Impact of Nurse-Led Intervention on the Level of Anxiety and Depression among Chronic Kidney Disease Patients at Bhubaneswar, Odisha, India

Impact of Nurse-Led Intervention on the Level of Anxiety and Depression among Chronic Kidney Disease Patients at Bhubaneswar, Odisha, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Nurse-Led Intervention on the Level of Anxiety and Depression among Chronic Kidney Disease Patients at Bhubaneswar, Odisha, India Rashmimala Pradhan, Pravati Tripathy, Debaprasad Kar, Smritikana Adak, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7317534/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background Chronic Kidney disease (CKD) patients face ongoing challenges, including lifestyle changes, medication adherence, and managing treatment complexities and complications daily. The aim was to find out the impact of Nurse-led intervention on the level of anxiety and depression among CKD patients. Methods This study was conducted at Institute of Medical Sciences (IMS) and SUM Hospital in Bhubaneswar, Odisha, and focused on CKD patients. The sample consisted of CKD patients aged over 18 years who were proficient in Odia, excluding those with existing mental illness or undergoing psychotherapy. Using block randomization with block sizes of 5 and concealed allocation sequences, participants were distributed to either control or an experimental group.The initial sample size was calculated at 60 participants to accommodate potential dropouts during the study period. Results The Nurse-led intervention helped reduce the anxiety levels among CKD patients at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients, which shows a statistically significant F (2.036) df-29, p < 0.001 and F (26.314) df-2, p < 0.001.Nurse-led intervention on depression scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients, which shows a statistically significant F (22.049) df-29, p < 0.001 and F (75.192) df-2, p < 0.001. Conclusion The nurse-led intervention significantly reduces the score of hospital anxiety and depression scalein CKD patients, highlighting the vital role of nursing care in improving mental health, lifestyle changes and overall wellbeing. Trial registration The clinical trial was registered with India’s Clinical Trial Registry (CTRI/2022/08/044974). Registration Date 260822 Anxiety Chronic kidney disease Depression Lifestyle change Nurse-led intervention Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Chronic Kidney Disease (CKD) is a progressive illness with five phases. In each stage, the patient continues to suffer from the condition and must take responsibility for his health, such as changing his food and lifestyle and taking massive doses of medicine according to the doctor's instructions. Adapting to a chronic condition can be challenging. Patients with CKD can be come across with a life-threatening diagnosis and the need for lifelong treatment, learn dialysis procedures, incorporate treatment into their daily lives, and handle transitions, treatment failures, side effects, and complications on a basis[ 1 ]. CKD is a traumatic disease that has significant psychological impacts on the sufferer. The entire course of treatment is perceived as a complex and challenging experience that includes various physical, social, and emotional constraints. These events result in considerable changes in family life and a loss of independence and reliance on the Social Security System [ 2 , 3 , 4 , 5 ]. Psychological problems such as Anxiety, [ 4 , 5 ] depression,[ 6 ] and nervousness[ 7 ] are common in dialysis patients due to the constraints induced by CKD. ‘Anxiety is defined as unpleasant mental feelings, preoccupations, and tension that are accompanied by bodily symptoms including agitation, headaches, and palpitations[ 8 ]. “Depression is a state of low mood and aversion to activity. The experience of depression of CKD patients affects a person's thoughts, behavior, motivation, feelings, and sense of wellbeing” [ 9 , 10 ] In India, the Screening and Early Evaluation of Kidney Disease (SEEK) programme, which began in 2006 and is a community-based voluntary health screening programme, revealed that the overall prevalence of CKD in the SEEK India cohort was 17.2%, with roughly 6% of patients having CKD stage 3 6. In an Indian study which is recently published, it was found the prevalence of Anxiety and depression in CKD patients were 28% and 61.3%, respectively[ 11 ]. In CKD patients, depression is the second most common disease after hypertension [ 12 ].The majority of risk factors for depression in CKD patients under dialysis include low educational status, being single, low socioeconomic status, duration of dialysis per week, low albumin, hypertension and being female gender [ 13 ]. Hence the objective of the study was to find out the impact of nurse-led intervention on the level of anxiety and depression among CKD patients. Research questions What are the levels of Anxiety and depression among CKD patients? To what extent does nurse-led intervention affect the level of Anxiety and depression among CKD patients? 2. METHODS Population, setting and design This study at IMS and SUM Hospital in Bhubaneswar, Odisha, India, focused on chronic kidney disease patients. An experimental design (Randomized Control Trial) was used for the study for evaluation of Nurse-led interventions to reduce Anxiety and depression among CKD patients. Sample and sampling technique The study included CKD patients aged more than 18 years, proficient in reading, communicating, and understanding Odia, and willing to participate. Patients diagnosed with or undergoing treatment for mental illness or psychotherapy and unstable were excluded. Using a block randomization method with block size 5, participants were randomly allocated to either the control group or interventional group. Allocation sequences were concealed in sequentially numbered sealed envelopes to ensure confidentiality and minimize potential bias. Sample size and power The sample size for this pre- and post-test study was determined using the formula adopted from a similar study by Mateti UV et al. The equation used was: \(\:\:\:n=\frac{{\left({\text{Z}}_{1-\propto\:/2}+{\text{Z}}_{1-{\beta\:}}\right)}^{2}{{\sigma\:}}^{2}}{{\text{d}}^{2}}+2\) Where Z 1−α/2 =1.96 (for α = 5%), Z 1−β =0.84(for 80% power), and d = 0.8, σ = 2, representing the minimum detectable difference between the two groups. Based on this calculation, the minimum sample size required for the study was 40 participants[14, 26]. The calculated total sample size of 40 needed for the study was determined. However, the researcher included an additional 50% of the calculated sample size to account for potential participant dropouts during the study. So, the total sample size was 60. Subsequently, data were gathered for statistical analysis. Description of measuring tool and scoring A self-structure questionnaire was used to collect the participants' socio-demographic and clinical baseline data. It had three sections: section A, section B, section C. Socio-demographic data such as age, sex, educational qualification, type of family, marital status, occupation, domiciliary status, monthly income, and distance from the home, addiction were in Section A. Clinical baseline data such as risk factors and co-morbidity were in section B. Hospital anxiety and depression scale (HADS) was kept in section C. HADS tool contains 14 items, seven items determine level of Anxiety and seven items determine level of depression. Each item had four alternatives, and the participant selected only one based on feelings. Each of these alternatives would be assigned a score from zero to three. The total score of either Anxiety or depression was between zero and 21. If the score is between 11 and 21, they are considered abnormal. The scores were between eight and eleven, deemed abnormal, and zero to seven were considered normal.After determining the validity of the tools, and the reliability was calculated using the Cronbach alpha formula. The values were 0.722 for Anxiety (Hospital Anxiety and Depression Scale (HADS), 0.854 for Depression (HADS) [27]. Procedures for data collection Authors asked eligible samples who were interested in joining the study to sign individual consent forms to enroll in the in intervention. We alsoprovided an information sheet that outline the study’s purpose, voluntary participation, confidentiality, intervention details, and involvement of the participants in the intervention. We collected the socio-demographic data and baseline clinical data from the medical records and participants on the day of admission. We assessed the level of Anxiety and depression by using the standardized tool Hospital Anxiety and Depression Scales (HADS). Over three sessions spaced 15 days apart, patients in the experimental group received a 30-minute educational and motivational talk (Information booklets) and deep breathing exercises at the ends of each session to enhance emotional support, manage mental and physical health, and adjust lifestyle habits. The data was collected from Jan 1, 2024 to October 31, 2024. Intervention Emotional support Supporting individuals with kidney disease involves addressing emotional wellbeing and optimizing sleep quality. Establishing support networks and engaging in daytime activities like exercise and laughter help prepare for restful sleep. Avoiding heavy meals, caffeine, and alcohol before bedtime, maintaining a consistent sleep schedule, and creating a peaceful bedroom promote better sleep. Relaxation techniques such as hot baths or aromatherapy and simple breathing exercises for night-time awakenings can aid in improving sleep quality. If unable to sleep after 20 minutes, moving to a different room and engaging in calming activities like reading are recommended while minimizing exposure to stimulating screens. These strategies are aimed at enhancing overall wellbeing and managing kidney disease. Manage mental health and physical health For CKD patients, managing mental and physical health involves open communication with family and healthcare personnel about emotions and challenges. Following medical advice, maintaining a kidney-friendly diet, exercising regularly, and ensuring sufficient sleep is crucial. Engaging in enjoyable activities and staying informed about your care empowers you. Additionally, nurturing social and spiritual connections supports overall wellbeing, bridging emotional and physical health for a balanced lifestyle despite kidney disease. Lifestyle changes Living with chronic kidney disease (CKD) involves educating yourself and working closely with your healthcare team. Advocate for yourself, manage medications, and monitor lab results regularly. Follow a kidney-friendly diet, exercise regularly, and understand your employment rights and insurance coverage. Manage related conditions like diabetes and high blood pressure, and be mindful of potential complications. If on dialysis, adhere to your treatment plan and take medications as prescribed. Lastly, prioritize emotional wellbeing and adjust to lifestyle changes for a good quality of life with CKD. Outcome measures : For this, the Nurse-Led Intervention with its objectives and session checklist along with the tool was reviewed by seven experts in medical-surgical nursing, nephrology, endocrinology, dietetics and clinical psychology. Using the WHO evaluation format, they rated the intervention on appropriateness, adequacy, clarity, feasibility, and content relevance, along with the logical sequence of sessions. Feedback from the evaluation forms was incorporated to refine the content, ensuring accuracy, clinical relevance, and practical applicability. Analysis of the data We used frequency and percentages to describe participants' characteristics. We used the Kolmogorov-Smirnov test to check the normality of the data. We used repeated measures of ANOVA to test the effect of nurse-led intervention on the level of depression and anxiety. 3. RESULTS We recruited sixty samples through block randomization into experimental and control groups and successfully collected outcome data for all 60 participants. Figure 1 illustrates the participants’ progression through the experimental study. Characteristics of participants The study results showed that the mean age in the experimental and control groups were (49.47 ± 13.42) and (48.47 ± 11.38) respectively. Regarding age distribution, the experimental group showed 10% aged 18–33 years, 40% aged 34–48 years, 33.33% aged 49–63 years, and 16.7% aged 64–78 years. The control group exhibited 13.3% aged 18–33 years, 43.3%aged 34–48 years, 23.3%aged 49–63 years, and 20%aged 64–78 years respectively. A homogeneity test indicated no significant difference in age distribution between groups (p = 0.849). In terms of distance from home to hospital, the experimental group had 50% within 151 km, with a mean distance of (65.21 ± 66.39). The control group had 60% within 151 km, with a mean distance of (47.8 ± 44.28) respectively. Regarding sex distribution, the experimental group had 66.7% males and 33.3% females, while the control group had 60% males and 40% females. The experimental group showed no illiterate individuals, a lower percentage in primary (0%) and high school education (3.33%) and higher percentages in postgraduate education (26.7%) compared to the control group, which had 6.6% illiterate, 19.8% primary, and 19.8% high school education. Both groups have similar percentages in undergraduate (experimental: 33.3%, control: 23.7%) and graduate education (experimental: 33.3%, control: 29.7%). Domiciliary status showed an even split between rural (56.7% experimental, 50% control) and urban (43.3% experimental, 50% control) residents across both groups. Occupation differed notably, with the experimental group having fewer farmers (6.7%) but more unemployed individuals (30%) and 26.7% homemakers compared to the control group (19.8% farmers, 9.9% unemployed and 33.3% homemakers). Regarding the type of family, the experimental group had 40% nuclear families, 56.7% joint families, and 3.3% extended families. In comparison, the control group had 46.7% nuclear families and 53.3% joint families, with no participants in extended families. Regarding marital status, the experimental group had 80% married participants and 20% unmarried, whereas the control group had 93.3% married and 6.7% unmarried individuals.Maximum 50% in the experimental group and 36.7% in the control group in an income between 20001–40000 rupees, 30% in experimental group and 46.7% in control group in the income less than 20000 rupees, 16.7% in experimental group and 13.3% in control group in the income between 40001–60000 rupees and 3.3% in experimental group and 3.3% in control group in the income above 60001 rupees respectively. Table 1 Frequency and percentage distribution of sample according to clinical findings such as risk factors, addiction and co-morbidities. N = 60 VARIABLES EXPERIMENTAL f (%) CONTROL f (%) Risk factors Type 2 DM 8 (26.66) 17 (56.66) Hypertension 24 (80) 26 (86.66) Other ( family history, obesity, kidney disease, Eclampsia) 7 (23) 1 (3.33) Addiction Pre-alcoholic 1 (3.33) 1 (3.33) Pre-smoker 5 (16.66) 4 (13.33) Tobacco chewing 17 (56.7) 18 (60) Mixed 1 (3.3) 1 (3.33) No addiction nil 3 (10) Co-morbidities Hypertension 28 (93.33) 29 (96.7) Type 2 DM 8 (26.7) 17 (56.7) Anaemia 29 (96.7) 30 (100) Undergoing hemodialysis Yes 28 (93.33) 27(90) No 2 (6.67) 3(10) Note : f = frequency, % = percentage, DM = Diabetic Mellitus Clinical data of the CKD patients, such as risk factors, co-morbidities, haemodialysis, and addiction, were represented in Table 1 . Effect of Nurse-led Intervention on Anxiety and Depression To test the effectiveness of nurse-led intervention onanxiety and depression, the following null hypothesis was formulated. H 01 There is no significant difference in mean pre-test and post-test anxiety and depression score ofchronic kidney patients between the experimental and control group. The data in Fig. 2 illustrates the changes in anxiety levels among CKD patients in both experimental and control groups at three different points in time: baseline, sixth week and twelfth week. In the experimental group, following nurse-led intervention, the percentage of CKD patients experiencing abnormal Anxiety decreased from 93.4% at baseline to 56.4% by the end of the 12th week. Border anxiety increased from 6.6–43.3% during the same period. In the control group, an increase in abnormal anxiety levels from 63.3% at baseline to 76.9% by the 12th week, alongside a decrease in borderline Anxiety from 33.4–23.1%. These findings highlight the potential effectiveness of the intervention in reducing severe anxiety levels among CKD patients compared to the control group. Table 2 Repeated measures of ANOVA on anxiety scores within experimental, between experimental control groups at different time points among CKD patients. N = 60 Source of Variation SS df MS F P Anxiety score 61.57 29 2.123 2.036 0.001* Week 54.87 2 27.433 26.314 0.001* Error 60.47 58 1.043 Total 176.9 89 *= significant at p < 0.05 level The data in Table 2 showed the results of repeated measures of ANOVA on the effectiveness of the nurse-led intervention on anxiety scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12thweek of a follow-up visit for CKD patients which shows a statistically significant at F (2.036) df-29, p < 0.001 and F (26.314) df-2, p < 0.001. The data in Fig. 3 depicts the levels of depression among CKD patients in both experimental and control groups across three-time points: baseline, 6th week, 12th week, and 12th week. In the experimental group, the percentage of patients experiencing abnormal depression decreased notably from 86.66% at baseline to 56.4% by the end of the 12th week. Meanwhile, the proportion of patients with borderline depression increased from 13.33–43.3% over the same period. While the control group showed an increase in abnormal depression levels from 63.33% at baseline to 83.33% by the 12th week, with no change in the percentage of patients with borderline depression. These findings underscore the potential benefit of the nursing-led intervention in reducing severe depression among CKD patients compared to the control group. Table 3 Repeated measures of ANOVA on depression scores within experimental, between experimental control groups at different time points among CKD patients. N = 60 Sources of variation SS df MS F P-Value Depression score 163.66 29 5.643 22.049 0.001* WEEK 38.49 2 19.244 75.192 0.001* Error 14.84 58 0.256 Total 216.99 89 The data in Table 3 shows the results of repeated measures of ANOVA on the effectiveness of the nurse-led intervention on depression scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients which shows a statistically significant at F (22.049) df-29, p < 0.001 and F (75.192) df-2, p < 0.001. According to the data (Table 2 /Fig. 2 and Table 3 /Fig. 3 ), hospital anxiety and depression (HADS) scores significantly decrease in the participants in the experimental group following the intervention. Thus, the nurse-led intervention was effective in reducing hospital anxiety and depression scores. 4. DISCUSSION In our study, the mean age was in the experimental group 49.47(SD ± 13.42) and in the control group, 48.47(SD ± 11.38). These results are similar to the study conducted by R T P Veetil et al.and Pradhan R et al. [ 14 , 15 ].Most of the participants in both the groups were male (66.7%in experimental group and 60% in control group)[16].In our study the co-morbidity, anaemia was slightly more prevalent in the control group (100%) than in the experimental group (96.7%). Hypertension showed a similar trend (96.7% vs 93.33%). However, Type 2 diabetes was notably higher in the control group (56.7% vs 26.7%).These results were consistent with the study conducted by Veetil et al.[ 14 ], Sharf AY et al. in anemia (90%) [ 17 ] as co-morbidity and in contrast, 100% haemodialysis patients (HD) had Hypertension (HTN) [ 18 ]. Our study represent that, repeated measures ANOVA showed a statistically significant reduction in anxiety scores within the experimental group over time [F(2.036), df = 29, p < 0.001] and between experimental and control groups across baseline, 6th week, and 12th week [F(26.314), df = 2, p < 0.001], in depression scores within the experimental group [F(22.049), df = 29, p < 0.001] and between experimental and control groups across baseline, 6th week, and 12th week [F(75.192), df = 2, p < 0.001].El-Monshed AH and El-Etreby RR (2019) made a research to evaluate the effect of Cognitive Behavioral nursing intervention on depression and Anxiety among chronic kidney disease patients with haemodialysis. Their findings indicated a highly remarkable difference in pre & post intervention depression scores(p ≤ 0.001). Additionally, the study reported a statistically significancedifference in pre and post intervention anxiety scores(p = 0.021). These results suggest that Cognitive Behavioral nursing intervention effectively reduces both depression and anxiety levels in chronic kidney disease patients undergoing maintenance haemodialysis [ 19 ]. Liao B., Zhao, L. et al. (2020) investigated the impact of comprehensive nursing intervention on Anxiety and depression among haemodialysis patients. Initially, insignificant differences in depression scores between the comprehensive nursing group (64.02 ± 28.58) and the conventional care group (64.15 ± 30.44) before the intervention. However, following the completion of the intervention, both groups demonstrated significant reductions in depression and anxiety scores (p < 0.01). Notably, the comprehensive nursing group showed significantly more substantial improvements in both depression (p = 0.041) and anxiety scores (p = 0.029) identify with theconventional care group. These findings highlight the efficacy of the comprehensive nursing intervention in enhancing mental health outcomes for haemodialysis patients relative to standard care practices [ 20 ]. Zhang QL and Wang S (2021) conducted a study examining the impact of clinically refined nursing interventions for patients receiving maintenance haemodialysis amidst the COVID-19 epidemic. Before the psychological intervention, patients scored 2.38 ± 0.30 for depression and 2.29 ± 0.27 for Anxiety on the 10-factor SCL-90 scale. Following the intervention, depression scores decreased to 1.59 ± 0.35 and anxiety scores decreased to 1.57 ± 0.23 (t depression = 6.02, p < 0.01; t anxiety = 7.99, p < 0.01). These findings indicate that the clinically refined nursing intervention effectively alleviated depression and Anxiety among patients receiving maintenance haemodialysis at the time COVID-19 epidemic [ 21 ]. A study highlighted, the impact on depression and Anxiety of nursing guidelines in critically ill patients having acute kidney injury (AKI) receiving haemodialysis. They found statistically significant changes in anxiety and depression levels between the control and intervention groups. Application of nursing guidelines resulted in significantly lower anxiety and depression levels in the intervention group compared to the control group (p < 0.001 for both Anxiety and depression) [22]. Duarte and Miyazaki (2009) conducted a randomized trial in Brazil to evaluate the impact on Cognitive-Behavioral Therapy (CBT) among patients receiving maintenance haemodialysis diagnosed with major depression using the Mini International Neuropsychiatric Interview (MINI). The study included an intervention group where significant reductions in the mean score of MINI central depression module were observed at three months (mean difference ± S.D: 4.5 ± 0.4, p < 0.001) and nine months (mean difference ± S.D: 4.4 ± 0.5 points, p < 0.001) compared to baseline. After three months, the mean change from baseline was remarkably more significant in the intervention group (4.5 ± 0.4) compared to the control group (2.1 ± 0.6) with p-value < 0.001. Similarly, after nine months, the intervention group (4.4 ± 0.4) showed a remarkably more significant mean change from baseline than the control group (2.9 ± 0.5) with a value of 0.031. These findings indicate that CBT was effective in reducing symptoms of major depression among chronic haemodialysis patients, demonstrating sustained benefits over nine months [23, 24, 25]. Limitation The research had self-reported measurements where there could be participants’ bias. 5. IMPLICATION FOR PRACTICE The findings highlight the significance of implementing nurse-led interventions as a part of routine care for chronic kidney disease patients. Regular psychological assessment and structured nursing strategies can help in early identification and management of anxiety and depression, leading to improved mental health outcomes, better treatment adherence, and enhanced quality of life. Integrating such interventions into dialysis units and nephrology care settings can promote holistic patient management and reduce the psychosocial burden associated with CKD. 6. CONCLUSION Based on our study findings, the nurse-led intervention significantly reduces the level of anxiety and depression among chronic kidney disease patients. The personalized care, consistent monitoring, and emotional support nurses provide with usual care substantially improve patients' mental health and lifestyle. This approach enhances the patient's wellbeing and indicates nursing interventions' critical role in managing chronic kidney disease.Future research should focus on conducting large-scale, multi-center randomized controlled trials to further evaluate the effectiveness of nurse-led interventions on anxiety and depression in patients with chronic kidney disease (CKD). Abbreviations 1. Chronic Kidney disease CKD 2. Institute of Medical Sciences IMS 3. Screening and Early Evaluation of Kidney Disease SEEK 4. Hospital anxiety and depression scale HADS 5. Analysis of variance ANOVA 6. Diabetic Mellitus DM 7. Haemodialysis HD 8. Hypertension HTN 9. Acute Kidney Injury AKI 10. Cognitive Behavioral Therapy–CBT 11. Mini International Neuropsychiatric Interview MINI Declarations ETHICAL APPROVAL Ethical permission was procured from the Institutional Ethical Committee of the Institute of Medical Sciences (IMS) and SUM Hospital on 8th November 2021 (Ref. No: IEC/IMS.SH/SOA/2021/235). Written consent was taken from the participant for the study. The data collection period was 1st Jan 2024 to october31st 2024. Trial registration: The clinical trial was registered with India’s Clinical Trial Registry (CTRI/2022/08/044974). Registration Date 26 October 2022 HUMAN ETHICAL CONSIDERATIONS AND CONSENT FROM PARTICIPANTS Ethical clearance and approval were obtained from the Institutional Review Board of SUM Nursing College, Siksha ‘O’ Anusandhan (Deemed to be University), Bhubaneswar (Approval No: Ref.no SOA/DU/SNC/IRB/447/2024). Formal permission was secured from the Medical Superintendent of IMS & SUM Hospital, Bhubaneswar, and the HOD of Nephrology Department as well as In-charge of Dialysis unit. The investigator introduced themselves to the participants, explained the purpose of the study, and assured them of confidentiality. Written informed consent was obtained from each participant before data collection. CONSENT TO PARTICIPANTS DECLARATION All procedures involving human participants (Haemodialysis patients) were conducted in accordance with the ethical standards of the Institutional Ethics Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from each participant before data collection. CONSENT FOR PUBLICATION : Not applicable Data availability statement We confirm that the data supporting the findings of this study will be shared upon reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conflict of interest There was no conflict of interest. Funding Self-funding Author contributions a. Conception and design: R. Pradhan, P. Tripathy, D. Kar, and S. Adak b. Acquisition, analysis, and interpretation of data: R. Pradhan, and S. Adak c. Manuscript drafting and revising it critically: R. Pradhan, P. Tripathy, D. Kar, and S. Adak, BhanuPriya, PuspanjaliMohapatro d. Approval of the final version of the manuscript: R. Pradhan, P. Tripathy, D. Kar, S. Adak, BhanuPriya e. Guarantor of accuracy and integrity of the work: R. Pradhan, Acknowledgements We would like to acknowledge the HOD of the Nephrology Department IMS &SUM hospital for providing the necessary facilities to carry out this research work. The authors thank all the CKD patients and other health professionals for their support. It is a part of randomized control trial study. References Cukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial aspects of chronic disease. J Am Soc Nephrol [Internet]. 2007;18(12):3042–55. https://doi.org/10.1681/asn.2007030345 . De Menezes FG, Abreu RM, Itria A. Cost-effectiveness analysis of paricalcitol versus calcitriol for the treatment of SHPT in dialytic patients from the SUS perspective. Brazilian J Nephrol [Internet]. 2016;38(3). https://doi.org/10.5935/0101-2800.20160048 . 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Effect of Educational Nursing Guidelines on Self-management and Health-Related Quality of Life for Hemodialysis Patients. Iranian Journal of Nursing and Midwifery Research. 2024;29(4):460-5. DOI : 10.4103/ijnmr . ijnmr_191_22 . El-Monshed AH, El-Etreby RR, Ahmed N, El-Boraie OA. Effect of cognitive behavioural nursing intervention on depression and Anxiety among patients on maintenance hemodialysis. IOSR J Nurs 2019 Doi: 10.9790/1959-0802065867 Liao B, Zhao L, Peng Y, Chen J, Chen W, Wang X. Effect of comprehensive nursing intervention on negative emotion, quality of life and renal function of hemodialysis patients. Int J ClinExp Med. 2020;13(2):949–57. https://ijcem.com/files/ijcem0101591 . Zhang QL, Wang S, Zhang Y, &Meng F. The effect of refined nursing intervention on patients undergoing maintenance hemodialysis in the hemodialysis centre during the COVID-19 epidemic. BMC Nurs, 2021Apri26;20(1):66. 10.1186/s12912-021-00584-5 Ahmed NA, Abdou FA, Ahmed ZA. Effect of Nursing Guidelines on Anxiety and Depression among Critically Ill Patients with Acute Kidney Injury and Undergoing Hemodialysis. Int J Novel Res Healthc Nurs. 2019;6(3):846–54. https://www.noveltyjournals.com/upload/paper/Effect%20of%20Nursing%20Guidelines%20on%20Anxiety-2100 . Duarte PS, Miyazaki MC, Blay SL. &Sesso, R. Cognitive–behavioural group therapy is an effective treatment for major depression in hemodialysis patients. Kidney Int. 2009;76(4):41421. https://doi.org/10.1038/ki.2009.156 . HamdiElzeiny H, Mahmoud M, El-Emary F. Efficacy of Psychological Interventions in Reducing the Prevalence and Intensity of Depression in Patients with Long-Term Hemodialysis. Egypt J Health Care. 2023;14(1):132–43. https://doi.org/10.21608/ejhc.2023.279723 . Valsaraj BP, Bhat SM, Latha KS. Cognitive behaviour therapy for anxiety and depression among people undergoing haemodialysis: a randomized control trial. J Clin Diagn research: JCDR. 2016;10(8):VC06. .https://doi.org/10.7860/jcdr/2016/18959.8383 . Mateti UV, Nagappa AN, Attur RP, Bairy M, Nagaraja SP, Mallayasamy S. Preparation, Validation and user-testing of pictogram –based PatientInformation Leaflet for hemodialysis patients. Saudi Pharm J. 2015;23(6):621–5. Kumar K, Kumar S, Mehrotra D, Tiwari SC, Kumar V, Dwivedi RC. Reliability and psychometric validity of Hindi version of Depression, Anxiety and Stress Scale-21 (DASS-21) for Hindi speaking head neck cancer and oral potentially malignant disorders patients. J Cancer Res Ther. 2019;15(3):653–8. Additional Declarations No competing interests reported. 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Pradhan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIie3RMUvDQBTA8RcOkuXaW680kK+Q46CZar9KSgaXU5yK4GCncyk4i1/iJsEtcOAtsXMlDsYhXYI4dqhgqlIzpLWjw/2nO44f78EB2Gz/MxcgBOh+n1MAb/rzgP4g7pbg9BACTULj/VtFV6Z8XZzdBa73+PC+mjwHUW9ZvKzgKACvk7YRPxMRF2HOJD5Nbmbzkt3fCs5mkLAp6rbOoyDcfk0cCYJDR2pH5cKlGFAMCIethCzLDRlJUnHnQ+qRejJlbw2XuwmNBxsyllRwVE8ZqwUM+hj0HlJ9kUTStwT5c52oTHDuh4bJnYsd14ut8+E1OdFONdFDZUxRVOcXASFZK2mEm5ft5x5ObDabzfbbJ/3aWT2HIfX5AAAAAElFTkSuQmCC","orcid":"","institution":"SUM Nursing College, Siksha O Anusandhan (Deemed to be University)","correspondingAuthor":true,"prefix":"","firstName":"Rashmimala","middleName":"","lastName":"Pradhan","suffix":""},{"id":534471692,"identity":"d08bb5fc-76c9-4d0d-800b-30fc5d793cf6","order_by":1,"name":"Pravati Tripathy","email":"","orcid":"","institution":"SUM Nursing College, Siksha O Anusandhan (Deemed to be 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04:19:02","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114261,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7317534/v1/6234a2d1c7d8d9a946365fcb.html"},{"id":94623424,"identity":"bac81785-cec7-4f21-94d1-5ae6d94bacb5","added_by":"auto","created_at":"2025-10-29 04:19:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39858,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design as per consort guidelines, 2010\u003c/p\u003e","description":"","filename":"RevisedBMCNURSELEDINTERVENTION1.png","url":"https://assets-eu.researchsquare.com/files/rs-7317534/v1/49df243ee4754c0386bc15ca.png"},{"id":94623381,"identity":"9289d42a-0ba3-4698-b23a-d1084fd8011a","added_by":"auto","created_at":"2025-10-29 04:19:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24235,"visible":true,"origin":"","legend":"\u003cp\u003eStacked bar chart showing the level of Anxiety between groups over time.\u003c/p\u003e","description":"","filename":"RevisedBMCNURSELEDINTERVENTION2.png","url":"https://assets-eu.researchsquare.com/files/rs-7317534/v1/c42b485c06068e590251ac4b.png"},{"id":94623229,"identity":"07d7cd04-7ee8-445a-bbf8-98ce77e0d26c","added_by":"auto","created_at":"2025-10-29 04:19:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21665,"visible":true,"origin":"","legend":"\u003cp\u003eStacked bar chart showing the level of Depression between groups over time.\u003c/p\u003e","description":"","filename":"RevisedBMCNURSELEDINTERVENTION3.png","url":"https://assets-eu.researchsquare.com/files/rs-7317534/v1/b02c6981c67f8ebf0abfdc6f.png"},{"id":94623775,"identity":"d0f43eba-ad2f-497c-9011-69e522a0e65e","added_by":"auto","created_at":"2025-10-29 04:19:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":853584,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7317534/v1/4fbbe619-1a31-485a-9105-943509aa0596.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Nurse-Led Intervention on the Level of Anxiety and Depression among Chronic Kidney Disease Patients at Bhubaneswar, Odisha, India","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eChronic Kidney Disease (CKD) is a progressive illness with five phases. In each stage, the patient continues to suffer from the condition and must take responsibility for his health, such as changing his food and lifestyle and taking massive doses of medicine according to the doctor's instructions. Adapting to a chronic condition can be challenging. Patients with CKD can be come across with a life-threatening diagnosis and the need for lifelong treatment, learn dialysis procedures, incorporate treatment into their daily lives, and handle transitions, treatment failures, side effects, and complications on a basis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCKD is a traumatic disease that has significant psychological impacts on the sufferer. The entire course of treatment is perceived as a complex and challenging experience that includes various physical, social, and emotional constraints. These events result in considerable changes in family life and a loss of independence and reliance on the Social Security System [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePsychological problems such as Anxiety, [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] depression,[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and nervousness[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] are common in dialysis patients due to the constraints induced by CKD. ‘Anxiety is defined as unpleasant mental feelings, preoccupations, and tension that are accompanied by bodily symptoms including agitation, headaches, and palpitations[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e“Depression is a state of low mood and aversion to activity. The experience of depression of CKD patients affects a person's thoughts, behavior, motivation, feelings, and sense of wellbeing” [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn India, the Screening and Early Evaluation of Kidney Disease (SEEK) programme, which began in 2006 and is a community-based voluntary health screening programme, revealed that the overall prevalence of CKD in the SEEK India cohort was 17.2%, with roughly 6% of patients having CKD stage 3 6. In an Indian study which is recently published, it was found the prevalence of Anxiety and depression in CKD patients were 28% and 61.3%, respectively[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn CKD patients, depression is the second most common disease after hypertension [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e12\u003c/span\u003e].The majority of risk factors for depression in CKD patients under dialysis include low educational status, being single, low socioeconomic status, duration of dialysis per week, low albumin, hypertension and being female gender [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Hence the objective of the study was to find out the impact of nurse-led intervention on the level of anxiety and depression among CKD patients.\u003c/p\u003e\u003cp\u003eResearch questions\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat are the levels of Anxiety and depression among CKD patients?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo what extent does nurse-led intervention affect the level of Anxiety and depression among CKD patients?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003c/span\u003e\u003c/ol\u003e"},{"header":"2. METHODS","content":"\u003cp\u003e\u003cb\u003ePopulation, setting and design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study at IMS and SUM Hospital in Bhubaneswar, Odisha, India, focused on chronic kidney disease patients. An experimental design (Randomized Control Trial) was used for the study for evaluation of Nurse-led interventions to reduce Anxiety and depression among CKD patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample and sampling technique\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study included CKD patients aged more than 18 years, proficient in reading, communicating, and understanding Odia, and willing to participate. Patients diagnosed with or undergoing treatment for mental illness or psychotherapy and unstable were excluded. Using a block randomization method with block size 5, participants were randomly allocated to either the control group or interventional group. Allocation sequences were concealed in sequentially numbered sealed envelopes to ensure confidentiality and minimize potential bias.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample size and power\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sample size for this pre- and post-test study was determined using the formula adopted from a similar study by Mateti UV et al.\u003c/p\u003e\u003cp\u003eThe equation used was:\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\:\\:n=\\frac{{\\left({\\text{Z}}_{1-\\propto\\:/2}+{\\text{Z}}_{1-{\\beta\\:}}\\right)}^{2}{{\\sigma\\:}}^{2}}{{\\text{d}}^{2}}+2\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eWhere Z \u003csub\u003e1−α/2\u003c/sub\u003e=1.96 (for α = 5%), Z\u003csub\u003e1−β\u003c/sub\u003e=0.84(for 80% power), and d = 0.8, σ = 2, representing the minimum detectable difference between the two groups. Based on this calculation, the minimum sample size required for the study was 40 participants[14, 26]. The calculated total sample size of 40 needed for the study was determined. However, the researcher included an additional 50% of the calculated sample size to account for potential participant dropouts during the study. So, the total sample size was 60. Subsequently, data were gathered for statistical analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDescription of measuring tool and scoring\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA self-structure questionnaire was used to collect the participants' socio-demographic and clinical baseline data. It had three sections: section A, section B, section C. Socio-demographic data such as age, sex, educational qualification, type of family, marital status, occupation, domiciliary status, monthly income, and distance from the home, addiction were in Section A. Clinical baseline data such as risk factors and co-morbidity were in section B. Hospital anxiety and depression scale (HADS) was kept in section C. HADS tool contains 14 items, seven items determine level of Anxiety and seven items determine level of depression. Each item had four alternatives, and the participant selected only one based on feelings. Each of these alternatives would be assigned a score from zero to three. The total score of either Anxiety or depression was between zero and 21. If the score is between 11 and 21, they are considered abnormal. The scores were between eight and eleven, deemed abnormal, and zero to seven were considered normal.After determining the validity of the tools, and the reliability was calculated using the Cronbach alpha formula. The values were 0.722 for Anxiety (Hospital Anxiety and Depression Scale (HADS), 0.854 for Depression (HADS) [27].\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcedures for data collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Authors asked eligible samples who were interested in joining the study to sign individual consent forms to enroll in the in intervention. We alsoprovided an information sheet that outline the study’s purpose, voluntary participation, confidentiality, intervention details, and involvement of the participants in the intervention. We collected the socio-demographic data and baseline clinical data from the medical records and participants on the day of admission. We assessed the level of Anxiety and depression by using the standardized tool Hospital Anxiety and Depression Scales (HADS). Over three sessions spaced 15 days apart, patients in the experimental group received a 30-minute educational and motivational talk (Information booklets) and deep breathing exercises at the ends of each session to enhance emotional support, manage mental and physical health, and adjust lifestyle habits. The data was collected from Jan 1, 2024 to October 31, 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEmotional support\u003c/p\u003e\u003cp\u003eSupporting individuals with kidney disease involves addressing emotional wellbeing and optimizing sleep quality. Establishing support networks and engaging in daytime activities like exercise and laughter help prepare for restful sleep. Avoiding heavy meals, caffeine, and alcohol before bedtime, maintaining a consistent sleep schedule, and creating a peaceful bedroom promote better sleep. Relaxation techniques such as hot baths or aromatherapy and simple breathing exercises for night-time awakenings can aid in improving sleep quality. If unable to sleep after 20 minutes, moving to a different room and engaging in calming activities like reading are recommended while minimizing exposure to stimulating screens. These strategies are aimed at enhancing overall wellbeing and managing kidney disease.\u003c/p\u003e\u003cp\u003eManage mental health and physical health\u003c/p\u003e\u003cp\u003eFor CKD patients, managing mental and physical health involves open communication with family and healthcare personnel about emotions and challenges. Following medical advice, maintaining a kidney-friendly diet, exercising regularly, and ensuring sufficient sleep is crucial. Engaging in enjoyable activities and staying informed about your care empowers you. Additionally, nurturing social and spiritual connections supports overall wellbeing, bridging emotional and physical health for a balanced lifestyle despite kidney disease.\u003c/p\u003e\u003cp\u003eLifestyle changes\u003c/p\u003e\u003cp\u003eLiving with chronic kidney disease (CKD) involves educating yourself and working closely with your healthcare team. Advocate for yourself, manage medications, and monitor lab results regularly. Follow a kidney-friendly diet, exercise regularly, and understand your employment rights and insurance coverage. Manage related conditions like diabetes and high blood pressure, and be mindful of potential complications. If on dialysis, adhere to your treatment plan and take medications as prescribed. Lastly, prioritize emotional wellbeing and adjust to lifestyle changes for a good quality of life with CKD.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome measures\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eFor this, the Nurse-Led Intervention with its objectives and session checklist along with the tool was reviewed by seven experts in medical-surgical nursing, nephrology, endocrinology, dietetics and clinical psychology. Using the WHO evaluation format, they rated the intervention on appropriateness, adequacy, clarity, feasibility, and content relevance, along with the logical sequence of sessions. Feedback from the evaluation forms was incorporated to refine the content, ensuring accuracy, clinical relevance, and practical applicability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis of the data\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used frequency and percentages to describe participants' characteristics. We used the Kolmogorov-Smirnov test to check the normality of the data. We used repeated measures of ANOVA to test the effect of nurse-led intervention on the level of depression and anxiety.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e We recruited sixty samples through block randomization into experimental and control groups and successfully collected outcome data for all 60 participants.\u003c/p\u003e\u003cp\u003eFigure\u0026nbsp;1 illustrates the participants\u0026rsquo; progression through the experimental study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCharacteristics of participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study results showed that the mean age in the experimental and control groups were (49.47\u0026thinsp;\u0026plusmn;\u0026thinsp;13.42) and (48.47\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38) respectively. Regarding age distribution, the experimental group showed 10% aged 18\u0026ndash;33 years, 40% aged 34\u0026ndash;48 years, 33.33% aged 49\u0026ndash;63 years, and 16.7% aged 64\u0026ndash;78 years. The control group exhibited 13.3% aged 18\u0026ndash;33 years, 43.3%aged 34\u0026ndash;48 years, 23.3%aged 49\u0026ndash;63 years, and 20%aged 64\u0026ndash;78 years respectively. A homogeneity test indicated no significant difference in age distribution between groups (p\u0026thinsp;=\u0026thinsp;0.849). In terms of distance from home to hospital, the experimental group had 50% within \u0026lt;\u0026thinsp;50 km, 40% within 51\u0026ndash;150 km, and 10%\u0026gt;151 km, with a mean distance of (65.21\u0026thinsp;\u0026plusmn;\u0026thinsp;66.39). The control group had 60% within \u0026lt;\u0026thinsp;50 km, 36.7% within 51\u0026ndash;150 km, and 3.3% \u0026gt;151 km, with a mean distance of (47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;44.28) respectively.\u003c/p\u003e\u003cp\u003eRegarding sex distribution, the experimental group had 66.7% males and 33.3% females, while the control group had 60% males and 40% females. The experimental group showed no illiterate individuals, a lower percentage in primary (0%) and high school education (3.33%) and higher percentages in postgraduate education (26.7%) compared to the control group, which had 6.6% illiterate, 19.8% primary, and 19.8% high school education. Both groups have similar percentages in undergraduate (experimental: 33.3%, control: 23.7%) and graduate education (experimental: 33.3%, control: 29.7%). Domiciliary status showed an even split between rural (56.7% experimental, 50% control) and urban (43.3% experimental, 50% control) residents across both groups. Occupation differed notably, with the experimental group having fewer farmers (6.7%) but more unemployed individuals (30%) and 26.7% homemakers compared to the control group (19.8% farmers, 9.9% unemployed and 33.3% homemakers).\u003c/p\u003e\u003cp\u003eRegarding the type of family, the experimental group had 40% nuclear families, 56.7% joint families, and 3.3% extended families. In comparison, the control group had 46.7% nuclear families and 53.3% joint families, with no participants in extended families. Regarding marital status, the experimental group had 80% married participants and 20% unmarried, whereas the control group had 93.3% married and 6.7% unmarried individuals.Maximum 50% in the experimental group and 36.7% in the control group in an income between 20001\u0026ndash;40000 rupees, 30% in experimental group and 46.7% in control group in the income less than 20000 rupees, 16.7% in experimental group and 13.3% in control group in the income between 40001\u0026ndash;60000 rupees and 3.3% in experimental group and 3.3% in control group in the income above 60001 rupees respectively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency and percentage distribution of sample according to clinical findings such as risk factors, addiction and co-morbidities. N\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVARIABLES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEXPERIMENTAL\u003c/p\u003e\u003cp\u003ef (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCONTROL\u003c/p\u003e\u003cp\u003ef (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRisk factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType 2 DM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (26.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (56.66)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (86.66)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther ( family history, obesity, kidney disease, Eclampsia)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAddiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-alcoholic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (16.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (13.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTobacco chewing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (56.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMixed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (3.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003enil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCo-morbidities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (93.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (96.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType 2 DM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (56.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnaemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (96.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUndergoing hemodialysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (93.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27(90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (6.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: f\u0026thinsp;=\u0026thinsp;frequency, % = percentage, DM\u0026thinsp;=\u0026thinsp;Diabetic Mellitus\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eClinical data of the CKD patients, such as risk factors, co-morbidities, haemodialysis, and addiction, were represented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEffect of Nurse-led Intervention on Anxiety and Depression\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo test the effectiveness of nurse-led intervention onanxiety and depression, the following null hypothesis was formulated.\u003c/p\u003e\u003cp\u003eH\u003csub\u003e01\u003c/sub\u003e There is no significant difference in mean pre-test and post-test anxiety and depression score ofchronic kidney patients between the experimental and control group.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe data in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the changes in anxiety levels among CKD patients in both experimental and control groups at three different points in time: baseline, sixth week and twelfth week. In the experimental group, following nurse-led intervention, the percentage of CKD patients experiencing abnormal Anxiety decreased from 93.4% at baseline to 56.4% by the end of the 12th week. Border anxiety increased from 6.6\u0026ndash;43.3% during the same period. In the control group, an increase in abnormal anxiety levels from 63.3% at baseline to 76.9% by the 12th week, alongside a decrease in borderline Anxiety from 33.4\u0026ndash;23.1%. These findings highlight the potential effectiveness of the intervention in reducing severe anxiety levels among CKD patients compared to the control group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRepeated measures of ANOVA on anxiety scores within experimental, between experimental control groups at different time points among CKD patients. N\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSource of Variation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeek\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26.314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eError\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e176.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*= significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe data in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e showed the results of repeated measures of ANOVA on the effectiveness of the nurse-led intervention on anxiety scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12thweek of a follow-up visit for CKD patients which shows a statistically significant at F (2.036) df-29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and F (26.314) df-2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe data in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e depicts the levels of depression among CKD patients in both experimental and control groups across three-time points: baseline, 6th week, 12th week, and 12th week. In the experimental group, the percentage of patients experiencing abnormal depression decreased notably from 86.66% at baseline to 56.4% by the end of the 12th week. Meanwhile, the proportion of patients with borderline depression increased from 13.33\u0026ndash;43.3% over the same period. While the control group showed an increase in abnormal depression levels from 63.33% at baseline to 83.33% by the 12th week, with no change in the percentage of patients with borderline depression. These findings underscore the potential benefit of the nursing-led intervention in reducing severe depression among CKD patients compared to the control group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRepeated measures of ANOVA on depression scores within experimental, between experimental control groups at different time points among CKD patients. N\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSources of variation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e163.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.643\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e22.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWEEK\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eError\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e216.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe data in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results of repeated measures of ANOVA on the effectiveness of the nurse-led intervention on depression scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients which shows a statistically significant at F (22.049) df-29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and F (75.192) df-2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003cp\u003eAccording to the data (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e/Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e/Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e), hospital anxiety and depression (HADS) scores significantly decrease in the participants in the experimental group following the intervention. Thus, the nurse-led intervention was effective in reducing hospital anxiety and depression scores.\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eIn our study, the mean age was in the experimental group 49.47(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;13.42) and in the control group, 48.47(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38). These results are similar to the study conducted by R T P Veetil et al.and Pradhan R et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e15\u003c/span\u003e].Most of the participants in both the groups were male (66.7%in experimental group and 60% in control group)[16].In our study the co-morbidity, anaemia was slightly more prevalent in the control group (100%) than in the experimental group (96.7%). Hypertension showed a similar trend (96.7% vs 93.33%). However, Type 2 diabetes was notably higher in the control group (56.7% vs 26.7%).These results were consistent with the study conducted by Veetil et al.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], Sharf AY et al. in anemia (90%) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e17\u003c/span\u003e] as co-morbidity and in contrast, 100% haemodialysis patients (HD) had Hypertension (HTN) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study represent that, repeated measures ANOVA showed a statistically significant reduction in anxiety scores within the experimental group over time [F(2.036), df\u0026thinsp;=\u0026thinsp;29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001] and between experimental and control groups across baseline, 6th week, and 12th week [F(26.314), df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001], in depression scores within the experimental group [F(22.049), df\u0026thinsp;=\u0026thinsp;29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001] and between experimental and control groups across baseline, 6th week, and 12th week [F(75.192), df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001].El-Monshed AH and El-Etreby RR (2019) made a research to evaluate the effect of Cognitive Behavioral nursing intervention on depression and Anxiety among chronic kidney disease patients with haemodialysis. Their findings indicated a highly remarkable difference in pre \u0026amp; post intervention depression scores(p\u0026thinsp;\u0026le;\u0026thinsp;0.001). Additionally, the study reported a statistically significancedifference in pre and post intervention anxiety scores(p\u0026thinsp;=\u0026thinsp;0.021). These results suggest that Cognitive Behavioral nursing intervention effectively reduces both depression and anxiety levels in chronic kidney disease patients undergoing maintenance haemodialysis [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Liao B., Zhao, L. et al. (2020) investigated the impact of comprehensive nursing intervention on Anxiety and depression among haemodialysis patients. Initially, insignificant differences in depression scores between the comprehensive nursing group (64.02\u0026thinsp;\u0026plusmn;\u0026thinsp;28.58) and the conventional care group (64.15\u0026thinsp;\u0026plusmn;\u0026thinsp;30.44) before the intervention. However, following the completion of the intervention, both groups demonstrated significant reductions in depression and anxiety scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Notably, the comprehensive nursing group showed significantly more substantial improvements in both depression (p\u0026thinsp;=\u0026thinsp;0.041) and anxiety scores (p\u0026thinsp;=\u0026thinsp;0.029) identify with theconventional care group. These findings highlight the efficacy of the comprehensive nursing intervention in enhancing mental health outcomes for haemodialysis patients relative to standard care practices [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eZhang QL and Wang S (2021) conducted a study examining the impact of clinically refined nursing interventions for patients receiving maintenance haemodialysis amidst the COVID-19 epidemic. Before the psychological intervention, patients scored 2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30 for depression and 2.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27 for Anxiety on the 10-factor SCL-90 scale. Following the intervention, depression scores decreased to 1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35 and anxiety scores decreased to 1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23 (t depression\u0026thinsp;=\u0026thinsp;6.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; t anxiety\u0026thinsp;=\u0026thinsp;7.99, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings indicate that the clinically refined nursing intervention effectively alleviated depression and Anxiety among patients receiving maintenance haemodialysis at the time COVID-19 epidemic [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A study highlighted, the impact on depression and Anxiety of nursing guidelines in critically ill patients having acute kidney injury (AKI) receiving haemodialysis. They found statistically significant changes in anxiety and depression levels between the control and intervention groups. Application of nursing guidelines resulted in significantly lower anxiety and depression levels in the intervention group compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both Anxiety and depression) [22]. Duarte and Miyazaki (2009) conducted a randomized trial in Brazil to evaluate the impact on Cognitive-Behavioral Therapy (CBT) among patients receiving maintenance haemodialysis diagnosed with major depression using the Mini International Neuropsychiatric Interview (MINI). The study included an intervention group where significant reductions in the mean score of MINI central depression module were observed at three months (mean difference\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D: 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and nine months (mean difference\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D: 4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 points, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to baseline. After three months, the mean change from baseline was remarkably more significant in the intervention group (4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) compared to the control group (2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6) with p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Similarly, after nine months, the intervention group (4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) showed a remarkably more significant mean change from baseline than the control group (2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5) with a value of 0.031. These findings indicate that CBT was effective in reducing symptoms of major depression among chronic haemodialysis patients, demonstrating sustained benefits over nine months [23, 24, 25].\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe research had self-reported measurements where there could be participants\u0026rsquo; bias.\u003c/p\u003e"},{"header":"5. IMPLICATION FOR PRACTICE","content":"\u003cp\u003eThe findings highlight the significance of implementing nurse-led interventions as a part of routine care for chronic kidney disease patients. Regular psychological assessment and structured nursing strategies can help in early identification and management of anxiety and depression, leading to improved mental health outcomes, better treatment adherence, and enhanced quality of life. Integrating such interventions into dialysis units and nephrology care settings can promote holistic patient management and reduce the psychosocial burden associated with CKD.\u003c/p\u003e"},{"header":"6. CONCLUSION","content":"\u003cp\u003eBased on our study findings, the nurse-led intervention significantly reduces the level of anxiety and depression among chronic kidney disease patients. The personalized care, consistent monitoring, and emotional support nurses provide with usual care substantially improve patients' mental health and lifestyle. This approach enhances the patient's wellbeing and indicates nursing interventions' critical role in managing chronic kidney disease.Future research should focus on conducting large-scale, multi-center randomized controlled trials to further evaluate the effectiveness of nurse-led interventions on anxiety and depression in patients with chronic kidney disease (CKD).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e1. Chronic Kidney disease\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCKD\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e2. Institute of Medical Sciences\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIMS\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e3. Screening and Early Evaluation of Kidney Disease\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSEEK\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e4. Hospital anxiety and depression scale\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHADS\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e5. Analysis of variance\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eANOVA\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e6. Diabetic Mellitus\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDM\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e7. Haemodialysis\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHD\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e8. Hypertension\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHTN\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e9. Acute Kidney Injury\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAKI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e10. Cognitive\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBehavioral Therapy\u0026ndash;CBT\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e11. Mini International Neuropsychiatric Interview\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMINI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical permission was procured from the Institutional Ethical Committee of the Institute of Medical Sciences (IMS) and SUM Hospital on 8th November 2021 (Ref. No: IEC/IMS.SH/SOA/2021/235). Written consent was taken from the participant for the study. The data collection period was 1st Jan 2024 to october31st 2024. Trial registration: The clinical trial was registered with India\u0026rsquo;s Clinical Trial Registry (CTRI/2022/08/044974). Registration Date 26 October 2022\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHUMAN ETHICAL CONSIDERATIONS AND CONSENT FROM PARTICIPANTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance and approval were obtained from the Institutional Review Board of SUM Nursing College, Siksha \u0026lsquo;O\u0026rsquo; Anusandhan (Deemed to be University), Bhubaneswar (Approval No: Ref.no SOA/DU/SNC/IRB/447/2024). Formal permission was secured from the Medical Superintendent of IMS \u0026amp; SUM Hospital, Bhubaneswar, and the HOD of Nephrology Department as well as In-charge of Dialysis unit. The investigator introduced themselves to the participants, explained the purpose of the study, and assured them of confidentiality. Written informed consent was obtained from each participant before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT TO PARTICIPANTS DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants (Haemodialysis patients) were conducted in accordance with the ethical standards of the Institutional Ethics Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from each participant before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that the data supporting the findings of this study will be shared upon reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea.\u0026nbsp; \u0026nbsp;Conception and design: R. Pradhan, P. Tripathy, D. Kar, and S. Adak\u003c/p\u003e\n\u003cp\u003eb.\u0026nbsp; \u0026nbsp;Acquisition, analysis, and interpretation of data: R. Pradhan, and S. Adak\u003c/p\u003e\n\u003cp\u003ec. Manuscript drafting and revising it critically: R. Pradhan, P. Tripathy, D. Kar, and S. Adak,\u0026nbsp;BhanuPriya, PuspanjaliMohapatro\u003c/p\u003e\n\u003cp\u003ed. Approval of the final version of the manuscript: R. Pradhan, P. Tripathy, D. Kar, S. Adak,\u0026nbsp;BhanuPriya\u003c/p\u003e\n\u003cp\u003ee. \u0026nbsp; \u0026nbsp;Guarantor of accuracy and integrity of the work: R. Pradhan,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the HOD of the Nephrology Department IMS \u0026amp;SUM hospital for providing the necessary facilities to carry out this research work. The authors thank all the CKD patients and other health professionals for their support. It is a part of randomized control trial study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial aspects of chronic disease. 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J Cancer Res Ther. 2019;15(3):653\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anxiety, Chronic kidney disease, Depression, Lifestyle change, Nurse-led intervention","lastPublishedDoi":"10.21203/rs.3.rs-7317534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7317534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eChronic Kidney disease (CKD) patients face ongoing challenges, including lifestyle changes, medication adherence, and managing treatment complexities and complications daily. The aim was to find out the impact of Nurse-led intervention on the level of anxiety and depression among CKD patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study was conducted at Institute of Medical Sciences (IMS) and SUM Hospital in Bhubaneswar, Odisha, and focused on CKD patients. The sample consisted of CKD patients aged over 18 years who were proficient in Odia, excluding those with existing mental illness or undergoing psychotherapy. Using block randomization with block sizes of 5 and concealed allocation sequences, participants were distributed to either control or an experimental group.The initial sample size was calculated at 60 participants to accommodate potential dropouts during the study period.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe Nurse-led intervention helped reduce the anxiety levels among CKD patients at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients, which shows a statistically significant F (2.036) df-29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and F (26.314) df-2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.Nurse-led intervention on depression scores within experimental, between experimental and control groups at different periods, i.e. baseline, 6th week and 12th week of a follow-up visit for CKD patients, which shows a statistically significant F (22.049) df-29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and F (75.192) df-2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe nurse-led intervention significantly reduces the score of hospital anxiety and depression scalein CKD patients, highlighting the vital role of nursing care in improving mental health, lifestyle changes and overall wellbeing.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eThe clinical trial was registered with India\u0026rsquo;s Clinical Trial Registry (CTRI/2022/08/044974). Registration Date 260822\u003c/p\u003e","manuscriptTitle":"Impact of Nurse-Led Intervention on the Level of Anxiety and Depression among Chronic Kidney Disease Patients at Bhubaneswar, Odisha, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:10:51","doi":"10.21203/rs.3.rs-7317534/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T12:29:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-01T09:34:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168697415813688374347830704318115538475","date":"2026-01-01T06:32:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60401819205568399755282665226783293374","date":"2025-12-31T14:56:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96856033855052388793086065078529084461","date":"2025-12-29T10:32:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T12:36:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202514323052222928644690250212511168173","date":"2025-11-12T09:39:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53003250917921009707753571003771560003","date":"2025-11-10T13:42:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169400665895456288577602670593058085657","date":"2025-11-08T01:33:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208453049640735346888454984830169026490","date":"2025-11-07T13:44:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T05:59:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138422173434418666442150695922539007498","date":"2025-10-23T04:56:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317082851163935216229962092548059593372","date":"2025-10-15T03:10:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283243370156042109034400297644663678166","date":"2025-10-14T13:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T11:23:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-31T18:25:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T10:18:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-08-26T10:14:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7910c34-5145-49a7-9969-c0f3074b9cc2","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T07:38:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:10:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7317534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7317534","identity":"rs-7317534","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}