with end stage renal disease (ESRD),
with the potential of improving
adherence may improve quality of
life and extend the lifespan.
Adherence to fluid restrictions is
difficult for patients receiving HD
(Welch, 2001). Adherence can
demand major lifestyle modifications
because of the many restrictions
imposed by the treatment regimen,
not only in one’s physical routines,
but also in aspects of imposed social
interruptions that can impact quality
of life (Tovazzi & Mazzoni, 2012).
Nonadherence to fluid restrictions
among patients receiving HD, lead-
ing to fluid retention between treat-
ments, may result in increased co-
morbidities and death. Research has
been inconclusive in determining
options to enhance adherence to fluid
restrictions in adult patients receiving
HD. There is a lack of knowledge
about which factors affect this popula-
tion’s health-seeking behaviors relat-
ed to fluid restriction adherence.
Karen M. Estridge, DNP, RN, is an Assistant
Professor, Assessment Coordinator; College of
Nursing and Health Sciences, Ashland University,
Ashland, OH.
Diana L. Morris, PhD, RN, FAAN, FGSA, is
an Associate Professor, Director of the University
Center on Aging and Health; Frances Payne Bolton
School of Nursing, Case Western Reserve
University, Cleveland, OH.
Katharine Kolcaba, PhD, RN, is an Associate
Professor, Emeritus; School of Nursing, University
of Akron, Akron, OH.
Chris Winkelman, PhD, APRN, CCRN,
CNE, FCCM, FAANP, is an Associate Professor;
Frances Payne Bolton School of Nursing, Case
Western Reserve University, Cleveland, OH.
Nephrology Nursing Journal January-February 2018
Continuing Nursing
Education
Katharine Kolcaba
Chris Winkelman
Copyright 2018 American Nephrology Nurses Association.
Estridge, K.M., Morris, D.L., Kolcaba, K., & Winkelman, C. (2018). Comfort and fluid
retention in adult patients receiving hemodialysis. Nephrology Nursing Journal, 45(1),
25-33, 60.
Successful hemodialysis treatments for patients with renal failure depend on patient
adherence to prescribed treatment regimens. Lack of adherence may contribute to patient
discomfort between hemodialysis treatments. This article reports a descriptive, correla-
tional feasibility study that utilized Kolcaba’s Comfort Theory as a framework. The pur-
pose of the study was to determine a potential relationship between comfort and fluid
retention (a proxy for adherence) in adults with end stage renal disease receiving
hemodialysis. A convenience sample of 51 patients receiving hemodialysis was studied.
Comparisons of patient weight gain between hemodialysis treatment sessions measured
fluid retention by proxy. Results indicated no significant relationship between the vari-
ables of comfort and adherence to fluid restrictions. However, this finding has potential
to support clinical practice to minimize weight gain to sustain comfort. Awareness of
comfort as a consideration for adherence to prescribed treatment regimens may help
nurses coach individuals to improve treatment adherence.
Key Words: Hemodialysis, comfort, adherence, interdialytic weight gain.
Further examination about this United States. According to the 2017
aspect of treatment for kidney failure is annual report by the United States
needed to inform potential new oppor- Renal Data System (USRDS), there
tunities for intervention. Therefore, were over 703,243 prevalent ESRD
this project sought to answer the fol- cases, which is an increase of 3.4%
lowing research question: What is the from the previous year. Of those
relationship between comfort and fluid cases, 63.3% were treated with HD
retention among adults receiving therapy. There was also an increased
chronic HD? Based upon the theoreti- incidence of newly reported cases of
cal framework and literature, we ESRD that reached 124,114 in 2015.
hypothesized that patients with greater For year 2015, estimated Medicare
comfort would be associated with a spending for patients with chronic kid-
lower fluid retention. ney disease (CKD) and ESRD aged
65 years and older exceeded $98 bil-
lion (USRDS, 2017).
Problem
One major contributor to CKD
The number of patients undergo- and ESRD costs is the failure of
ing HD continues to increase in the patients to follow prescribed treat-
Acknowledgement: The authors would like to thank Dr. Jacqueline K. Owens for her kind and invaluable
assistance with manuscript preparation and editing.
Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this
continuing nursing education activity.
Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can
be found on page 34.
Vol. 45, No. 1 25
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
Conceptual Framework for Comfort Theory
Healthcare
Needs of Comforting
Patient/ Interventions
Family
Source: Kolcaba, 2007b. Used with permission.
ment regimens. Poor patient adher-
ence is a serious problem that leads to
medical, social, emotional, and eco-
nomic consequences that could ulti-
mately compromise empirically
based treatment guidelines (Howren
et al., 2016). The meta-analysis by
Welch and Thomas-Hawkins (2005)
was inconclusive in determining suc-
cessful options to avoid fluid retention
and promote fluid restriction adher-
ence in patients receiving chronic
HD, and noted insufficient data avail-
able to inform clinical practice guide-
lines. Tovazzi and Mazzoni (2012)
suggested that adherence to restric-
tions includes individual motivations,
mental control, and patient experi-
ences, including time and a support
system.
Theoretical Framework
The guiding framework for this
preliminary feasibility study was
Kolcaba’s (1994) Comfort Theory.
Comfort is essential for all persons,
especially those with healthcare
needs. Kolcaba (1991) defined com-
fort through the domains of ease,
relief, and transcendence in physical,
psychospiritual, environmental, and
sociocultural contexts. Increased
comfort for patients receiving HD
26
Figure 1
Kolcaba’s Conceptual Framework
Health-
Intervening Enhanced
Seeking
Variables Comfort
Behavior
Internal Peaceful
Behaviors Death
may lead to improved adherence to
fluid restrictions by these individuals
as needs are addressed or met.
Kolcaba’s (2007b) Comfort Theory
suggests that increased comfort leads to
health-seeking behaviors in the popula-
tion receiving HD. Positive patient out-
comes may include improved adher-
ence, decreased dialysis times, reduced
dialysate usage, decreased nursing
hours, and overall improved lived
experience for patients. As a result,
improved institutional outcomes of
reduced co-morbidity and mortality
rates could occur (see Figure 1).
Kolcaba (2003) stated that “adopting
the Theory of Comfort will demon-
strate that institutions with higher nurs-
ing staffing, professional atmosphere,
and patient-oriented value systems are
more likely to achieve financial and
health-related goals” (p. 153).
Literature Review
Multiple studies have been conduct-
ed related to Comfort Theory. Kolcaba
and associates have studied patients in
hospice care (Kolcaba, Dowd, Steiner,
& Mitzel, 2004; Vendlinski & Kolcaba,
1997), those with early stage breast can-
cer (Kolcaba & Fox, 1999), patients with
chronic urinary bladder syndrome
(Dowd, Kolcaba, & Steiner, 2000), and
Nephrology Nursing Journal
Best
Practices
Institutional
Integrity
Best
Policies
External
Behaviors
those undergoing end of life experi-
ences (Novak, Kolcaba, Steiner, &
Dowd, 2001). Additional studies consid-
ered holistic comfort in perianesthesia
patients (Wilson & Kolcaba, 2004), pro-
tocols in pediatric patients (Kolcaba &
DiMarco, 2005), hand massage in nurs-
ing home residents (Kolcaba, Schirm, &
Steiner, 2006), and comparison of
touch, coaching, and interventions in
college students (Dowd, Kolcaba,
Steiner, & Fashinpaur, 2007). In these
studies, comfort interventions produced
positive correlations with various
health-seeking behaviors.
Davison and Jhangri (2010) sur-
veyed 591 patients receiving HD and
concluded that symptom burden in
patients with ESRD was substantial
with a tremendous impact. Approxi-
mately 50% of patients with ESRD
experienced chronic pain, with 82%
reporting this pain as having moder-
ate to severe intensity. Bourbonnais
and Tousignant (2012) studied 25
patients receiving outpatient HD and
found that actual discomfort could be
categorized into 4 themes: physical
(procedural and joint pain), clinic dis-
comfort (chairs, temperature), emo-
tional and social pain (time sacrifice
and isolation from lengthy treat-
ments), and managing pain in the
context of the dialysis unit (seeking
January-February 2018 Vol. 45, No. 1
comfort measures during HD treat-
ments). The more fluid retention
patients experienced, the longer the
actual dialysis treatment, and thus,
more discomforts. They further found
that unresolved discomforts can have
a profound effect on patients’ willing-
ness to continue dialysis or other
treatment regimens.
Factors identified in the literature
have suggested why patients receiving
HD may not practice adherence to
prescribed fluid regimens. For exam-
ple, Kugler, Maeding, and Russell
(2011) conducted a cross-sectional,
multicenter, comparative study of 456
adult patients receiving HD in 12 out-
patient HD clinics. This study con-
cluded that nonadherence persists as
one of the most challenging tasks for
patients with chronic conditions, sug-
gesting that patient condition-related,
socioeconomic, and healthcare sys-
tem-related factors may contribute to
nonadherence to diet and fluid restric-
tions.
In relation to HD and the impact
on comfort, a study by Kutner,
Zhang, McClellan, and Cole (2002)
found an association of three psy-
chosocial variables that also impacted
adherence during treatment to which
the patients consented. Variables
included little or no perceived control
over future health, depression, and
perceived effects of kidney disease on
daily life.
It is evident that adherence to fluid
restrictions is difficult and can lead to
negative outcomes. Adherence can
impact care, patient comfort, and ulti-
mately, institutional outcomes, includ-
ing costs for this population. The pur-
pose of this study was to determine
the relationship between comfort and
fluid retention (a proxy for adherence)
in adults with ESRD who receive HD.
Methods
Design
The study was a descriptive, corre-
lational, cross-sectional design. This
feasibility study sought to determine if
a relationship existed between the
two variables of adherence to fluid
restrictions (measured via fluid reten-
tion) and comfort.
Setting
The study was conducted at two
for-profit dialysis clinics in the
Midwest of the United States. Both
clinics were proximately located,
managed by the same corporation,
and shared a medical director and
upper level administrative team. The
clinics were housed in free-standing,
single-story buildings with surround-
ing private parking lots and easy
entry access for patients. Patients
reported for treatments three days per
week with varying shifts. Most HD
treatments lasted approximately four
hours.
Sample
A convenience sample of adults
with ESRD was enrolled. Eligibility
criteria included persons aged 18 years
or older who received HD treatments
in one of two dialysis clinics in the
Midwest. Participants were required
to obtain a score of at least 8 of 10 on
the Short Portable Mental Status
Questionnaire (SPMSQ), a brief ques-
tionnaire to assess patients for organic
brain dysfunction (Pfeiffer, 1975); have
decisional capacity; and possess the
ability to read. Co-morbidities (dia-
betes, hypertension, lung disease,
heart disease, or primary renal disease)
were permitted and recorded. Ex-
clusion criteria were weight greater
than 500 pounds and/or patients who
experienced an acute event (new onset
influenza, dialysis-related conse-
quences requiring non-typical, intense
care) on a day of data collection.
Variables
Comfort. The operational defini-
tion of comfort was the score on a
Likert-type scale using Kolcaba’s
(2007c) General Comfort Question-
naire (GCQ), adapted for this popula-
tion per Kolcaba’s (2007a) guidelines
(see Figure 2). The instrument for this
study contained 48 self-report items.
Responses to items were scored on a
6-item Likert scale ranging from 6
(strongly agree) to 1 (strongly dis-
agree). Higher scores reflect higher
levels of comfort. Twenty-five nega-
tively worded questions appeared on
the questionnaire to reduce response
bias. The questionnaire was adminis-
tered at the beginning of the study to
determine the comfort level for each
participant.
Previous reliability testing of
Kolcaba’s General Comfort Ques-
tionnaire yielded a Cronbach’s alpha
of 0.88 (Kolcaba, 1992). The adapted
Hemodialysis Questionnaire yielded a
Cronbach’s alpha of 0.85. The reading
level of the tool was grade 2.5 accord-
ing to the Flesch-Kincaid Grade Level
via Microsoft Windows 2007
(Microsoft Corporation, 2007).
Fluid retention. Fluid retention as
a proxy for adherence was opera-
tionally defined as the patient’s inter-
dialytic weight gain (IDWG) of 2.5
kilograms (kg) or less during the week
and 3.5 kg or less over a 2-day week-
end or holiday period, as suggested by
the study dialysis clinics. The mean
was calculated by averaging the
IDWG of visits over the 2-week study,
excluding holidays. The IDWG was
measured as the amount of weight
gained between the conclusion of one
dialysis treatment and the beginning
of the next dialysis treatment. Welch
(2001) reported that although the
weight gain criterion for nonadher-
ence varies among studies, generally,
daily weight gain greater than 1 kg to
1.5 kg is considered in excess.
López-Gómez, Villaverde, Jofre,
Rodriguez-Benítez, and Pérez-García
(2005) defined IDWG as “mainly the
result of salt and water intake between
two dialysis sessions” (p. S-63). López-
Gómez and colleagues (2005) also
noted that IDWG varies between
patients but is a common method of
measuring compliance/adherence.
Ideally, when patients receiving
chronic HD followed the prescribed
fluid restriction regimen, the patient’s
IDWG should not increase beyond
expected parameters as determined
by the physician. Fluid retention was
measured by pre-HD and post-HD
weight measurements in increments
of 0.1 kg via electronic scale.
Demographic items. The pri-
mary investigator (PI) created a

Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 27

Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis

Figure 2
Adapted General Comfort Questionnaire
demographic tool consisting of 16
items, found in Table 1. Items includ-
Hemodialysis Questionnaire
ed age; sex; race, marital status; edu-

1. My body is relaxed right now.

cation level; history of HD treat-
ments, fluid intake, salt intake via
2. I feel useful because I’m working hard. consumed foods, and urinary output;
3. I have enough privacy. health insurance; and co-morbidities.
4. There are those I can depend on when I need help.
5. I don’t want to exercise.
6. My condition gets me down.
Protection of Human Subjects
7. I feel confident.
The study commenced upon ap-
8. I feel dependent on others.
proval from the university’s and dial-
9. I feel my life is worthwhile right now.
ysis setting’s Institutional Review
10. I am inspired by knowing that I am loved.
Boards (IRBs). All participants re-
11. These surroundings are pleasant.
ceived three weekly HD treatments at
12. The sounds keep me from resting.
one of two dialysis clinics in the
13. No one understands me.
Midwest. Patients were approached
14. My pain is difficult to endure.
two weeks prior to the study and
15. I am inspired to do my best.
informed of the opportunity to partic-

16. I am unhappy when I am alone.

ipate. Signed consent was obtained at

17. My faith helps me to not be afraid.

that time.

18. I do not like it here.

19. I am swollen right now.
Procedure
20. I do not feel healthy right now.
21. This room makes me feel scared.
The Hemodialysis Questionnaire

22. I am afraid of what is next.

was adapted according to instructions

23. I have a favorite person(s) who makes me feel cared for.

provided on Dr. Kolcaba’s website
(Kolcaba, 2007a). To establish face
24. I have experienced changes which make me feel uneasy. validity of the adapted comfort tool,
25. I am hungry. two authors (Estridge and Kolcaba),
26. I would like to see my doctor more often. reviewed each question for clarity.
27. The temperature in this room is fine. Prior to administration of the
28. I feel very tired. Hemodialysis Questionnaire, the sur-
29. I can rise above my pain.
veys (Hemodialysis Questionnaire
30. The mood around here uplifts me.
and demographic questionnaire) were
31. I am content.
piloted with seven patients at a similar
32. This chair (bed) makes me hurt.
HD clinic in the Midwest.
33. The view inspires me.
We anticipated that some patients
34. I am thirsty.
might need assistance due to the
35. I feel out of place here.
number of items on the Hemodialysis
36. I feel good enough to walk.
Questionnaire and completing the
37. My friends remember me with their cards and phone calls.
questionnaire during their HD treat-

38. My beliefs give me peace of mind.

ment. The PI also developed a proto-

39. I need to be better informed about my health.

col to use should a participant request

40. I feel out of control.

assistance in completing the surveys.

41. I feel crummy because I am bored.

The protocol included individual

42. This room smells terrible.

assistance by the PI at the bedside,

43. I am alone, but not lonely.

instructions for reading questions to

44. I feel peaceful.

the subjects if necessary, and offering

45. I am depressed.
a large-print visual card to assist in
readability and understanding of the
46. I have found meaning in my life.
47. It is easy to get around here.
survey’s Likert scale.
Approximately 80% of partici-
48. I need to feel good again. pants required at least some assis-

Note: Adaptations from the original GCQ are bolded.

tance to complete all items in the sur-

Source: Tool created by Karen M. Estridge; adapted from Kolcaba, 2007a.

veys; this may be because all patients
were connected to the HD machines

28 Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1

 Table 1
Demographic Data of Sample

Mean 64 years
Median 65 years
Age
Youngest 44 years
Oldest 87 years
Male 28 (54.9%)
Sex
Female 23 (45.1%)
Married 21 (41.2%)
Never married 6 (11.8%)
Single (living with someone) 3 (5.9%)
Marital status
Separated 2 (3.9%)
Divorced 14 (27.5%)
Widowed 5 (9.8%)
Caucasian 24 (66.7%)
Race African American } other 15 (29.4%)
American Indian } other 2 (3.9%)
Less than 8 years 2 (3.9%)
High school or equivalent 35 (68.6%)
Vocational/technical degree 9 (17.6%)
Education level
Bachelor’s degree 2 (3.9%)
Master’s degree 1 (2.0%)
“Other” 2 (3.9%)
Employed 36 hours/week 1 (2.0%)
Employed 16 to 35 hours/week 3 (5.9%)
Employment status Unemployed 5 (9.8%)
Unable to work 25 (49%)
Retired 17 (33.3%)
Medicare/Medicaid 51 (100%)
Payment source
Additional insurance (non-exclusive) 23 (46%)
Cardiovascular disease 47 (92.2%)
Diabetes mellitus 29 (56.9%)
Diseases/other conditions (non-exclusive) Lung disease 5 (9.8%)
Other 12 (23.5%)
More than one medical condition 35 (68.8%)
Received treatments 4 months to 1 year 15 (29.4%)
Received treatments 2 to 5 years 29 (56.9%)
Treatment history
Received treatments more than 6 years 5 (9.8%)
Other 2 (3.9%)
3 hours in length 4 (7.8%)
More than 3, but fewer than 4 hours 22 (43.1%)
Treatment session duration
4 hours 20 (39.2%)
More than 4 hours in length 5 (9.8%)

Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 29

Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis

Table 2
Participants’ Salty Food Consumption

• Potato chips, corn chips, pretzels 13 (25.5%)

• Pickles, canned meats, clam soups, salty fish 18 (35.5%)
Foods consumed
• Frozen, prepared meals 4 (7.8%)
greater than once weekly
• Packaged meat, cheese, prepared pasta 23 (45.1%)
• Salty meat: hot dogs, deli lunch meats, sausage 16 (31.4%)
• Less than 8 ounces 5 (9.8%)
• Up to 16 ounces 9 (17.6%)
Daily fluid intake • Up to 24 ounces 12 (23.5%)
• UP to 32 ounces 15 (29.4%)
• Greater than 32 ounces 10 (19.6%)
• 0 ounces 1 (21.6%)
Daily urinary output • 4 to 8 ounces 19 (37.3%)
• Greater than 8 ounces 21 (41.2%)

during data collection and eagerly
accepted the offer of help. The PI fol-
lowed the protocol to provide assis-
tance. No missing data were noted
because of assistance from the PI with
survey completion.
Data Management
Data were entered into the
Statistical Package for the Social
Sciences (SPSS) – 19 (SPSS for
Windows, Rel. 19.0., 2010) for analy-
sis. Correlations were calculated
between the summed one-time com-
fort scores and mean IDWG, as meas-
ured over a period of four weeks.
Planned Analysis
All data were planned to be sum-
marized by means (ratio level) and
frequencies (interval, ordinal, and
nominal level) as appropriate. A test
of association was planned for the
study’s single research question:
What is the relationship between
comfort and fluid retention among
adults receiving HD? This was an
early feasibility study with no previ-
ous reports in the literature, so a test
of association was a reasonable
approach. Both variables (comfort
and IDWG) were ratio level; thus,
Pearson’s r was the best test of associ-
ation. If assumptions for this test sta-
tistic (i.e., linearity, outliers/extreme
values, and restriction of range) were
not met, we planned to use a
Kendall’s rank test to ensure viola-
tions of assumptions around Pearson’s
would not lead to erroneous results.
Secondary analysis of selected
patient characteristics to determine if
there were differences in either com-
fort or IDWG were also undertaken
using independent t tests. Assumptions
for this test statistic were examined (the
need for a correction when unequal
variances occurred) were undertaken
to yield optimal results.
Results
Sample
Fifty-one adult subjects participat-
ed in this study. Demographic infor-
mation was obtained to describe per-
sonal characteristics and lifestyle
related to being a patient receiving
HD. Complete demographic infor-
mation is presented in Table 1.
The demographic survey also
included questions about dietary habits
that may contribute to IDWG. There
were seven items related to food intake,
fluid intake, and urinary output. These
data are summarized in Table 2.
Regarding usual comfort and/or
discomfort, 13 (25.5%) subjects took
prescription medications for pain
more than once daily. Subjects were
also asked about the number of edu-
cational sessions they received
regarding fluid restrictions. Twenty-
four (47.1%) received less than 5 ses-
sions, 11 (21.6%) received 6 to 9 ses-
sions, 9 (17.6%) received 10 or more
events, 5 (9.8%) were not sure of the
number of educational events, and 2
(3.9%) did not know if they had
received any education.
Comfort
The Hemodialysis Questionnaire,
used to measure comfort, contained
48 self-report, comfort-related items
as described above. The maximum
obtainable comfort score was 288. In
this sample, total comfort scores
ranged from 146 to 258, with a mean
score of 203.25 (standard deviation
[SD]=26.09) and median score of
202.00 (see Table 3).
Interdialytic Weight Gain
Subjects were weighed prior to
and immediately following each treat-
ment per clinic policy. Subjects’
weights were extracted from patient
charts for measurement from two
weeks immediately prior to the
administration of the Hemodialysis
Questionnaire to avoid any
Hawthorne effect, bias, or change in
routine by participants. Holidays and

30 Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1

 Table 3
Comfort Scores of Participants

Minimum Score Maximum Score Mean Score Standard Deviation

Total Sample 146 243 203.25 26.09
Male 146 243 201.68 25.79
Female 150 242 205.17 28.89

Table 4
Participant Interdialytic Weight Gain (IDWG) in Kilogram by Sex

Minimum IDWG Maximum IDWG Mean IDWG Standard Deviation

Total Sample 0.92 5.80 2.71 1.10
Male 1.03 5.81 2.83 1.20
Female 0.92 4.93 2.55 0.97

Table 5
Participant Interdialytic Weight Gain (IDWG) in Kilogram by Race

Mean IDWG Standard Deviation

Total Sample
significance was demonstrated in
2.71 1.10 comfort reported between Whites
Caucasian (N=34) 2.49 1.00
and nonwhites (t=0.266; df=44.85;

Other (N=17) 3.14 1.17

extended weekends were avoided to
preserve subjects’ normal pattern of
weight gain. The average IDWG
ranged from 0.92 to 5.8 kg. The mean
average weight gain was 2.71 kg, with
an SD of 1.1. Table 4 reports weight
gain overall and by sex.
Hypothesis Testing
The association between comfort
and fluid retention was not significant
(r=0.028; p=0.844). Scatter plots indi-
cated a restricted range in weight
gain, and restricted ranges of vari-
ables may deflate the correlation
value; thus, a Kendall’s tau (rank) was
undertaken. This test does not have
an assumption around data distribu-
tion. Kendall’s rank analysis was also
insignificant (r=0.01; p=0.909). The
confidence interval (CI) was small
and crossed zero, further supporting
no effect. Assuming an insignificant
effect size of less than 0.10 (0.09), this
preliminary feasibility study had a
power of 59.5% to detect an associa-
tion between comfort and IDWG.
Secondary Analyses
To further understand how patient
characteristics may relate to comfort
and IDWG, we undertook additional
analyses. We investigated correlations
between sex and race with comfort
scores because both women and non-
Whites have different expectations
related to comfort and healthcare out-
comes (fluid-related weight loss) in
the literature (Novak et al., 2001;
Zhang & Baik, 2013).
Gender and comfort. Women
rated comfort slightly higher (n=23;
M=205.17; SD=26.89) compared to
men (n=28; M=201.68; SD=25.79).
An independent t test indicated there
was no significant difference based on
sex regarding comfort (t=0.472;
df=49; p=0.639).
Race and comfort. Summary
data revealed the mean comfort score
for Whites at 204.47 (SD=19.25) and
all others at 202.65 (SD=229.12).
These differences were tested with an
independent samples t test, and no
p=0.791).
Gender and weight gain. The
mean IDWG was 2.55 kg for women
and 2.83 kg for men, further detailed
in Table 4. Independent samples t test
supported a finding of no significant
difference between weight gain in
women compared to men (t=0.362;
df=49; p=0.364).
Race and weight gain. For com-
parison purposes related to race, non-
whites included African Americans
(n=15) and Native Americans (n=2).
The IDWG for Whites (n=34;
M=2.49 kg; SD=1.00) was lower than
the IDWG for nonwhites (n=17;
M=3.14 kg; SD=1.17). These results
are summarized in Table 5. An inde-
pendent t test for differences for
IDWG for race was significant
(t=1.106; p=0.015). There was a signif-
icant difference in weight gain, with
nonwhites gaining more weight
between dialysis treatments in this
sample.
Discussion
There was no significant relation-
ship between comfort and IDWG.
This finding was different than what

Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 31

Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
we hypothesized based on Kolcaba’s
theory. Although results were not sta-
tistically significant, this finding has
potential clinical importance. Com-
fort Theory suggests that as persons
pursue comfort interventions, they
also engage in health-seeking behav-
iors (Kolcaba, 2003). In a study by
Smith and colleagues (2010), psycho-
logical factors, physical factors,
beliefs, attitudes, self-efficacy, and
environmental factors affected pa-
tients receiving HD and adherence to
fluid restrictions. A pattern of seeking
healthy behaviors was not strongly
supported in this preliminary study.
This study’s results are similar to
Welch’s (2001) study results, which
determined that successful adherence
to treatment regimens was influenced
by patient willingness (or not) to fol-
low restrictive and often uncomfort-
able lifestyle changes. Study results
offer evidence to support current clin-
ical practice to minimize IDWG to
sustain comfort.
Specifically, data did not support
the assertion that subjects with the least
weight gain had greater association
with comfort or vice versa. In this
study, correlations between comfort
scores and weight gain were very
small, ranging from 0.01 to 0.28, indi-
cating a small rather than moderate
effect size. These small correlations and
lack of significance initially suggested
that comfort and IDWG of an average
of 3 kg were not related. However,
because most patients were dialyzed at
2- to 3-day intervals, and averaged a
weight gain of 3 kg between dialysis
periods, it is not surprising that patients
did not report a change in comfort. The
mean IDWG in this study (2.7 kg) is
very close to guidelines suggested for
patient management (i.e., 2.5 kg is the
goal). It may be that an average of
under 3 kg of weight gain is not suffi-
cient to be associated with a decrease in
comfort; it is a weight gain that neither
increases nor decreases comfort.
Alternatively, this study was under-
powered, and a larger sample size or
one with a wider range of weight gain
may yield significant associations
between comfort and IDWG.
Secondary analyses did not sup-
32
port a difference in reports of comfort
between sexes; comfort was similar
between women and men. Similarly,
self-reported comfort was compara-
ble between Whites and non-Whites.
This is somewhat different than what
has been reported in the literature
and may be specific to the sample of
patients with ESRD and receive HD
regularly. Further, there was no signif-
icant difference between men and
women in the IDWG.
One recent report indicates men
are more likely to have a greater
IDWG (Artan et al., 2016). In our
study, men and women had similar
IDWGs. It may be because our study
was underpowered to detect this dif-
ference or that these subjects were
more compliant/adherent to treat-
ment because they had weight
changes close to clinical goals.
The only significant finding was
that Whites had a significantly
reduced IDWG compared to non-
whites. In this sample, Whites had an
average IDWG at the clinical goal of
less than 2.5 kg between HD treat-
ments. However, the difference of
0.65 kg IDWG may not be clinically
important, and the average of 3.14 kg
IDWG in nonwhites is very close to a
20% variation (considered reasonable
in many patient-centered outcomes).
It is not clear if the clinical goal of 2.5
kg was based on a homogenous or
heterogeneous population. The clini-
cal implication for nurses who spe-
cialize in dialysis treatment is that
non-Whites may need more educa-
tion or increased effort around self-
management approaches to help
them achieve clinical goals.
Limitations
The greatest limitations of this fea-
sibility study were its preliminary
nature and the convenience sam-
pling. As a preliminary study, it was
not powered adequately to detect dif-
ferences in comfort. However, an
effect size can now be used to deter-
mine sufficient sample size for future
studies. Convenience sampling may
limit generalizability. Subjects were
fairly homogenous, self-selected, and
voluntarily reported dietary and fluid
Nephrology Nursing Journal
intake. Finally, patients who were less
successful in adhering to fluid restric-
tion guidelines may have opted out of
this study.
Other potential limitations includ-
ed a possible bias in subject responses
from overhearing socially desirable
responses by other participants.
Question fatigue due to the number
of items (48 questions with six possi-
ble responses on the Hemodialysis
Questionnaire) may have contributed
to the narrow range of results. In
addition, scheduling practices and
clinic policy sometimes meant
patients were at the facility much
longer than the scheduled HD treat-
ment, which may also have con-
tributed to subject fatigue.
Implications for Clinical
Practice
Consistent with Kolcaba’s (2003)
theory, determining patient health-
care needs, providing comfort inter-
ventions, identifying challenges, set-
ting goals to establish health-seeking
behaviors, and instituting supportive
nursing actions to promote well-being
will lead to best practices in providing
comfort measures to patients receiv-
ing HD. It is yet to be determined if
enhanced long-term comfort because
of following restricted fluid intake
guidelines will occur. Awareness of
unique comfort needs as a considera-
tion for adherence to prescribed treat-
ment regimens may help nurses
coach individuals with ESRD.
Ghimire, Castelino, Lioufas,
Peterson, and Zaidi (2015) and Zhang
and Baik (2013) suggest significant
findings of an IDWG difference in the
context of race. This finding, and the
call from Frazão and colleagues
(2015) for individualized education,
may offer implications for practice
helpful to address various patient dis-
parities. Specific implications for clin-
ical practice resulting from this cur-
rent study include:
• Increase nurse awareness about
potential population differenc-
es. With increased awareness of
potential differences in comfort
and adherence needs, nurses can
individualize interventions to sup-
January-February 2018 Vol. 45, No. 1
 port difficult treatment regimens.
More precise nursing interventions
that include variables, such as cul-
tural practices or food preferences
of different races, may help in-
crease adherence.
• Consider comfort care specifi-
cally with respect to adherence
to difficult regimens. Careful
evaluation of comfort care tenets,
specifically as they may impact
adherence, may assist vulnerable
patients to achieve better out-
comes. According to the Comfort
Theory, holistic comfort is the
immediate experience of being
strengthened through ease, relief,
and transcendence (Kolcaba,
2003). Nurses providing HD must
accurately assess specific individ-
ual patient comfort needs because
these may vary by race, ethnicity,
or other patient lifestyle practices.
This holistic comfort may empow-
er patients receiving HD to
improve self-care and increase
adherence to fluid restrictions.
• Continue to set weight gain
goals during HD to minimize
IDWG. It is important to learn that
a weight gain of 2.7 kg (average)
between dialysis treatments is not
associated with comfort/discom-
fort. This finding begins to establish
the mid-to-upper value of weight
gain that may impact comfort.
It is important for nurses to
explore individual characteristics and
needs to effectively plan care with
patients struggling to address difficul-
ties of managing fluid intake (Tovazzi
& Mazzoni, 2012). By intentionally
learning more about each patient,
including personal responses and
overall comfort status, nurses provid-
ing HD may better target unique
aspects of nursing care to meet each
patient’s needs.
Conclusion and Recommendations
for Further Research
Further studies about patients
receiving HD based on Comfort
Theory are necessary to determine
relevant nursing interventions to sig-
nificantly impact comfort for this pop-
Nephrology Nursing Journal January-February 2018
ulation. This study yields preliminary
results that support the clinical goal of
gaining about 1 kg/day of no dialysis.
It would be interesting to study the
outliers in future research because
extremely high (6 to 7 kg) or low (less
than 2 kg) weight gainers may have
different perceptions of comfort.
Expanding the study to include
eight or more weeks of IDWG meas-
urement may help accurately deter-
mine a potential relationship between
comfort and adherence to fluid restric-
tions. In addition to extending the
duration of measurement, repeated
Hemodialysis (comfort) Question-
naires would provide additional infor-
mation about adherence of patients
receiving HD and accompanying val-
ues of comfort. Studies that include
numerous HD clinics with greater
numbers of subjects would provide
useful data to assist nurses to more
accurately provide supportive care to
this population of patients.
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continued on page 60
33
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awareness of comfort as a consideration for patients on hemodialysis Aji, L., & Beck, D. (2017). Effect of fluid status on access blood flow measure-
to help improve treatment adherence. ments as observed in a hospital-based hemodialysis unit servicing inpa-
tients and outpatients. Nephrology Nursing Journal, 44(5), 462-464.

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34 Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1

Comfort and Fluid
Retention
continued from page 33
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