|Year : 2016 | Volume
| Issue : 1 | Page : 29-36
|How are families taught to look after their children on peritoneal dialysis?
Reem S Alhameedi1, Jacqueline Collier2
1 Faculty of Health Sciences, The University of Southampton, Southampton, United Kingdom
2 Faculty of Social Science, University of East Anglia, East Anglia, United Kingdom
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|Date of Web Publication||15-Jan-2016|
| Abstract|| |
For patients to be started on peritoneal dialysis (PD), they need to be trained on how to perform dialysis at home. Understanding how to carry out dialysis is difficult for adults, but perhaps even more challenging for parents of children. This study was performed to examine the PD teaching programs for parents of children with end-stage renal disease (ESRD) and to explore the issues related to educating parents of children with ESRD. A survey method was used to carry out the research through the distribution of self-completed questionnaires to pediatric dialysis units (ten units) in Saudi Arabia in both governmental and non-governmental hospitals. The questionnaire content was identified using information gained from other research performed in the field of home PD training. The questionnaire was piloted with experienced renal nurses. Questionnaires were distributed to 87 specialized nurses within the ten PD units. Descriptive statistical analysis SPSS (19.00) was used to analyze the data. Statistical tests were used to distinguish the relationship and the significant effects between variables. The response rate was 72% (n = 63). Peritonitis rates varied in each hospital, and ranged from zero to three episodes per patient-year (median 1.17 episodes per patient-year). There was a significant association between home visits and peritonitis rates (P <0.01). This study has provided an initial overview of pediatric PD training programs in Saudi Arabia and has provided valuable data in this regard.
|How to cite this article:|
Alhameedi RS, Collier J. How are families taught to look after their children on peritoneal dialysis?. Saudi J Kidney Dis Transpl 2016;27:29-36
|How to cite this URL:|
Alhameedi RS, Collier J. How are families taught to look after their children on peritoneal dialysis?. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Aug 2];27:29-36. Available from: https://www.sjkdt.org/text.asp?2016/27/1/29/174065
| Introduction|| |
Most reports agree that peritoneal dialysis (PD) training programs continue to play an important role in pediatric PD. Several authors have suggested the need for an organized teaching protocol for the families of children with end-stage renal disease (ESRD). , Others indicated that a pediatric home training program is unique and requires more training time compared with an adult home training program.  The findings of studies examining the relationship between training programs and incidence of peritonitis rates have been mixed. For example, one study showed that the longer the training program, the lower the incidence of peritonitis in PD patients,  while another study showed no correlation between peritonitis rates and training time. 
In Saudi Arabia, studies have shown high rates of peritonitis among pediatric PD patients. , However, although there have been several studies carried out around the world, there are no previous studies investigating the practice of PD training programs and its relation to peritonitis in Saudi Arabia. The purpose of this study is to investigate the way parents are being taught to look after their children on PD in Saudi Arabia and to identify whether there is a relationship between peritonitis rates and training, with a view to making recommendations for practice improvement.
In this study, we aimed to examine the PD teaching programs for parents of children with ESRD in ten hospitals with pediatric renal programs in Saudi Arabia. We also explored the issues related to educating parents of children with ESRD.
| Subjects and Methods|| |
The research population was defined as all qualified nurses (dialysis nurses or pediatric medical nurses) who are assigned to care for pediatric patients on PD. Therefore, this research approached the whole population and not just a sample of this population. Ten units were identified that delivered PD to children. This research looked at the ways of teaching parents about PD and to find out if there is a correlation between training and peritonitis rates.
The survey research option was the method chosen to access the data needed to answer the research question. In order to gather information from participants in different locations in a big country such as Saudi Arabia, selfadministered questionnaires were distributed around the different regions of the country. Five units were located in Riyadh, four units were in Jeddah and one unit was located in Tabouk. Surveys were collected between March 2005 and May 2005.
After each hospital obtained ethical approval, each unit received the appropriate number of questionnaires through the nursing administrator and the head of the participating unit. Eighty-seven questionnaires were sent out to the ten units involved, and each staff nurse received one questionnaire. A letter accompanied each questionnaire stating clearly that if a nurse wished to participate in the study, he/she could fill it in and place it in the envelope provided, if not he/she could simply put the blank questionnaire in the envelope provided, seal it and give it to the ward secretary who would then return it. After that, the questionnaires were collected by the principal investigator from the hospitals. Both confidentiality and anonymity were maintained throughout the process.
| Statistical Analysis|| |
Descriptive statistical analysis of the data was carried out. The Statistical Package for Social Scientists, SPSS (19.00), was used to analyze the data. Most data were not normally distributed and so statistical tests such as the non-parametric Mann-Whitney test and Spearman's rho test were used to distinguish the relationships and the significant effects between variables.
| Results|| |
Eighty-seven questionnaires were sent out to the ten hospital units; sixty-three questionnaires were completed and returned (response rate = 72%). [Table 1] summarizes information about the ten hospitals.
The number of nurses responding from these ten hospitals ranged from one to 16. Some of the units, especially those that had no specialized renal or dialysis unit, had a larger numbers of nurses sharing the responsibility for PD and received larger numbers of questionnaires while other units had one or two nurses assigned for PD patients. With regard to the number of patients, the findings show that there were 86 pediatric patients on PD in Saudi Arabia. With regard to infection episodes in the ten hospitals, peritonitis episodes varied in each hospital and ranged from zero to three episodes per patient-year (median 1.17 episodes per patient-year).
The majority of nurses (85.7%) said they did not provide home visits to families; only 14.3% did so. The Mann-Whitney test shows a significant association between the number of home visits to patients and the peritonitis rate (P <0.01).
The analysis of training timescale for both continuous ambulatory peritoneal dialysis (CAPD) and continuous cycler peritoneal dialysis (CCPD) showed that for CAPD, 54 nurses answered the question but for CCPD only 34 nurses replied, which left 29 missing responses. However, the timescale for training varied, with CAPD training taking a longer time than CCPD. Most of the nurses said that it took one to two weeks to train CAPD and only one week to train CCPD. [Figure 1] illustrates the comparison between both modalities; it shows a median of a two-week period for CAPD against a one-week period for CCPD training timescale. More details about the timescale for CAPD trainings are shown in [Figure 2] and the details about timescale for CCPD training are shown in [Figure 3]. Spearman's rho test was used to identify the correlation between the training time and the peritonitis rates. There were no statistically significant correlation between the two (r = 0.262, P = 0.056).
|Figure 1: Comparison between continuous ambulatory peritoneal dialysis and continuous cycler peritoneal dialysis training time.|
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|Figure 2: Timescale for continuous ambulatory peritoneal dialysis training.|
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Allocation of nurses for peritoneal dialysis training
66.7% of the participants said that only one nurse is usually assigned per new family for the PD training, 20.6% said that there is more than one nurse responsible for each family and only 6.3% said that each nurse teaches specific tasks for each new family [Figure 4].
Of 63 nurses, 59 answered the question about which materials are used for training; the findings showed that the most common material used was educational booklets (85.7%) [Table 2]. The Mann-Whitney test showed a significant association between the use of educational booklet as training materials and lower peritonitis rate (P = 0.05). However, the same test showed no association between the use of video tape as training materials and peritonitis rate (P = 0.242)
What to teach?
According to the findings, the most common techniques taught are hand-washing (98.4%), dialysis techniques (93.7%) and medications (92.1%), while changing the PD line (46%) and flushing the PD catheter (39.7%) were the least common techniques that were taught in the PD programs [Table 3].
Nurses were asked about how long they instruct parents to wash their hands before PD exchanges. The answers varied; the majority, 28 (44.4%), said for 1 min, while a further 14 nurses (22.2%) said for 3 min. Nurses were also asked about whether they instructed patients to use antibacterial soap and antiseptic gel [Table 4].
|Table 4: Instruction on the use of antibacterial soap and antiseptic gel.|
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A non-parametric Mann-Whitney test was performed, which indicated that there was an association between the instructed use of antibacterial soap and the peritonitis rate (i.e., the greater the use of antibacterial soap, the less the infection rate; P <0.001). The same test showed no association between instruction to use antiseptic gel and peritonitis rates (P = 0.134).
Complications of PD
Nurses were asked to mark on a scale of 1-5 the most common and the least common complication of PD. With regard to peritonitis, of the 63 nurses, 56 (88.9%) responded; 35 (55.6%) of them indicated that peritonitis is the most common complication. The second most common complication identified by 17 (27%) of the nurses was abdominal pain. However, the majority of respondents, 41 (65.1%), stated that constipation is the least common complication with PD therapy [Table 5].
| Discussion|| |
The median of infection rates in the ten hospitals was 1.17 episodes per patient-year. These results are lower than the rates previously reported in Riyadh (2.5 episodes per patient-year)  and lower than the results reported by Mirza et al (1.3 episodes per patient-year).  These findings are also much better than the results reported from other Arab countries such as Tunisia (6.5 episodes per patient-year). 
The fact that most of the nurses indicated that they do not provide home visits may be because their organizations or hospitals do not provide transport services for staff nurses to visit patients. Another reason may be the fact that many patients live in rural areas, in the deserts away from the cities, which makes it difficult to visit them. Nursing staff shortages in the units may also be a reason for it being difficult to send nurses to visit families. Spearman's rho test shows a significant correlation between home visits to patients and peritonitis rate (P <0.01). This finding indicates that home visits should be included in the PD training program for parents of children as the home conditions affect the outcome of the dialysis and the infection rates.
The findings of this study showed different training timescales for CAPD compared with CCPD, when most of the nurses said that it took one to two weeks to train CAPD and only one week to train CCPD. In contrast, previous reports from the UK illustrate that the mean time for CAPD training ranged from one to 2 weeks, while it took more time for CCPD, ranging from one to eight weeks.  Another study stated a mean time of training for both modalities of 6 + 2.2 days (1 day = 6 h).  In Japan, training was reported to occur for 1 h/day over a 35-day period,  while in the US it was reported that the mean training time was 10 days, although they indicated that training does not stop after a set number of days. 
However, it is feasible that there is a variation in training time in different places. Using Spearman's rho, this study showed no correlation between PD training time and peritonitis rates. These results are similar to the previously reported results.  On the other hand, others did find that the greater the amount of training time spent on theory and pratical/technical content, the lower was the associated peritonitis rate (P <0.01). 
Regarding allocation of nurses for PD training, the study findings are similar to those reported by earlier studies. ,, In addition, the need for training by primary nurses was also supported by other authors. , However, the allocation of the same nurse per family will improve consistency in the training and prevent confusion among parents. It also helps to build a close relationship between parents and nurses, which can be reflected in better compliance with training and therefore a better training outcome.
Also, with regard to the most common techniques taught, the findings are similar to the results reported in the UK with regard to teaching dialysis techniques and how to give medication. 
It is feasible that peritonitis (55%) is the most common complication associated with PD therapy in Saudi Arabia, and it could be that abdominal pain and fibrin in fluid is also related to infection-related problems. These results are similar to the ones reported in Tunisia, which indicate that peritonitis was considered to be the main complication of PD therapy. 
This study has taken a step in the direction of examining pediatric PD training programs in Saudi Arabia. The study findings indicate that there is no correlation between the training time and peritonitis rates. However, this study did indicate a significant correlation between the use of educational booklet as training materials and peritonitis rate (P = 0.05). Also, a significant correlation between home visits and peritonitis rate was identified (P <0.01), as also a significant association between instruction to use antibacterial soap and peritonitis (P <0.001).
In addition, the findings of the study suggest that PD programs in Saudi Arabia are varied in structure; nurses who are responsible for the training of parents are varied in their specialties, background and practices.
For the successful use of these research findings in Saudi Arabia, some recommendations are made as a starting point for the change and development of PD training programs in Saudi Arabia. These recommendations are as follows:
- It is preferable that pediatric PD training programs should be developed separately from adult programs because it has been shown that training for pediatrics takes longer than for adults and that there are more procedures to be taught compared with adult teaching programs. However, if a combined program is to be developed, there should at least be a primary PD nurse responsible only for the pediatric patients and for training their families.
- There should be financial support from hospital administrations for PD programs in their units: e.g., providing educational booklets as training materials for parents and also financial support for transport services should be provided from the hospital so that nurses can provide home visits to patients before the start of PD therapy, which is an essential part of the training because the nurse can assess the home environment and therefore can predict possible risks of infection.
Pediatric PD has increased dramatically over the past few years because the transplantation system is very slow. Therefore, nurses and doctors should work together to improve PD in Saudi Arabia. This study has provided an initial overview of pediatric PD training programs and has provided valuable data in this regard. However, there is a need for further research within this field in order to explore in greater depth and provide further information on how to improve the practice of PD training programs. Also, replication of the study after a few years can be useful to monitor any improvement in the practice and, in the future, other more-expanded studies should investigate this issue in greater detail.
Conflict of Interest: None declared.
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Reem S Alhameedi
Faculty of Health Sciences, University of Southampton, Southampton, SO17 1BJ
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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