Perceptions of nurses and clients about nursing care in kidney transplantation

Abstracts

Objective

To analyze the perceptions of nurses and transplanted patients about the pre-transplantation nursing consultation of kidney transplantation.

Methods

Qualitative study with content analysis as the methodological approach. The participants were ten nurses and two categories were identified (contents and user demands in the immediate pre-transplantation phase; and conceptions, behaviors, expectations and emerging situations during and after the kidney transplantation and 20 transplanted patients with two categories (previous experiences with restrictions imposed by the dialysis; and unexpected or conflicting situations identified during and after the transplantation). The research instrument contained the variables related to the sample characteristics, guiding questions and situations of overcoming according to the perceptions of nurse specialists and post-transplanted patients.

Results

Coincidence and complementariness was found between the subjects’ approaches and the forms of coping during and after the transplantation.

Conclusion

The nursing consultation in the pre-transplantation phase is important to incorporate the orientations into the experiences and behaviors of transplanted patients in the course of the transplantation process and after the procedure.das orientações às vivências e comportamentos das pessoas transplantadas ao longo do processo de transplantação e após a realização do procedimento.

Nursing care; Kidney transplantation; Nursing, practical; Nursing process; Nursing research

Objetivo

Analisar as percepções de enfermeiros e dos transplantados sobre a consulta de enfermagem pré-transplante do transplante renal.

Métodos

Estudo qualitativo tendo a análise de conteúdo como aporte metodológico. Participaram dez enfermeiros com identificação de duas categorias (conteúdos e demandas dos usuários na fase de pré-transplante imediato; e concepções, comportamentos, expectativas e situações emergentes no trans/pós-transplante renal) e 20 transplantados com duas categorias (experiências prévias com restrições impostas pela diálise; e situações inesperadas ou conflituosas identificadas no transplante e na fase pós-transplante). O instrumento de pesquisa continha as variáveis relacionadas com a caracterização da amostra, questões norteadoras e situações de superação segundo percepções de enfermeiros especialistas e pessoas pós-transplantadas.

Resultados

Houve coincidência e complementariedade entre as abordagens dos sujeitos e as formas de enfrentamento no trans/pós-operatório.

Conclusão

A consulta de enfermagem no período pré-transplante renal é importante para a incorporação das orientações às vivências e comportamentos das pessoas transplantadas ao longo do processo de transplantação e após a realização do procedimento.

Cuidados de enfermagem; Transplante de rim; Enfermagem prática; Processos de enfermagem; Pesquisa em enfermagem

Introduction

The kidney transplantation is a surgical act that consists in the ablation of one person’s organ and its implantation in another person. It is indicated for people with stage 5 chronic kidney failure. Preemptive transplantation can be considered though, defined as the practice of transplantation before the patient starts the kidney replacement therapy.⁽¹⁾

Kidney transplantation is the preferred option, contributing towards greater survival and a better quality of life for these clients.^(2,3)

Kidney transplantation can be practiced using a healthy organ from a dead or live donor (relative or not). It allows the subject to regain their way of life, generally altered by the aspects involved in the dialysis treatment.^(4-6)

The comparison between the number of kidney transplants and the number of people awaiting a kidney reveals the magnitude of this public health problem. As a result, the government spends resources on the management and maintenance of dialysis patients and impede patients from using the benefits of the transplantation.⁽⁷⁾

It is important to highlight that patients under dialysis, especially hemodialysis, live with several nuances the treatment imposes, including dependence on a machine to survive, the need to live with a treatment access, which is the arteriovenous fistula, graft or double-lumen catheter, and with limitations, such as dietary and fluid volume restrictions. This reality entails negative impacts for the biopsychosocial being and lifestyle of the patients and their families.^(8,9)

The abovementioned situations underline the importance of the transplantation in these people’s life. The risks inherent in the post-kidney transplantation are high.⁽¹⁰⁾ Hence, due to the presence of complications, rejection or not of the graft, the kidney transplantation may mean an abrupt interruption of the transplanted subject’s expectations, representing the need to return to the dialysis treatment, living with its nuances or even with death.

Nursing care is important across the kidney transplantation process in different aspects, highlighting the patient and the family’s preparation for the transplantation, the organ procurement, maintenance of the potential donor in brain death, as well as during and after the transplantation.

The nurses need to prepare to welcome and take care of these patients, respecting their activity context, contributing towards the integrality of care. The nursing consultation is a soft technology modality the nurses use to guide and express their evidence-based professional activities in the work environments and in specialized care.

The premises that justify the development of this research are: 1) living with dialysis treatment is a stressful and bothersome reality that can interfere in the quality of life of patients and their family members; 2) awaiting a kidney can come with disinformation, hampering the assimilation of the defense mechanism to cope with the procedure and the post-transplantation period; 3) the nursing consultation is a care technology modality that can allow the nurses to identify the care needs and demands to cope with the kidney transplantation process and 4) patients’ failed/successful transplantation experiences can guide therapeutic conducts to be included in the content of the nursing consultation in the pre-kidney transplantation period.

In view of the above, the objective in this research was to analyze the nurses and transplanted patients’ perceptions of the nursing consultation in the pre-kidney transplantation period.

Methods

This qualitative study, which adopts content analysis as the methodological approach, was undertaken in 2013 at a specialized nephrology service in an interior city of the State of Minas Gerais and involved nurses and patients after kidney transplantation.

The intentional sample consisted of: 1) Ten nurses who worked with kidney replacement treatment patients before and/or after a kidney transplantation and 2) 20 post-transplantation patients, in coherent verbalization conditions, male and female, over 18 years of age.

The exclusion criteria were: nurses and absent post-transplantation patients (vacation, leave, diseases, trip or absence from the consultation).

The research instrument contained the following research variables: characterization of the participants; guiding question (Post-transplantation patient: did you participate in a nursing consultation? How do you assess the care received? After the kidney transplantation, what situation(s) did you consider unexpected? What did you expect from the transplantation? What did you expect after having received the kidney transplantation? What would you like to receive clarifications about or what are you interested in? and Nurses: How do you conceive the renal transplant patient and the patient to deal with in the kidney transplantation process? What do you consider that needs to be discussed during the pre-renal transplantation nursing consultation? After the renal transplant, what situation do you consider unexpected in your professional experience? What expectation do you witness about the kidney transplant candidates when they submit to the renal transplantation? How do you feel when dealing with people in the kidney transplantation process? What do you consider important to discuss in the pre-renal transplant nursing consultation to favor coping and adherence to the treatment in the post-transplantation period? and additional information.

The data were collected during individual interviews and digitally recorded, held in a private environment and triggered by the guiding questions.

The collected data were organized and analyzed according to the thematic categorical content analysis technique. The recorded data were transcribed and then, the subjects’ discourse was subject to floating reading.

Next, for the sake of further exploration, the material was read repeatedly. This fact permitted the division of the text into recording units and the identification of emerging categories. For that purpose, the software NVivo version 10 was used and the similarity of codes criterion was adopted to identify the units of meaning. The clusters were presented through dendrograms and pie charts, aiming to show the strengths of the link between the units of meaning established, according to Jaccard’s correlation criteria available in that software.

This information added rigor to the data analysis and interpretation, as it favored a graphical image of the links between the thematic categories and the research problem, corresponding to the conceptions of the transplanted patients and the nurse specialists with regard to the contents and utility of the nursing consultation in the pre-renal transplant period. The content analysis was based on literature relevant to the theme.

The research development complied with the Brazilian and international ethical standards for research involving human beings.

Results

Among the 20 transplanted patients, 55% were women between 35 and 43 years of age; 80% had less than eight years of education and 5% ≥14 years; 16.6% were retired and had no stable occupation and 10% were students and general maintenance workers, respectively. The mean waiting time for the renal transplant was two years (range between four months and seven years); 55% of the transplants involved a deceased donor and 75% of the participants took part in the nursing consultation in the pre-kidney transplantation phase.

Among the ten nurses, eight were nephrology specialists; 50% had between five and nine years of professional experience and 30% more than ten years; the length of activity in nephrology ranged between two months and 17 years, with 50% between five and ten years, and the religion practiced was Catholic (50%); Kardecist (20%) and protestant (30%).

Four clusters were identified, two of which served to express the nurses’ impressions (1- contents and demands of the users in the immediate pre-transplantation phase and 2- conceptions, behaviors, expectation and possible situations that emerge during and after the renal transplant) and two to express the transplanted patients’ impressions in the post-procedure period (1- previous experiences with restrictions and kidney replacement therapy and 2- unexpected or conflicting situations that emerged during and after the transplantation) (Figure 1).

Figure 1
Perception of nurses and transplanted patients according to similar coding clusters and respective correlation strengths

Discussion

The limitations in the study results are related to the qualitative method, which does not provide evidence, but can reveal new aspects of the research problem.

The results indicated that, in practice, the pre-transplantation phase is a rich moment that can favor educational approaches, clarification of doubts, reduction of anxiety and reassertion of treatment adherence behaviors in the post-transplantation phase, that is, components that picture the nurse’s activity area and are essential to guarantee the success of the transplantation therapeutics.

The contents the participating nurses highlighted permeated the need to identify the conceptions, knowledge, information and needs individually; the assessment of the users’ expectations and expected lifestyle in the post-transplant phase. Hence, the professionals who have contact with the users throughout the transplant process identify and have reached a consensus on these elements, whether in situations of success or failure.

In the category “contents and demands of users in the immediate pre-transplantation phase”, the requisites, preparations and emerging needs in the pre-renal transplant phase were addressed, expressed in the thematic axes “content addressed and work in the pre-transplant phase” as shown in the dendrogram (Figure 1).

In the pie chart (Figure 1), it could be identified that, in the nurses’ perspective, there was a causal nexus between the contents addressed during the nursing consultation and the possible causes the patients experienced in the course of the renal transplant (intra or immediate or late post-transplant phase). This fact was evidenced by the correlation lines of the knots constructed by means of the coding similarity technique, based on Jaccard’s correlation coefficient. These lines picture the range of the nurses’ perception and experience with the renal transplant process, to the extent that it takes the form of professional perception of the emerging needs and care demands since the pre-transplantation until the intra and post-transplant phase, due to the fact that they know the problems and reasons for failure that may emerge.

There is evidence that adherence in the post-kidney transplant period is more significant without side effects of the immunosuppressive drugs and with appropriate professional monitoring, including compliance with the orientations on how to proceed on certain occasions. This can contribute to return to the previous activities. The relevance of assessing the transplanted patient’s behavior with regard to the health professionals’ orientations is highlighted, with a view to identifying the threshold of non-adherence to the conducts established, especially regarding the medication prescribed in the kidney transplantation context.⁽¹⁰⁾

In the category “conceptions, behaviors, expectations and possible emerging situations during the intra/post-kidney transplant period”, the intent was to understand the participants’ expectations and their information and conceptions about what they experienced during and after the renal transplant, with a view to maximizing the adherence to the treatment and recovery.

The nurses who are active in nursing consultations are affiliated with the transplantation service itself and those who dealt with the users in the kidney replacement phase reaffirmed the importance of addressing some contents in the nursing consultation as a form of preparation, getting familiar with situations they would face in the immediate and mediate post-transplantation phase and adhering to the treatment, aware of the relevance of their conducts to optimize the transplanted organ.

According to the patients going through the renal transplant process, the nursing consultation addressed the conceptions, knowledge and expectations built based on the desired lifestyle for the post-transplantation phase.

The doubts and uncertainties the people who will receive a kidney transplant makes them reaffirm the absence of care and/or treatment in the post-transplantation period, hampering their coping when these situations emerge in the post-transplantation period. The process of providing information and clarifying doubts is fundamental to adjust a healthy and responsible behavior.⁽¹⁰⁾

In addition, there is the personal lack of experience, although they can approximate what will happen to them through the experiences shared with the situation of other colleagues undergoing renal replacement therapy.

Experiencing the possibility of the transplant as a magical formula capable of putting an end to the feeling of being stuck due to the dialysis treatment, overcoming the dissatisfaction with not being able to work and/or study, being obliged to maintain limitations and changes in dietary habits and fluid intake can make the transplant be wanted and sought to overcome these limitations, without influencing the care the transplant procedure will demand. A study that assessed the quality of life before and after the transplant showed an important improvement in the general quality of life in the domains measured, clearly showing the positive result of the renal transplant in the transplanted patients’ lives, mainly in their physical health and social relationships.⁽²⁾

Strategies like the nursing consultation and the use of a questionnaire to measure the quality of life of people who are receiving a transplant can provide evidence of contents that are to be discussed, so that the changes will not turn into situations that are disappointing or impede a high-quality life.

It should be added that the information in the correlation circle, which shows the connections between the categories, permit identifying the lack of links between category 2 (assessment in pre-transplantation life) and categories 3 (current status), 4 (expectations before and after) and 6 (unexpected or conflicting situations) and, therefore, the frailty of these participants to find therapeutic support.

This is equivalent to saying that candidates for a kidney are unable to perceive all possibilities and specific needs that will emerge in the course of the transplantation process during the pre-renal transplant phase. They will need a consolidated interpersonal trust relationship and a bond of referral to use when the demands and needs emerge.

That is the nurses’ view, as demonstrated by the connections between all categories that picture the transplantation process. They have therapeutic resources that can be used during the nursing consultations with kidney transplant candidates, in coping with the transplantation process and in living with a transplanted kidney.

Although the chronic kidney failure is not cured after the renal transplant, i.e. drugs need to be taken, dietary restrictions/care continue and bodily care is needed, the possibility of a transplant is seen as something favorable, with mental repercussions.⁽¹¹⁾

The inclusion of the family members and their understanding can contribute to the treatment and the adherence to the recommended therapeutic conducts. International experiences exist with information centers to clarify doubts.⁽¹²⁾

Evidence exists in the literature that the information and sensitization process of the patients who will undergo a renal transplant favors the overcoming of the limitations that are therapeutically recommended during the post-renal transplantation period, besides helping with adherence to the use of the immunosuppressive drugs, to the extent of reducing the occurrence of graft rejection.⁽¹³⁾

Conclusion

The nursing consultation during the pre-renal transplant period is important to incorporate the orientations into the experiences and behaviors of the transplanted patients in the course of the transplantation process and after the procedure.

Referências

• ¹
  Stevens PE, Levin A; Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158(11):825-30.
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  Weber M, Faravardeh A, Jackson S, Berglund D, Spong R, Matas AJ, et al. Quality of life in elderly kidney transplant recipients. J Am Geriatr Soc. 2014;62(10):1877-82.
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  Garcia GG, Harden P, Chapman J. The global role of kidney transplantation. Nephrol Dial Transplant. 2013;28(8):e1-5.
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  Chadban SJ, Barraclough KA, Campbell SB, Clark CJ, Coates PT, Cohney SJ, et al. KHA-CARI guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Nephrology (Carlton). 2012;17(3):204-14.
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  Israni AK, Salkowski N, Gustafson S, Snyder JJ, Friedewald JJ, Formica RN, et al. New national allocation policy for deceased donor kidneys in the United States and possible effect on patient outcomes. J Am Soc Nephrol. 2014;25(8):1842-8.
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  Blandino MV, Govantes MA, Chaves VC, Pereira Palomo P, Bernal Blanco G, Gonzalez Roncero FM, et al. Information channels and the dynamics of uptake of living kidney donors: a retrospective study in a reference area. Transplant Proc. 2011;43(6):2157-9.
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  Fuzinatto CR, Marin SM, Maissiat GD. Adherence to immunosuppressive treatment in post-renal transplant patientes: a descriptive-explorative-exploratory study. Online Braz J Nurs (Online). 2013;12(2). [citado 2015 Fev 16]. Disponível em: http://www.objnursing.uff.br/index.php/nursing/article/view/3865/htm.
  » http://www.objnursing.uff.br/index.php/nursing/article/view/3865/htm

Publication Dates

• Publication in this collection
  July-Aug 2015

History

• Received
  12 Feb 2015
• Accepted
  4 Mar 2015