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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 526-534
The Attitude of Physicians towards Education and Rehabilitation of Patients on Chronic Dialysis: A Questionnaire Survey

Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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In this study, we aimed to evaluate the attitude of physicians in the Kingdom of Saudi Arabia (KSA) towards the education and rehabilitation of chronic dialysis patients. Questionnaires were sent to 155 physicians working in 148 dialysis centers. They included 109 centers (73.6 %) in the Ministry of Health (MOH), 18 (12.2%) in governmental non-MOH sector and 21 centers (14.2 %) in private hospitals that together care for a population of more than 7,900 chronic dialysis patients. The study was performed between January and March 2006. Responses were received from 141 physicians (90.9%) from 140 (94.5%) dialysis centers. There were 134 (97.1%) respondents who believed that the ideal ratio of patients per dialysis nurse should be < 3, 132 (97.1%) believed that the ideal ratio of patients per physician should be < 25, 120 (88.9%) believed that the ideal ratio of patients per dietitian should be < 50, and 102 respondents (81.0%) believed that the ideal ratio of patients per social worker should be < 50. There were 46 respondents (32.6%) who always and 53 (37.6%) who mostly found time to educate the patients about the various options available for renal failure treatment. Educational tools, such as reading materials and audiovisuals, were only available to 56 respondents (42.7%). There were 88 (63.3%) respondents who always discussed results of laboratory tests in detail with their dialysis patients, while 48 (34.5%) informed patients when any abnormality was discovered. There were 130 respondents (94.9%) who believed that their patients were satisfied with services of the physicians, 53 (39.0%) with the dietitian's, 57 (42.5%) with the social worker's, and 131 (94.9%) with the nurses' services. Our survey suggests that that the current practices concerning education and rehabilitation of patients in the dialysis centers in the KSA may not be satisfactory. More studies are needed to explore these issues.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. The Attitude of Physicians towards Education and Rehabilitation of Patients on Chronic Dialysis: A Questionnaire Survey. Saudi J Kidney Dis Transpl 2006;17:526-34

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. The Attitude of Physicians towards Education and Rehabilitation of Patients on Chronic Dialysis: A Questionnaire Survey. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Aug 1];17:526-34. Available from: https://www.sjkdt.org/text.asp?2006/17/4/526/32491

   Introduction Top

Surveys of the attitudes of physicians toward their practices in the dialysis units are one of the tools used to evaluate the quality of care provided to patients on regular dialysis. [1],[2],[3]

Education and rehabilitation are major goals in any dialysis center's quality care. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] There are many factors that affect this process in­cluding the availability and expertise of the personnel, apart from their conduct towards the patients. [17],[18],[19],[20],[21],[22],[23],[24],[25] Different educational tools may aid in accomplishing the task of im­parting proper education to patients on regular dialysis. [26],[27],[28],[29] Patients' satisfaction has been emphasized, not only as a parameter of high quality service, but also as a goal of all the services offered including education and rehabilitation.[30],[31],[32],[33]

The use of dialysis has rapidly expanded in the Kingdom of Saudi Arabia (KSA) over the years. Areas that need to be studied while assessing the quality of services offered in the dialysis centers in the KSA are factors that hinder the education and rehabilitation of patients in each center and the availability and expertise of the personnel. This will help in planning educational and rehabilitative strategies as well as enhancing communication in this field.

Aim of the study

The aim of this study is to survey the attitude of physicians in dialysis units in Saudi Arabia towards patient education and rehabi­litation and factors involved in this process.

   Materials and Methods Top

We sent a questionnaire to 155 physicians; the heads of 148 active dialysis centers in the KSA and seven other consultants working in these centers This covered decision makers in 109/148 centers (73.6 %) in the Ministry of Health (MOH), 18/148 centers (12.2%) in governmental non-MOH sector and 21/148 centers (14.2 %) in private hospitals that together care for a population of more than 7,900 chronic dialysis patients. The study was performed between January and March 2006.

The questionnaire was intended to evaluate the following aspects in the practice of phy­sicians who care for chronic renal failure (CRF) patients in the KSA and included the following:

a) The perception of physicians on the significance of the ratios of the different categories of personnel to the dialysis patients that help global services rendered to the patients and their education.

b) The perception of healthcare personnel in dialysis centers to the importance of regular meetings with patients.

c) The importance of having an appropriate patient load on patient education efforts.

d) Patient satisfaction with available services. e) The importance and availability of educational tools.

f) The importance of other factors such as securing basic health services on patient education.

We considered the best answers as those in accordance with the common denominator of the established guidelines and practices in the United States of America (USA) [34] and Europe [35] that include the following: a) A recommendation to consider patients' education as an important feature of their care.

b) A recommendation to allocate enough time by the members of nephrology team for patients' education.

c) A recommendation to use all the possible means of education.

d) A recommendation to seek patients' satis­faction and consider it as an important goal for quality care in the dialysis centers.

   Statistical methods Top

Data were entered into a Microsoft Excel file. The description and data analysis were conducted with the statistical program (SPSS). The valid percent of the answers was considered according to the frequency of the answers to each corresponding question.

Pearson Chi-Square test was used through­out the analysis to test the significance of differences between groups and sub-groups. Significance was set as P< 0.05.

   Results Top

141 out of 155 physicians (90.9%) answered the questionnaire from 140 dialysis centers (94.5%). These physicians treated 7,450 of the dialysis patients (94.3%) in the KSA; there were 108 respondents (98.1%) from the MOH centers, 14 (58.3 %) from non-MOH centers and 19 (90.4%) from private dialysis centers.

[Table - 1] shows the answers related to staff availability for dialysis patient education. 134 respondents (97.1%) believed that the ideal ratio of patients per dialysis nurse should be < 3, 132 respondents (97.1%) believed that the ideal ratio of patients per physician should be < 25, 120 respondents (88.9%) believed the ideal ratio of patients per dietitian should be < 50, while 102 respondents (81.0%) believed that the ideal ratio of patients per social worker should be 0 50. In addition, 71 respondents (51.1%) believed that direct meeting(s) of all the staff with patients would promote better education, rehabilitation and patient satis­faction. A dietitian was either not available, or did not have regular meetings with the patients, according to 60 (43.8 %) and 37 respondents (27.0%), respectively. Similarly, a social worker was either not available or did not interact with the patients regularly according to 51 (36.7%) and 36 respondents (25.9%), respectively.

[Table - 2] shows the issues related to time allocation of dialysis staff for patient edu­cation. There were 46 respondents (32.6%) who always and 53 (37.6%) who mostly found the time to discuss and educate patients with ESRD about treatment options such as peritoneal, hemodialysis and trans­plantation. There were 90 respondents (63.8%) who rated the laboratory in their hospitals as average in satisfying the needs of their dialysis patients. Moreover, 90 respondents (65.2%) believed that pursuing problems of the laboratory, pharmacy and stores inter­fered with the patient education.

[Table - 3] shows the physicians' beliefs about the significance of dialysis patient education. 56 respondents (42.7%) noted that they had both reading materials and audiovisual aids available as education tools in their dialysis centers, while the others had neither tool available. 137 respondents (98.6%) believed that the availability of educational videotapes to patients about topics such as nutrition, blood access, etc. would better educate their patients. 88 respondents (63.3%) discussed laboratory tests in detail with their dialysis patients all the time, while 48 (34.5%) informed patients only if an abnormality was found. Moreover, 118 respondents (83.7%) said that such a discussion was necessary and satisfying, while the others found it unnecessary or a waste of time.

[Table - 4] depicts patient satisfaction with healthcare-related services. 130 respondents (94.9%) believed that most of their dialysis patients were currently satisfied with physician services, 53 (39.0%) were satisfied with the dietitians, 57 (42.5%) were satisfied with social workers, and 131 (94.9%) were satisfied with nursing services.

[Table - 5] shows differences in study parti­cipant responses according to their affiliation. In comparison to non-MOH and private dialysis centers, a significantly lower percent­age of the MOH center patients had regularly scheduled one-on-one interactions with the dietitian, rated the laboratory as above average for the needs of the dialysis patients, or believed that most of the dialysis patients were satisfied with the dietitian services. In comparison to MOH and private dialysis centers, the non-MOH dialysis center patients had significantly higher percentages of regularly scheduled one-on-one interaction with the social worker. Finally, the private centers had higher percentage of respondents who always found time to discuss and educate ESRD patients about treatment options such as peritoneal hemodialysis and transplant­ation when compared with the MOH and non-MOH centers.

[Table - 6] shows differences in responses of the respondents when they were grouped according to center size. In comparison with the larger dialysis centers, the smaller centers (less than 10 dialysis machines and less than 25 regular dialysis patients) had significantly less regularly scheduled one-on­one interactions with the social worker, less patient meetings per week, decreased feelings of work overload, lower laboratory ratings, and decreased patient satisfaction..

   Discussion Top

The current survey attempted to depict physician attitudes in dialysis centers in the KSA towards patient education and rehabi­litation in their respective centers.

Our results showed that the majority of respondents believed there should be a low patient load for all dialysis team members to offer better patient care. Some members of the team such as dietitians and social workers were not available in a large number of dialysis centers in the KSA. Previous studies have proposed ratios of patients to staff, which closely matches what was found in our survey. [36],[37],[38],[39],[40],[41],[42],[43] Additionally, these ratios have a direct impact on the time allocated for patient education.

The majority of respondents in our study found some time to discuss available treat­ment options with the patient and had less than 100 patient-interactions per week. Recently, a recommendation to limit patient interaction has been proposed and promoted. Inadequate laboratory and pharmacy services as well as securing vascular access were also rated time consuming by the majority of respondents, thus restricting the patient education process. [44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56]

The overwhelming majority of respondents in our study welcomed the use of different educational tools such as reading and audio­visual materials related to renal failure. However, a direct discussion was considered the most satisfying.

The beliefs of the respondents about patient satisfaction were interesting since almost all of them concurred that the patients were satisfied with the physicians' and nurses' services but not with the dietitian or social workers. This was mostly because of the shortage of the latter two in many centers. Providing these services to patients is essential and should be implemented. The shortages and/or low quality of staff hinder the implementation of satisfactory educational programs, which are crucial to reducing anxiety and stress imposed on the patients.[14],[21],[26],[27],[28],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56]

There are uneven dialysis practices among the health sectors in the KSA due to differ­ences in staffing patterns and availability of support services. In our study, we found significantly lower percentages of staffing and rating of support services in the MOH sector. The smaller centers with less than 10 dialysis machines and less than 25 patients had greater shortages of support services and staffing, but less workload in comparison with the larger centers. These differences need to be further validated by studies aimed at determining the cost effectiveness of staff ratios and patient outcomes including survival and satisfaction.

   Conclusion Top

We conclude that the current practices concerning education and rehabilitation of patients in the dialysis centers in the KSA may not be satisfactory. There are many centers that are overloaded and overworked. More studies must be conducted to explore the quality of services rendered to patients in the dialysis centers and the effect of education on their outcome and satisfaction. Providing more tools for education may help as well in this process.

   Acknowledgement Top

We would like to thank Roche pharma­ceuticals in Saudi Arabia for their grant that made this study possible.

   References Top

1.Powe NR, Thamer M, Hwang W, et al. Cost-quality trade-offs in dialysis care: a national survey of dialysis facility admini­strators. Am J Kidney Dis 2002;39(1):116-26.  Back to cited text no. 1    
2.Zimmerman DL, Selick A, Singh R, Mendelssohn DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003;18(2):305-9.  Back to cited text no. 2    
3.Van Waeleghem JP, Elseviers MM, De Weerdt DL, et al. A survey of nephrology nursing care and treatments in Belgium. Nephrol News Issues 1998;12(11):53-6.  Back to cited text no. 3    
4.Levin A, Lewis M, Mortiboy P, et al. Multi­disciplinary predialysis programs: quanti­fication and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis 1997;29:533-40.  Back to cited text no. 4  [PUBMED]  
5.Klang B, Bjorvell H, Berglund J, et al. Predialysis patient education: effects on functioning and well-being in uraemic patients. J Adv Nurs 1998;28:36-44.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Ravani P, Marinangeli G, Tancredi M, et al. Multidisciplinary chronic kidney disease management improves survival on dialysis. J Nephrol 2003;16:870-7.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.McMurray SD, Johnson G, Davis S, McDougall K. Diabetes education and care management significantly improve patient outcomes in the dialysis unit. Am J Kidney Dis 2002;40(3):566-75.  Back to cited text no. 7    
8.Fester S.CAN the new K/DOQI guidelines make a difference for the CKD patient. Nephrol News Issues 2002;16(5):27-9.  Back to cited text no. 8    
9.Latham CE.Is there data to support the concept that educated, empowered patients have better outcomes? J Am Soc Nephrol 1998;9(12 Suppl):S141-4.  Back to cited text no. 9    
10.Ravani P, Marinangeli G, Stacchiotti L, Malberti F.Structured pre-dialysis programs: more than just timely referral? J Nephrol 2003;6(6):862-9.  Back to cited text no. 10    
11.Marron B, Martinez Ocana JC, Salgueira M, et al. Spanish Group for CKD. Analysis of patient flow into dialysis: role of education in choice of dialysis modality. Perit Dial Int 2005;25 Suppl 3:S56-9.  Back to cited text no. 11    
12.Mingardi G.Quality of life and end stage renal disease therapeutic programs. DIA-QOL Group. Int J Artif Organs 1998;21(11):741-7.  Back to cited text no. 12    
13.Murray BM, Malireddi K, Vavilala V. Delivery of predialysis care in an academic referral nephrology practice. Ren Fail 2005; 27(5):571-80.  Back to cited text no. 13    
14.Johnstone S, Walrath LL, Wohlwend V, Jobe LD, Thompson C. Overcoming early learning barriers in hemodialysis patients: the use of screening and educational rein­forcement to improve treatment outcomes. Adv Chronic Kidney Dis 2004;11(2):210-6.  Back to cited text no. 14    
15.Obialo CI, Ofili EO, Quarshie A, Martin PC. Ultralate referral and presentation for renal replacement therapy: socioeconomic impli­cations. Am J Kidney Dis 2005;46(5):881-6.  Back to cited text no. 15    
16.Niu SF, Li IC. Quality of life of patients having renal replacement therapy. J Adv Nurs 2005;51(1):15-21.  Back to cited text no. 16    
17.Zoccali C. Nephrology in the clinic and quality in nephrology. J Nephrol 2003; 16(6):785-6.  Back to cited text no. 17    
18.Bath J, Tonks S, Edwards P. Psychological care of the hemodialysis patient. EDTNA ERCA J 2003;29(2):85-8.  Back to cited text no. 18    
19.Moore H, Reams SM, Wiesen K, Nolph KD, Khanna R, Laothong C. National Kidney Foundation Council on Renal Nutrition survey: past-present clinical practices and future strategic planning. J Ren Nutr 2003; 13(3):233-40.  Back to cited text no. 19    
20.Ran KJ, Hyde C. Nephrology nursing practice: more than technical expertise. EDTNA ERCA J 1999;25(4):4-7.  Back to cited text no. 20    
21.Rubin HR, Jenckes M, Fink NE et al. Patient's view of dialysis care: development of a taxonomy and rating of importance of different aspects of care. CHOICE study. Choices for Healthy Outcomes in Caring for ESRD. Am J Kidney Dis 1997;30(6):793-801.  Back to cited text no. 21    
22.Connor AJ, Williams SM. Psychosocial needs in renal failure: development of a renal support team. EDTNA ERCA J 1996; 22(3):36-7.  Back to cited text no. 22    
23.Smith GO Jr. The role of physician assistants in improving renal care. Nephrol News Issues 2004;18(5):51-6.  Back to cited text no. 23    
24.Schulman G. Mortality and treatment moda­lity of end-stage renal disease. Ann Intern Med 2005;143(3):229-31.  Back to cited text no. 24    
25.Bolton WK. The role of the nephrologist in ESRD/Pre-ESRD care: a collaborative approach. J Am Soc Nephrol 1998;9(12 Suppl):S90-5.  Back to cited text no. 25    
26.Hooper JM, Rainer E, Banks RA. Haemo­dialysis patients' knowledge and beliefs about medication. EDTNA ERCA J 1996;22(3):38-40.  Back to cited text no. 26    
27.Leonard MO. Current nursing practice in dialysis care: a summary. J Dial 1976-77; 1(2):181-208.  Back to cited text no. 27    
28.Bender K, Swartz MD. The role of nephrology nurses and technicians in the implementation of NKF-DOQI. Nephrol News Issues 1999;13(4):21-3.  Back to cited text no. 28    
29.Pollak VE. Computerization of the medical record: use in care of patients with end­stage renal disease. Kidney Int 1983; 24(4):464-73.  Back to cited text no. 29    
30.Coupe D. Making decisions about dialysis options: an audit of patients' views. EDTNA ERCA J 1998;24(1):25-6,31.  Back to cited text no. 30    
31.Andreucci VE, Kerr DN, Kopple JD. Rights of chronic renal failure patients undergoing chronic dialysis therapy. Nephrol Dial Transplant 2004;19(1):30-8.  Back to cited text no. 31    
32.Ageborg M, Allenius BL, Cederfjall C. Quality of life, self-care ability, and sense of coherence in hemodialysis patients: a comparative study. Hemodial Int 2005;9 Suppl 1:S8-14.  Back to cited text no. 32  [PUBMED]  
33.Tsay SL, Hung LO. Empowerment of patients with end-stage renal disease-a randomized controlled trial. Int J Nurs Stud 2004;41(1):59-65.  Back to cited text no. 33    
34.K-DOQI Guidelines group. Vascular access guidelines. Am J Kidney Dis 2001; 37(1)Suppl (1):153-7.  Back to cited text no. 34    
35.European Best Practice Guidelines Group. Measurement of renal function, when to refer and when to start dialysis. Nephrol Dial Transplant 2002;17 Suppl (7):10.  Back to cited text no. 35    
36.Hover J. A look at new directions for the dialysis technician. Part III. Nephrol News Issues 1990;4(9):17-9.  Back to cited text no. 36    
37.Held PJ, Garcia JR, Pauly MV, Cahn MA. Price of dialysis, unit staffing, and length of dialysis treatments. Am J Kidney Dis 1990; 15(5):441-50.  Back to cited text no. 37    
38.Bolton WK. Nephrology nurse practitioners in a collaborative care model. Am J Kidney Dis 1998;31(5):786-93.  Back to cited text no. 38    
39.Balhorn J. Patient classification used as a tool for assessment of staff/patient ratios. EDNTNA ERCA J 1998;24(1):13-6.  Back to cited text no. 39    
40.Kessler DM, Kessler DH, Knibloe ME. A dialysis patient classification system for establishing nurse/patient ratios. ANNA J 1990;17(5):367-70; discussion 371.  Back to cited text no. 40    
41.Bevan J, Linton A. Continuous quality improvement: maintaining quality of care with changing staffing patterns. J CANNT 1998;8(2):33-5.  Back to cited text no. 41    
42.Godin MA. A patient classification system for the hemodialysis setting. Nurs Manage 1995;26(11):66-7.  Back to cited text no. 42    
43.Houchins G. Taking a closer look at employee turnover in the dialysis unit. Nephrol News Issues 1995;9(9):37-8.  Back to cited text no. 43    
44.Holley JL. Nephrologists as primary care providers: a review of the issues. Am J Kidney Dis 1998;31(4):574-83.  Back to cited text no. 44    
45.Perry E, Buck C, Newsome J, Berger C, Messana J, Swartz R. Dialysis staff influence patients in formulating their advance dire­ctives. Am J Kidney Dis 1995; 25(2):262-8.  Back to cited text no. 45    
46.Heard-K. Improving patient outcomes in a dialysis unit: an integrated approach to CQI. J Nurs Care Qual 1994;9(1):44-50.  Back to cited text no. 46    
47.Oka M, Chaboyer W. Dietary behaviors and sources of support in hemodialysis patients. Clin Nurs Res 1999;8(4):302-14; discussion 314-7.  Back to cited text no. 47    
48.Carter JL. Nursing considerations in support of a patient pursuing his dream. Nephrol Nurs J 2000;27(1):53-6.  Back to cited text no. 48    
49.Tietze MF. Maintenance hemodialysis stressors, hierarchy of human needs, and nursing interventions: a patient perspective. AANNT J 1984;11(1):13-7.  Back to cited text no. 49    
50.Bocchino CA. The stress factor: its effect on hemodialysis patients and staff. J Am Assoc Nephrol Nurses Tech 1978;5(3):151-5.  Back to cited text no. 50    
51.Dickerson Z. Stress factors in hemodialysis. Nephrol Nurse 1980;2(1):19-20,66.  Back to cited text no. 51    
52.Bedell JR, Kilpatrick DG, Robinson J, Gilbert G, Miller WC. Anxiety during hemodialysis sessions: discrepant evaluations of patients and nurses. J Am Assoc Nephrol Nurses Tech 1978;5(2):72-6.  Back to cited text no. 52    
53.Ran KJ, Hyde C. Nephrology nursing practice: more than technical expertise. EDTNA ERCA J 1999;25(4):4-7.  Back to cited text no. 53    
54.Nilsson LG, Anderberg C, Ipsen R, Persson E, Andersson G. Quality decision making in dialysis. EDNTNA ERCA J 1998;24(4):11-4.  Back to cited text no. 54    
55.Bender FH, Holley JL. Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey. Am J Kidney Dis 1996;28(1):67-71.  Back to cited text no. 55    
56.Mitch W, McClellan WM. Patterns of patient care reported by nephrologists: implications for nephrology training. Am J Kidney Dis 1998;32(4):551-6.  Back to cited text no. 56    

Correspondence Address:
Muhammad Ziad Souqiyyeh
The Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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