Patient-Staff Interactions and Mental Health in Chronic Dialysis Patients
Swartz, Richard D., Perry, Erica, Brown, Stephanie, Swartz, June, Vinokur, Amiram, Health and Social Work
In the United States, nearly 450,000 individuals now undergo chronic dialysis, with more than 50,000 new patients appearing each year (United States Renal Data Service [USRDS], 2005). Complications are common, and there is predictable and relentless attrition from the population, with an annual mortality rate of 15 percent to 20 percent (USRDS, 2005). On a day-to-day basis, dialysis treatment substantially alters normal lifestyle, including large amounts of time several days per week spent on treatment and related activities, multiple prescription medications, multiple dietary restrictions, and residual symptoms that interfere with full participation in work, school, or household management (USRDS, 2005). It is no surprise that patients are often depressed and that interpersonal interactions are affected (Rhodes, 1981). In fact, clinically significant depression affects as many as 30 percent or more of dialysis patients and is associated with higher mortality (Christensen & Ehlers, 2002; Deoreo, 1997; Kimmel, Peterson, Weihs, Simmens, et al., 2000; Lopes et al., 2002; Watnick, Kirwin, Mahnensmith, & Concato, 2003) and lower levels of adherence to the medical regimen (Kimmel et al., 1995, 1998; Kimmel, Peterson, Weihs, Simmens, et al., 2000).
Dialysis treatment is ongoing, often lasting many years, virtually until the end of life; thus, the chronic dialysis unit presents a unique opportunity to observe specific psychosocial phenomena (Rhodes, 1981; Wuerth, Finkelstein, Kliger, & Finkelstein, 2000), including the quality of interpersonal relationships formed between patients and staff. Yet, the influence of such interpersonal phenomena on mental health is not emphasized in the dialysis literature. It is important to address this oversight because quality relationships are associated with improved general health and well-being (House, Landis, & Umberson, 1988) and may be particularly so in chronically in individuals such as dialysis patients.
Although patient--staff relationships have not been studied in depth, several studies have examined the importance of social support in the dialysis setting. In one early study, social support appears to predict sociability and correlates to some degree with the presence of anxiety in chronic dialysis patients at baseline but does not predict longer term outcomes in mental health (Burton, Kline, Lindsay, & Heidenheim, 1988). McClellan and colleagues (1993) reported that patients' perceptions of support from family or dialysis staff did not correlate with mortality, but this study did not evaluate other clinical or mental health outcomes. Other researchers reported that dyadic family relationships correlate with mortality and with social support but that social support does not independently predict outcome (Kimmel, Peterson, Weihs, Shidler, et al., 2000). In a study from a large international dialysis database, Saran and colleagues (2003) reported that adherence (as a surrogate) is worse in larger dialysis units, which might have less patient--staff interaction, but did not report on social support in particular or on mental health outcomes in general.
We hypothesized that quality interpersonal relationships between dialysis patients and staff have a beneficial effect on patient mental health. In particular, the present study was designed to test whether patients who perceive interactions to be more open and personal also have higher well-being and less depression. We have focused on open communication (open disclosure in this study) as indicative of these perceptions because Christensen and Ehlers have (2002) suggested that perceived social support among dialysis patients is conducive to more open expression in interpersonal communications and that open expression is associated with less depression and anxiety (Christensen & Ehlers, 2002). This construction is supported by others who have suggested that clearer and more honest communication in the dialysis setting reduces anxiety and enhances the perceived quality of service (Giancchino, Manzato, DePiccoli, & Ponzetti, 2000), that patient satisfaction is influenced by perceptions of the interpersonal atmosphere (Wuerth et al. …