Nurses’ Behavior and Support Systems as External Factors of Nurse-

Patient Interaction in the Dialysis Unit

Ika Yuni Widyawati, Ika Nur Pratiwi, Laily Hidayati, Tintin Sukartini, Abu Bakar

and Lailatun

Ni’mah

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Nurse-Patient Interactions, Nurse Behavior, Social Support, Dialysis Patient, Interpretative

Phenomenological Approach.

Abstract: The quality of nurse-patient interaction is one factor that affects patients’ adherence. However, a study

providing an overview of factors in nurse-patient interaction for improving or maintaining dialysis

adherence in patients has not been found. The aim of this study was to provide an overview of the various

factors of the interaction between nurses and patients undergoing dialysis, in adherence with fluid and

dietary restrictions. A qualitative research design with an interpretive phenomenology approach was used in

this study. The unit of analysis used was the disclosure or exposure of external factors from the nurse-

patient interaction process, especially in fluid and dietary restrictions. Fifteen participants were selected

based on the following inclusion criteria (patients with a minimum age of 18 years, receiving similar

dialysis therapy for at least 3 months, in stable medical condition [not currently in acute condition requiring

immediate medical treatment], and not experiencing psychological problems). In-depth interviews

accompanied by field notes were used in this study. Analysis of the themes based on the goal of the research

included nurses’ behavior and social support. The results provide an overview of findings regarding nurse-

patient interaction factors that can serve as baseline data for the development of care, both in nursing

assessment and intervention, aimed at improving the adherence to dietary and fluid restrictions of dialysis

patients.

1 BACKGROUND

Patients on dialysis face many challenges in their

lives, in which they have to recognize their disease

and follow, cope with, and adapt to their treatment

and changes in their lives and behavior (Royani et

al., 2013). Patients undergoing dialysis must follow

rules to make their lives adequate (Kidney Disease:

Improving Global Outcomes [KDIGO] CKD Work

Group, 2013). Physically, patients undergoing

regular dialysis have kidney damage that affects the

body's ability to maintain metabolism, fluid, and

electrolyte balance, leading to a uremic condition

(Black & Hawks, 2009; Smeltzer & Bare, 2008).

Physical changes, the complexity of the rules to

be followed, and the psychological stress

experienced by the patient continues throughout

their life (Kaptein et al., 2010). Various stressors

they experience means that dialysis patients are

unable to accept changes and feel they have no

control over their lives (Warrior, 2015).

Not all patients are in favor of the treatment

process and this affects their willingness to control

their behavior (Warrior, 2015; Wijaya, 2005). The

failure of management and treatment of dialysis

patients are due to the non-adherence of patients

(Addo, 2015). Non-adherence of patients on dialysis,

regarding fluid restriction and diet programs, has an

impact on the occurrence of complications, an

increased length of stay, decreased productivity, and

can even cause death (Alikari et al., 2015; Payne et

al., 2013; Saran et al., 2003).

Interventions to improve the adherence to diet

and fluid restrictions in dialysis patients have been

conducted. The success of interventions to improve

adherence depends on a series of factors, such as the

realistic assessment of the knowledge and

understanding of the patient regarding the regimen

of therapy given, clear and effective communication

between health professionals and patients, and

fostering a sense of trust in the therapeutic

relationship (Martin et al., 2005).

Widyawati, I., Pratiwi, I., Hidayati, L., Sukartini, T., Bakar, A. and Ni’mah, L.

Nurses’ Behavior and Support Systems as External Factors of Nurse-Patient Interaction in the Dialysis Unit.

DOI: 10.5220/0008319700140021

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 14-21

ISBN: 978-989-758-336-0

Nurses play an important role in this regard. In

addition to providing care, nurses also provide

additional assistance to patients in the form of

interpersonal support and encouragement that aims

to help patients effectively cope with stress, improve

their welfare, and accelerate their recovery (De los

Ríos Castillo & Sánchez-Sosa, 2002). The

partnership and collaboration that exists between

health professionals and patients can maximize

compliance, foster patient satisfaction, and improve

the health of patients (Martin et al., 2005).

The results of literature studies show that some

studies confirm that nurse-patient interactions

contribute to patient compliance. Research

conducted by Ningsih, Rachmadi, and Hammad

(2012), revealed that the rate of patient compliance

does not depend on demographic data, but the

quality of the interaction between health and other

factors. Other studies show that factors affecting

fluid intake is related to education, self-concept,

patients’ knowledge, health professionals, and

family involvement (Kamaluddin, 2009). Both

studies used quantitative research, but the interaction

of patients and nurses is a subjective process, so it is

necessary to conduct research using a qualitative

design.

Research providing an overview of nurse-patient

interaction factors in fluid-limiting and dietary

adherence in dialysis units is relatively limited and

necessary. The qualitative research prior to the topic

of interaction factors of nurses and patients had been

conducted by Loghmani, Borhani, and Abbaszadeh

(2014) and focuses on the excavation of factors that

influence the communication aspects between the

nurses and patients’ families. The aim of this study

is to provide an overview of various factors in the

interaction process of nurses and patients

undergoing dialysis in compliance with fluid and

dietary restrictions.

2 METHODS

This research uses a qualitative research design and

the chosen approach is interpretive phenomenology

because the researcher intends to interpret the

findings of the research. In this case, the researcher

intends to analyze the activity of nurses and dialysis

patients to obtain a picture of various factors in the

interaction process between them. The unit of

analysis used in this study is the disclosure or

exposure of external factors in the nurse-patient

interaction process.

There were 15 patients included in this research

and they were selected based on inclusion criteria.

The inclusion criteria was patients with a minimum

age of 18 years, have been receiving similar dialysis

therapy for at least three months, in stable medical

condition (not currently experiencing an acute

condition requiring immediate medical treatment),

and not experiencing psychological problems.

In-depth interviews (in-depth interviews)

equipped with field notes (field notes) were used in

this study. The validity of the data was conducted by

confirming the transcription of the interview results

with the participants. Inter-researcher and theory

triangulation were used to maintain data stability and

maintain the objectivity of the data. The aim to

triangulate data by involving fellow researchers was

to enrich the findings of results, while theory

triangulation conducted by researchers, using the

theory of nurse-patient interactions from Imogene

King, provided another perspective regarding what

nurse-patient interaction is. This research has been

ethically approved by the Medical Research Ethics

Commission Faculty of Nursing Universitas

Airlangga No.: 326-KEPK.

3 RESULTS

Background data of participants are provided in

Table 1. Participants described external factors

affecting the enhancement of adherence through

nurse-patient interaction into two themes: 1) nurse

behavior; and 2) social support. Descriptions of

these themes and sub-themes can be seen in Table 2.

Table 1: Specific characteristics of the

participants.

Characteristics

Gender

Male

Female

Age

Young Age (18–65 y.o)

Middle Age (66–79 y.o)

Education

Elementary

Middle

Higher

Length of Dialysis (in years)

<5 years

5–10 years

Nurses’ Behavior and Support Systems as External Factors of Nurse-Patient Interaction in the Dialysis Unit

Table 2: Description of external factors affecting nurse-patient interaction in enhancing diet and fluid-limitation

adherence.

Themes

Sub-themes

Transcription Quotes

Nurses

Behavior

Caring

person

Facing with

the careless

one

"I am most happy and feel welcomed if the nurse smiles at me. It’s like she gave me an

opportunity for us to get closer to each other and discuss anything including my

difficulty to limit consuming fruit and drink a lot of water" (P10).

“Ns. Xxxx, I’ve always loved her, it’s always a wonderful discussion with her. She is a

good listener, tries to know what kind of reason that makes it difficult for me to

adhere. She never judges me” (P3).

"I am so pleased to communicate with the nurse when she (the nurse) is willing to do

that. The nurse’s attitude showed that she opens herself to discuss with me and my

wife” (P8).

"... if the nurse was nice and friendly ... it would be nice for me to start to

communicate with her" (P12).

"I always trust nurses who are very skillful. I have a perception that skillful nurses are

the ones who have more knowledge than others. When she gives me advice, I can be

sure that worth for me" (P5).

“... I’d rather not try to communicate with the nurse who keeps silent and does not

even smile when I meet her” (P2).

"I always try what the nurse said, because I believe they know better than me. What

we want as a patient is the nurse can give us enough information, so we can avoid the

wrong step" (P4).

"I feel afraid when the nurse seems not confident with herself. How can I trust what

she says when she looks hesitant and not so sure?" (P13).

Social

Support

Source of

social

support

The form of

Social

support

The

influence of

social

support

"My wife who became a security guard at the same time is my source of strength. She

always supports me to communicate with all nurses when I feel some difficulties"

(P2).

"My mom who accompanied me through all this from the beginning. She initiated

interaction with nurses, doctors and others" (P8).

"When I feel not in the mood to interact with others, including nurses, my sister is

always beside me and encourages me to do so" (P10).

"Fellow patients are giant shoulders for each other. When we met and chatted, we

motivate and inform each other" (P12).

"My wife always motivates me" (P3).

"Talking with nurses and doctors, or fellow patients provides additional information

for me" (P6).

"Discussions with other people makes me feel relieved” (P1).

"Fellow patients always ask or discuss with me, how can I stay healthy and fit even

though it was already five years of dialysis. The nurses used me for an example when

they gave advice to other patients and yes it’s an honor to me" (P15).

"The more motivated I am from nurse or fellow patients more cheerful I am" (P10).

"Mostly I start to interact with nurses, other patients or their families because they

welcome me to the society. It’s a comfort to me" (P3).

"... maybe because I am understanding much better now about my disease and the

treatment that I should follow, I think that good cooperation between me and the nurse

is beneficial for my life too" (P14).

"I feel more relaxed right now, try to face everything ahead. If I need more

information I can ask the nurse, doctor or other patients. I am enjoying every process"

(P2).

"As a moslem I should be ikhlas, this is what makes me look patient through all five

years" (P4).

"I can tell you that I am more receptive to information now and have started reducing

negative thoughts in my head" (P13).

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

3.1 Nurses’ Behavior

This nurses’ behavior factor was demonstrated by all

participants. Nurses’ behavior within the nurse-

patient interaction process, supports patient

compliance behavior in terms of diet and fluid

restriction. The image of the nurse as a caring person

is shown by the behavior of a person full of smiles, a

good listener, an open-minded attitude, friendly, and

skillful.

When a nurse is careless, their behavior in the

nurse-patient interaction process is less supportive of

patient compliance in terms of diet and fluid

restriction. Less caring nurses are portrayed by

participants as having less attention to the needs of

patients, are less informative, and display hesitant

behavior during discussions or actions.

3.1.1 A Caring Person

Nurses who show a caring attitude to patients

interact more intensively, including conveying

various matters related to compliance that must be

achieved. Participants conveyed that there are many

rules to follow, which tire and bore patients.

Communication with health workers must be an

effort to discuss reducing the risk of non-

compliance. Participants revealed that

communication, as part of the nurse-patient

interaction process, can be realized when the nurse

shows caring behavior towards a patient.

Patients feel they can initiate more intensive and

open interactions with nurses. Various compliance

issues can be well discussed the best solutions can

be sought. An overview of a caring nurse from a

participant's perspective is shown in the transcription

quote shown in Table 2.

3.1.2 Facing Careless Nurses

Participants illustrate that their interactions with

nurses sometimes caused a decline in their good

spirit. Some participants said that this was because

the interaction was with careless nurses.

Participants said that nurses who were less

attentive to the needs of patients, less informative

and displayed hesitant behavior during discussions

or actions made the patient feel disbelief regarding

the care or advice by nurses. An overview of

careless nurses from the participants perspective is

shown in the transcription quotes in Table 2.

3.2 Social Support

Social support is the last theme that emerges as an

external factor affecting nurse-patient interaction.

This theme consists of the following sub-themes: 1)

the source of social support, including the family,

parents, and peers; 2) form of social support (in the

categories of emotional [attention and motivation],

informational, instrumental/material [lightening

burden] and appreciation [pride]); 3) the influence of

social support (consisting of a change of attitude

[cheap smile, initiation of communication and

cooperative], and psychological changes [feeling

more calm, more patient and having positive

thoughts).

3.2.1 Sources of Social Support

The nurse-patient interactions described by the

participants were not only influenced by the two

individuals involved, i.e. patients and nurses, but

also by other individuals who were in the circle of

interactions. Some participants described their

experiences when initiating interaction with nurses

during which the participants were new to

undergoing dialysis and not yet aware of the rules.

At that time, nurse-patient interaction is not

immediate but is initiated by the spouse or other

family member.

Participants illustrate that, at the time of the

initial dialysis, the patient felt denial with the

conditions to be faced. Dialysis is not a preferred

treatment option, so in the early days of patient’s

diagnosis, they prefer to be left alone and avoid

interaction, not only with health workers, but also

with family members or friends.

Participants also described the nurse-patient

interaction process after the first year of dialysis.

Dialysis patients are in a routine, such as patients,

who must undergo hemodialysis (HD) (twice a

week, four or five hours each time) and strive to

remain obedient to the rules described, under various

conditions or complications during dialysis or post-

dialysis, and various other problems (whether

physical, psychological, social, or economic). These

conditions create a new tension in the nurse-patient

interaction process.

Participants convey frequently that the good

intentions of nurses in giving warnings or

reassertions cause a feeling of pressure on the

patient. This also occurs in the nurse-patient

interaction process associated with adherence to diet

and fluid restriction, therefore patients may refuse to

interact with nurses. Therefore, nurses still must

Nurses’ Behavior and Support Systems as External Factors of Nurse-Patient Interaction in the Dialysis Unit

communicate various things that are needed through

existing support systems. The source of social

support in the participant's view is shown in the

transcription quotes in Table 2.

3.2.2 Forms of Social Support

External factors of social support that influence the

nurse-patient interaction process is described by

participants in various forms, such as emotional

support, informational support, instrumental/material

support, and appreciation. Participants said that the

various forms of support they have received are

needed by patients undergoing dialysis.

Some participants said that dialysis and all the

rules that must be followed are an extraordinary

burden of life, so the various forms of support that

are provided can lighten the burden. The

participants’ views of social support are shown in

the transcriptions in Table 2.

3.2.3 The Influence of Social Support

Social support was described by participants as

providing a positive influence on nurse-patient

interaction. Positive influences felt by participants

can change participants' attitudes and support them

in adhering to fluid restrictions and dietary rules.

Changes experienced by participants include

changes in attitudes and psychological conditions.

Participants conveyed that nurses’ efforts in

approaching patients when they are not being

cooperative can soften the patient and change their

psychological condition. Eventually, the nurse-

patient interaction process is more intensive and

helps the psychological condition to improve as is

support provided by family or other patients. The

influences of social support from the participants’

perspective are shown in the transcription quotes in

Table 2.

4 DISCUSSIONS

Nurses’ behavior appears to be one of the themes

that emerges as an external factor affecting nurse-

patient interaction. The nurse-patient relationship is

a means of exchanging information and their

involvement in care (Millard, Hallett, & Luker,

2006). Therefore interpersonal nurse-patient

interactions should be an important element of

patients involvement in care and help to determine

the success of patients including their adherence to

treatment recommendations (Chatwin, 2008;

Nordby, 2007; Stoddart et al., 2012).

Nurses are trained to interact well and are

expected to have interpersonal dimensions that help

the patients being treated (De los Ríos Castillo &

Sánchez-Sosa, 2002). Nurses in special units, such

as dialysis units, also receive training to improve

their competence and abilities.

The nurse-patient interaction process is seen in

nursing and caring situations (Scheel, Pedersen, &

Rosenkrands, 2008). Caring is evidence of the

application of interactions that embody cognitive,

aesthetic, and competence skills (Scheel, Pedersen,

& Rosenkrands, 2008). Participants stated that a

caring attitude made the patient feel at ease and they

felt they had the support to pass the day successfully

in the dialysis unit.

The caring attitude shown by nurses make

patients undergoing dialysis more comfortable in

openly discussing their adherence. This is consistent

with research performed by Owens (2006) whose

research says that the verbal and non-verbal caring

behavior of the nurses influences and improves

patients' medication adherence.

Qualified nurses will certainly gain the trust of

patients, and vice versa. If a nurse cannot act

according to the expectations of patients, this will

certainly cause stress on the patient and affect the

interaction process (Garcia et al., 2014; King, 2007).

Skilled nurses who create a good interpersonal

relationship will make patients more open in sharing

difficulties and experiences to achieve and maintain

their health (Caris-Verhallen, Timmermans, & Van

Dulmen, 2004; Zhang et al., 2001).

The non-caring response expressed by some

participants referred to previous experiences in

which participants received treatment from nurses

who did not show good competence when acting;

they knew this because the nurse who treated them

was new to the unit. The clinical experience of the

nurse will help build the nurse's competence (Kim &

Kim, 2015). Nurses who have minimal experience

will certainly experience barriers in interacting with

patients. A hesitant attitude in acting may arise as a

nurse’s self-precaution.

A less informative or discriminatory attitude

expressed by the participants is also an important

note in nurse-patient interaction. The interaction

between nurses and patients is not merely an

interaction in the form of communication but every

item that connects the nurse and their patient will

directly show how the interaction between them is

intertwined. Both positive verbal and non-verbal

interactions will certainly help build a therapeutic

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

atmosphere among nurses and their patients.

Interaction, in the form of poor communication, will

have an impact on the emotional discomfort of

patients (Williams & Irurita, 2004).

In this research, social support became an

external factor that influenced the nurse-patient

interaction process. The participants stated that

social support components were helping them to

initiate better communication with nurses.

Therefore, keeping them motivated in knowing more

about their diet and fluid regimen. As we all know,

dialysis patients must adhere to many lifestyle

changes, including diet and fluid restriction.

Adherence to diet, fluids, and dialysis is the

cornerstone of renal failure treatment (Ahrari,

Moshki, & Bahrami, 2014).

The burden of life and the burden of the disease

can make them become reclusive to others,

including nurses; this is a detrimental for patients.

However, nurses should give advice to support

patients and encourage them to adhere. Providing a

good nurse-patient interaction process is important

for healthcare professionals of dialysis centers. This

can support communication with the patient, and

convince and motivate them. Therefore, all barriers

must be broken to persuade HD patients and bring

them into adherence behaviors (Victoria, Evangelos,

& Sofia, 2015). Social support from their families

provide patients with practical help buffer the

stresses of living with the illness (Miller &

DiMatteo, 2013).

Much research has shown that social support

correlates with treatment adherence behaviors

(Vardanjani et al., 2013; Miller & DiMatteo, 2013),

dietary adherence and fluid restrictions (Ahrari,

Moshki & Bahrami, 2014), medication adherence

(Scheurer et al., 2012), but research that

demonstrates the correlation of social support and

nurse-patient interaction was less known.

5 CONCLUSIONS

Based on information that has been described in the

research and analysis discussion, the researchers

have highlighted that there are two external factors

affecting nurse-patient interaction: nurses’ behavior

and social support. The results of this study are

expected to provide a material consideration for

proper nursing care and the development of

appropriate nursing interventions for each issue that

was experienced by patients in each phase, as well

as materials for the professional development of

nurses and quality improvements in nursing.

ACKNOWLEDGEMENTS

The researchers are grateful to all participants in this

study.

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