Continuing Care of the Renal Patient:

A Guide for Nurses

Samantha Leatherland, BMedSci, RN, DipHSW (Open)

The author is with Nottingham University Hospitals NHS Trust, Kings Mill Satellite Dialysis Unit, Nottinghamshire, England.

The purpose of this article is to examine aspects of chronic renal failure in order to create a guide for nurses
to help them manage patients with this condition more effectively. This is a literature review, with the literature
search conducted using online databases and health science libraries. Two themes pertinent to chronic renal
failure management—coping and adaptation and self-efficacy and empowerment—are discussed. Reflections from
my practice are related to the discussion, and as a result of the findings, suggestions are made on how nursing
practice and research can be improved in the area of chronic renal failure.

ailure of the kidneys means the chronic renal failure are among the most and it may no longer be possible for them

F body cannot excrete certain waste

products, excess water, and salts or
control the body’s acidity; therefore,
it results in death if untreated.1 In addition,
hemoglobin production, blood pressure,
and bone formation are affected when the
kidneys fail. Renal failure is classified as
either acute or chronic. Acute renal failure
tends to be caused by either decreased
perfusion of the kidneys, structural damage
to the kidneys, or obstruction to drainage of
urine from them.2 It is characterized by a
sudden cessation of renal function but is
generally reversible if successful treatment
is administered for both the cause and
the potentially lethal effects of the renal
dysfunction (fluid overload, hyperkalemia,
and acidosis).3
In contrast, chronic renal failure has
a slow, insidious onset, during which
irreversible damage to kidney tissue occurs
until eventually renal function is insuffi-
cient to sustain life and some form of renal
replacement therapy is required.4 The cause
of chronic renal failure is either primary
renal disease, which is a disease of the renal
system itself, that sees the structure of the
kidney progressively destroyed or damaged
or secondary renal disease, in which a
systemic disease process destructively
affects the kidney.3
Sufferers of renal failure have to cope
with numerous physical symptoms because
of their disease. Indeed, according to
Germain and McCarthy, patients with
symptomatic of any chronic disease group.5
With reduced renal function comes uremia,
the symptoms of which include a general
feeling of weakness, nausea, vomiting,
reduced appetite, and a bitter taste in the
mouth.6 As renal function deteriorates
further, the symptoms worsen and include
inability to concentrate, irritability, itching,
breathlessness, restless legs, leg cramps,
edema, insomnia, sexual problems, and low
fertility.7
In addition to having the symptoms of
the disease itself, renal patients also have to
endure complex medication and treatment
regimens and their side effects.8 In the case
of hemodialysis, side effects can encom-
pass hypotension, cramps, and nausea and
vomiting during dialysis, and quite often
after dialysis a “washed-out” feeling can
occur that may last up to 24 hours.5 Fluid
and dietary restrictions have to be tolerated,
too, along with facing the threat of reduced
life expectancy and coping with permanent
invasive procedures to enable dialysis
access.9,10
Beyond the Physical Symptoms
The impact of chronic renal failure does not
stop with these physiological stressors,
though; patients also suffer socially and
financially. For example, because of their
illness and the demands of their treatment,
patients are restricted in their choices of
occupation, hobbies, and leisure activities,
to be the main breadwinner in the family or
to socialize with friends and colleagues.11
Conversely, though, Auer offers the
reminder that for some patients, the regular
trips to the hospital for treatment can be a
welcome social activity.12
Clearly, though the negative aspects
of renal failure far outweigh any positive
aspects, and it is easy to appreciate the
psychological stress that the disease may
bring. Uncertainty about the future, for
example, means life’s goals and values are
drastically altered, and the reliance on
dialysis can result in a loss of autonomy
and control.11,13 Body image concerns
because of dialysis access surgery can
affect self-esteem and feelings of sexual
attractiveness and desirability and there-
fore impinge on existing or forming new
emotional relationships. 14 Also, role
changes threaten the identity, pride, and
self-image of patients who do not wish to
become a burden or liability.12 Ultimately,
patients have to contend with possibly
losing all they have become and achieved
throughout their life. Perhaps unsurpri-
singly then, the prevalence of depression
is also high in patients with chronic renal
failure.15
Even those patients who are lucky
enough to undergo renal transplantation
still have frequent hospital appointments
and have to cope with a strict regimen of
medications and their side effects.
Therefore, once chronic renal failure

November 2007 Dialysis & Transplantation 1

 Continuing Care of the Renal Patient
strikes, it is clearly an illness for which
long-term management is paramount.
Despite this, I believe that very little
help is given to enable patients to under-
stand, live with, and manage their illness.
Instead, the main focus when people are
hospitalized as a result of their condition is
simply to sort out the problem and
discharge the patient as rapidly as possible.
Many admissions, however, are a result of
patients having difficulty managing their
medications, becoming fluid overloaded
or hyperkalemic, or developing access
problems such as line or fistula infections
in those on hemodialysis or peritonitis in
those on peritoneal dialysis. These are
problems that could have been prevented
were patients given more information,
education, and support. Considering that
chronic renal failure is on the rise, such
ongoing care of these patients is an
all-important factor in their nursing
management.1
Coping and Adaptation
When faced with the multiple stressors that
chronic renal failure poses, sufferers have
to find ways to cope and adapt. Having an
understanding of coping and adaptation
should enable nurses to help patients
with this process or at least see them better
able to empathize with what patients are
experiencing.
A Transitional Process
In the literature the idea of coping and
adaptation as a transitional process is
common. Auer, for example, suggests that
when patients are diagnosed with renal
failure, they go through a process similar to
that of bereavement.12 This involves the
experience of shock and numbness, denial,
grief, and anger before finally reaching
some degree of acceptance. Hooper and
Cohen describe a similar adjustment
process, suggesting patients experience
shock, something termed “encounter reac-
tion,” which is characterized by disorgan-
ized thinking and a range of feelings
including loss, grief, despair, hopelessness,
and sometimes denial, then last achieving
an uneasy acceptance.16
Patients can experience these stages in
random order for varying lengths of time
2 Dialysis & Transplantation November 2007
and often revisit them, which poses
difficulties for nurses as one day a patient
may appear to be accepting his or her
situation, but the next day the same patient
may be back to being tearful and angry.16
Nurses therefore need to be astute in order
to establish which stage their patients are at
Very little help is given to patients to help them
understand, live with, and manage their illness.
Many hospital admissions are a result of
problems that could have been prevented
through this type of support.
on each occasion they care for them.
Another interesting element of the two
models is that they suggest that denial is a
normal reaction. This may come as a
surprise to some nurses, as it is often
believed that the patient in denial is failing
to cope and adjust. In fact, denial is a
defense mechanism used by patients to
protect themselves from overwhelming
situations and give themselves time to
assimilate the impact of the illness.17
The use of denial by most patients will
gradually diminish as they come to
terms with the threats imposed by their
illness.17
Identify How Your Patients Cope
Cognitive appraisal theory provides another
explanation of how people cope. This theory,
presented in 1984 by Lazarus and Folkman,
suggests that when faced with a change to
their situation people assess both its poten-
tial threat and their ability and resources
to manage it.18 Successful coping is
dependent on accurate appraisal of the
change and possession of the necessary
skills and resources to deal with it.6
Cognitive theory goes on to state that there
are two types of coping strategies: problem
focused, which is aimed at managing or
altering the problem, for instance, con-
fronting the situation or seeking informa-
tion about it; and emotion focused, which is
directed at reducing emotional distress
but does not tackle the problem, such as
avoidance, distancing, or self-blame.19
In practice, one example of problem-
focused coping I have seen is a patient who,
to gain some control over her treatment,
learned to insert dialysis access needles
into her own fistula. Another woman,
however, had a dialysis line but refused to
look at it and requested it be covered with a
dressing at all times, which is clearly an
example of denial, an emotion-focused
coping strategy.
According to the research of Lok,
Welch and Austin, Lindqvist et al., and
Gilbar et al., individuals who use problem-
focused strategies adapt and adjust more
quickly and effectively to a diagnosis of
chronic renal failure, experiencing less
depression and psychological distress and
showing greater efficiency in managing
their condition.20-23 Therefore, these studies
suggest that it is important for nurses to
identify patients’ coping styles, as those
using emotion-focused methods may run an
increased risk of not being able to handle
their illness well.22 Nurses could also assist
patients to use problem-focused strategies
by providing support, information, and
problem-solving strategies,20 a suggestion
that relates to the theme of empowerment
that will be discussed below.
The use of a particular coping style or
strategy is largely a product of a person’s
attitudes and beliefs.24 Hasler and
Schofield, for example, state that previous
experience of ill health, knowledge of
disease, and personal style may all influence
the interpretation of illness, meaning
patients with identical symptoms and con-
ditions may see the threat very differently
and therefore cope very differently.25
In the literature searched, two theories
are evident that support this perspective: the
learned helplessness theory and the locus
of control theory. In the former, patients’
inability to cope is said to be a result of
having their previous coping behaviors either
not reinforced or maybe even punished.26
The patients therefore feel that no matter
what they do, it is wrong and will not help—
hence, learned helplessness. The locus
of control theory suggests that there are
Continuing Care of the Renal Patient
two types of people: those with an internal
locus of control, who believe they can con-
trol their life and events around them; those
with an external locus of control, those who
adopt a fatalistic belief that they have no
influence over events at all.11 In my experi-
ence this difference can be evident immedi-
ately, with some patients asking what you,
the nurse, are going to do to help them, and
others asking what they can do for them-
selves.
To help those in either the learned
helplessness condition or with an external
locus of control, Andersen suggests pro-
viding encouragement and initially giving
them small self-care tasks to complete
as little achievements can boost their confi-
dence and put them on the road to attaining
control over their life again.26 As with the
previous section, this also links in with the
second theme of this review because of its
parallels with self-efficacy.
Care Providers Can
Impact Coping
Patients’ coping and adaptation can be
affected by the attitudes and actions of
health care workers, too. Andreucci et al.,
for example, state that “patients may find it
more difficult to adapt when clinicians
devote their energies to the technical
aspects of care at the expense of personal
interaction.”27 Personal interaction with
patients is easy to achieve in my current
area of work on a dialysis unit, as there is a
caseload of 72 patients seen three times a
week for four hours at a time for their
hemodialysis treatment. On the wards,
however, it can be much more difficult to
build a relationship, as other nursing tasks
are often assigned priority, and the general
pressures of the workload, frequent poor
staffing levels, and time can be against the
staff. However, it is while on the ward as
inpatients that patients require the most
psychological care, as they will be worried
about the cause of their hospitalization and
its treatment and consequences.
Also important to recognize, though, is
that just as patients differ in the way they
cope, so do nurses in the way that they
deliver care, and for some, technical care
comes easier than emotional care.28 This is
clear to see on the dialysis unit as certain
staff members focus greatly on direct patient
care, whereas others concern themselves
with the workings of the dialysis machines.
The need to support patients psycho-
logically has been highlighted in recent
government publications. Both the National
Service Framework (NSF) for Renal
Services1 and the NSF for Long-Term
Conditions,29 for example, say care planning
should recognize patients’ psychological
needs in order to minimize deterioration in
mental health, and they suggest that to
As a result of attending a group education
program, patients’ stress and depression
levels were reduced. They began to view their
illness as a surmountable challenge.
meet these needs, specialist staff members
should be made use of. The best specialists,
according to Wright and Weinman, are
health psychologists, whose input they
consider intrinsic to the promotion of
psychological care of patients with chronic
illnesses.30 Similarly, Sedgewick states that
clinical psychologists can be a great asset to
the renal unit.11 In my unit, however, there is
no dedicated psychologist to work with renal
patients; a referral to the hospital psycho-
logists can be made if deemed necessary,
but I have never known this to be done.
Self-Efficacy and
Empowerment
The impact of empowerment and self-
efficacy on the management of chronic
renal failure is now considered. The term
self-efficacy relates to “a person’s feelings
and thoughts about their own capability of
accomplishing a task,” whereas empower-
ment refers to the process of helping people
acquire the skills and knowledge required
to increase control over their own life.31-32
Therefore, anything that increases self-
efficacy and empowers patients is likely to
aid the management of their condition.
Educate Your Patients
According to Johnson-Taylor et al., the best
way to achieve this increase is to give
patients information and education about
their illness and how to manage it.33
Six years later this is echoed by the govern-
ment in its recommendation that “expert
patient programs” be introduced.34 An aim
of these programs is to help patients recog-
nize and act on symptoms, make the most
effective use of medicines and treatments,
understand the implications of professional
advice, access social and employment
services and leisure activities, and develop
strategies to deal with the psychological
consequences of their illness.34 There is,
however, no specific guidance on how this
patient education should be carried out.
Information Groups
Many suggestions for ways to execute
patient education are provided in the nursing
literature, though. Auer, for example,
suggests that for pre-dialysis or pre–liver
donor transplant patients, it is useful to
have information groups, where patients
and families are invited to attend sessions
run by the nursing staff or preferably a
multidisciplinary team.12 She says such
groups enable teaching, reassurance, and
group support, encourage active participa-
tion in treatment, and facilitate the asking
of questions. Delivering these sessions on a
group basis is also both time- and cost-
effective.
In my unit, information groups are run
for those considering live donor trans-
plants. The groups are facilitated by two
specialist nurses (transplant coordinators),
and people who have undergone the proce-
dure of receiving or donating a kidney also
attend. An information group is also run for
patients who are considering continuous
ambulatory peritoneal dialysis (CAPD) as a
treatment option. These patients are invited
along to listen to a talk from the CAPD
nurses and to view a video about the therapy
and what it involves. No doubt this is useful,
but I believe the sessions would be more
beneficial if, like the live donor transplant
group, there were expert patients involved to
answer questions and give their perspective
November 2007 Dialysis & Transplantation 3
 Continuing Care of the Renal Patient
on the treatment. Although potential CAPD
patients can access an information session,
there is no such group for those considering
hemodialysis treatment. Instead this option
is just discussed with patients during their
routine appointments at pre-dialysis clinic,
and if they want to, they can visit the unit
where they would dialyze. However, such a
visit is likely to be a rather intimidating
experience, facing a busy unit, technical-
looking equipment, and staff and patients
whom they have probably never met before.
Patients may therefore feel unable to ask
questions or voice any concerns that they
may have.
Handouts
Another method of patient education is the
use of leaflets and handouts.25 These can be
used in addition to information groups to act
as a reminder of what has been discussed in
the sessions or independently to provide
information about a particular treatment or
procedure. My unit has numerous leaflets
and booklets available on all aspects of renal
disease and treatment, and in my experience
these are useful for increasing the know-
ledge of both patients and staff.
Education to Improve Well-Being
Several research articles have focused on
patient education, too. Klang et al., for
example, evaluated a pre-dialysis education
program facilitated by a nephrologist, renal
nurse, dietician, physiotherapist, and social
worker that consisted of four classroom-
based sessions examining renal disease and
dietary management, renal replacement
therapies, physical exercise training, and
the impact of chronic renal failure on econ-
omy, family, and social life.35 The
researchers found that patients who parti-
cipated in this program showed improved
functional and emotional well-being
compared with those who did not. To me,
this education program sounds good, as it
provides patients with information about
their condition and the management of it
and introduces them to members of the
renal team.
Tsay et al. similarly investigated the
effectiveness of an adaptation-training pro-
gram to help patients with end-stage renal
disease cope with illness-related stressors.9
In this program a renal clinical nurse
4 Dialysis & Transplantation November 2007
specialist and a psychotherapist delivered
eight group sessions covering stress manage-
ment, problem solving, coping with symp-
toms, self-care, and self-management. As a
result of attending the program, the
researchers say that patients’ stress and
depression levels were reduced, and thus
their quality of life improved and also began
to view their illness as a surmountable chal-
lenge.
In the Leake et al. study, it was found
that enabling patients to educate and
empower fellow patients, such as in infor-
mation groups or self-help groups, also
benefited them. This is because by pre-
senting themselves as people who were
managing or learning to manage their con-
dition, they increased their own self-effica-
cy, or self-evaluation, as Leake et al. call
it.10
Possible Roadblocks
Increasing the empowerment and self-
efficacy of patients is important because with
improved knowledge of their disease and
greater competence in managing it, they
become more confident, independent, and
motivated29 and more concordant with
treatment,12 and they experience fewer
hospital readmissions36 and have a better-
quality doctor–patient relationship.34
However, not all patients will want to
participate actively in their own care or will
be able to do so.29 As Kralik et al. state,
for example, transport to venues and confi-
dence in attending group meetings may
be prohibitive factors as far as education
programs and information groups are
concerned.37
Other patients may be unable to
participate because of physical disabilities
or psychiatric illness, whereas some quite
simply derive security from the nurse-
knows-best stance.31 Good assessment is
therefore vital to establishing who would
benefit from empowerment and self-efficacy
training.
Providing training can be problematic
for nurses too. According to Harrison,38 for
instance, when it comes to educating
patients, many nurses lack the required
skills, knowledge, and self-esteem.
Tutoring nurses is therefore essential to
developing their ability and their con-
fidence. It is worrying, however, that
nurses lack knowledge about how to
practice in accordance with the NMC
Professional Code of Conduct.39 When
working with patients who have a chronic
condition, though, it can sometimes seem
like you know less than they do, as
ultimately they are the ones living with and
experiencing the illness, so they often
become very knowledgeable. A profe-
ssional can still contribute to an expert
patient’s education, however, by providing
a different perspective on things, for
example, or by keeping them up to date
with the latest developments.
A final explanation for why nurses
may fail to educate and empower patients is
offered by Crumbie, who suggests that “the
ownership of medical knowledge provides
the health care professional with power,”
which they can be reluctant to relinquish.40
Where this is the case, attitude changes
are required, with care needing to be seen
as a partnership between the patient and
professional.
Ultimately, it has to be accepted that
because of their frequent contact with
patients who have a long-term illness, nurses
are in a prime position to facilitate patients’
self-management of their condition.37 This
is especially true at my place of work, as
each nurse on the unit is assigned a group
of patients whose treatment and dialysis
adequacy they monitor; thus, acting as
a resource and educator to them seems a
logical addition to this role.
Recommendations
After performing this literature review it
seems appropriate to make the following
recommendations for future research and
for improving nursing practice.
Personal Interaction with Patients
First, to enable provision of the psycho-
logical support that patients clearly need to
help them cope and adjust, nurses need to
know more about when and how to assess
psychological state and implement psycho-
logical care. Performing a further literature
search to examine this subject may there-
fore be useful. It seems reasonable to
suggest, however, that the execution of
such care is the responsibility of a psycho-
logist not a nurse; so ideally all renal units
Continuing Care of the Renal Patient
should have such a specialist available to
their patients. An action that nurses can
perform to benefit their patients’ psycho-
logical health, though, is to make them-
selves available for patients to talk to. This
personal interaction is very important.
Therefore, those who usually prefer to avoid
this emotional care must strive to incorpo-
rate it into their practice.
One further suggestion regarding psy-
chological care is to obtain patients’ views
on whether and when psychological care
would be beneficial and who they feel
should provide it. This could be achieved
by setting up focus groups or through con-
ducting a phenomenological study.
Organize Patient
Education Groups
Next, to develop patients’ self-efficacy and
increase their empowerment levels, infor-
mation groups should be operated with
experienced patients involved to boost their
own confidence and enable peer support. In
my unit a hemodialysis information group
is definitely needed. In addition, every
opportunity to educate patients on a one-to-
one basis should be taken advantage of.
For instance, on my unit nurses could take
on the role of educators to their allocated
patients, as I will endeavor to do from now
on. Being attached to the machine to have
dialysis treatment makes patients a captive
audience, which means nurses could also
give them advice or facilitate a teaching
session at that time, too.
Whatever the method of education used,
all information given must be supported
with leaflets and handouts so that patients
can review them and refresh their memory
as necessary. Finally, in relation to the
theme of self-efficacy and empowerment,
because it has been suggested that some
nurses find educating patients difficult,
I also recommend regular reflection on
practice to evaluate teaching skills, and I
advise that nurses make use of training
courses to develop their teaching ability
where required.
Studies
In relation to nursing research, as well as
executing a qualitative phenomenological
study as advocated above, this topic of the
continuing care of the renal patient would
also benefit from further quantitative
studies that use appropriate sampling
techniques to generate random samples
and produce results that can be
generalized. More longitudinal studies are
needed, too, so that the effect of interven-
tions can be monitored over time. For
example, although Klang et al. found
Because of their frequent contact with patients
who have a long-term illness, nurses are in a prime
position to facilitate patients’ self-management of
their condition.
that when questioned three to nine months
after embarking on hemodialysis, patients
who had participated in a pre-dialysis
education program showed less functional
and mobility disabilities, improved mood,
and lower anxiety than did those who had
not participated, it would be interesting to
know whether these benefits were sustained
long term.35
Next, because only four of the studies
acquired to inform this discussion origi-
nated from the United Kingdom, I believe
there needs to be more research performed
in British renal units. I think this is
necessary; otherwise developments in
practice will be based largely on research
from countries that have different health-
care systems and different policies and
procedures and may have care and
treatment that depend on which health
insurance policy a patient holds. This
clearly is not ideal. Last, to further inform
practice and to complement this review,
I suggest that performing additional
literature reviews on the subject of
chronic renal failure would be useful to
explore related issues such as body image
or quality of life.
Summary and Conclusions
This literature review has examined
the continuing care of the renal patient
in order to act as a guide for those who
nurse them. Specifically, the area of
chronic renal failure was explored,
beginning with a description of what this
illness is and how it affects the sufferer was
given.
Discussion and analysis of the themes
of coping and adaptation and self-efficacy
and empowerment formed the subsequent
section of the review, and throughout the
discussion I incorporated my reflections on
my practice. In the final part of the article,
recommendations for improvements to
practice and for further research were
made. Overall, it is hoped that this article
has raised some issues that can be taken
into consideration by all renal nurses
and may also be transferable to those
working in other areas of chronic disease
management. D&T
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