The effect of self-care training on death anxiety in hemodialysis patients: A randomized clinical trial.

Diagnosing a chronic disease by confronting patients with their own mortality can cause them suffer from death anxiety.[ 1 ] Death anxiety consists of anxiety or fear of the thought of death or any idea related to dying.[ 2 ] In hemodialysis patients fear of death or death anxiety is one of the psychological issues.[ 3 ] Being caught with chronic kidney failure and facing the fact that this disease is progressive and irreversible, makes patients suffer from a high level of death anxiety.[ 4 ] Researchers have reported the prevalence of death anxiety in hemodialysis patients to be 60.4%.[ 5 ] Death anxiety was significantly higher in hemodialysis patients who were married, female, over 75 years old, and who lived with their families and needed self-care and social support.[ 6 ] Death anxiety can be associated with many negative consequences that can significantly affect the every life domain and daily performance.[ 7 ] Also, death anxiety as a basic fear can be the basis for the creation, maintenance and course of many psychological conditions.[ 8 ] For some people, the fear of death can lead to a decrease in satisfaction, happiness,[ 9 ] and quality of life.[ 10 ] A systematic review has revealed several psychosocial interventions that can address fear and death anxiety experienced by patients with chronic diseases. such as: meaning therapy, cognitive behavioral therapy, spirituality-based care, and educational interventions.[ 11 ] Recent research has indicated that patient-centered counseling promotes positive outcomes by encouraging patients to actively participate in treatment programs.[ 12 ] According to the World Health Organization (WHO), self-care is “the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a health care provider.”[ 13 ] The self-care programs increase people’s knowledge and awareness of their condition and enables them to better cope with their reduced physical and mental functioning by improving their psychological well-being,[ 14 ] restructuring cognitions, sustaining healthy escapes, maintaining mindfulness, creating a flourishing environment, cultivating spirituality and mission, fostering creativity and growth,[ 15 ] and probably death anxiety. Regarding the effect of self-care on anxiety, contradictory results have been reported, so that in a study counseling based on self-care reduces patients’ stress and anxiety by improving their sense of security.[ 16 17 ] While the level of death anxiety of hemodialysis patients was not affected by illness perception intervention, including self-care, in another study.[ 18 ] However, the researchers of this study did not find a similar study that considers the family-centered self-care from the perspective of death anxiety in hemodialysis patients. Considering the knowledge gap caused by the contradictory results and the limitations of similar studies, this study was designed with aimed of determining the effect of self-care training on death anxiety in hemodialysis patients.

In this study, the data from 50 hemodialysis patients were analyzed. The sampling process is shown in the CONSORT form in Figure 1 . Flow diagram of the randomization and sampling process The Shapiro-Wilk test results showed that, the distribution of quantitative variables was normal. The data analysis results showed that, the mean ± SD of the age of the subjects was 60.16 ± 14.01 with a minimum of 24 and maximum of 86 years. The gender of 25 (50%) patients was female. Education level of the 32 (64%) patients, were illiterate and under diploma, 13 (26%) had diploma and 5 (10%) had academic. Near half of the patients 24 (48%) were housewife, and the most was married 48 (96%). The mean ± SD of the dialysis history was 3.66 ± 2.42 with a minimum of 1 and maximum of 10 years. Results of independent t -test showed that the mean ± SD of the age in intervention group was 59.00 ± 16.59 and in control group were 61.32 ± 11.07. No significant statistical difference was observed between them ( P = 0.564). Also no statistically significant difference was observed between the study groups regarding mean ± SD of history of dialysis, gender, educational level, job, marital status, and underlying disease [ Table 1 ]. Comparison of the demographic characteristics between study groups *Pearson Chi-Square test. **Fisher Exact test. ***Independent t -test In the intervention group, the mean ± SD of DAS score was 8.04 ± 2.35 before the intervention and reach to 5.28 ± 1.65 after intervention. The results of paired t -test showed a statistically significant different ( P = 0.001). In control group the mean ± SD of DAS score was 8.04 ± 2.42 before the intervention and after intervention was 8.28 ± 2.42 with no statistically significant difference between them ( P = 0.228). In between group comparison there was no statistically significant difference in the pre-test scores of DAS between two groups ( P = 1.00). However a significant difference observed between groups in DAS score after the intervention ( P = 0.001) [ Table 2 ]. The comparison of DAS score within and between the study groups *Paired t -test. **Independent t -test

The family-centered self-care training as a simple, applicable, and efficient method can improve the death anxiety in hemodialysis patients. This study for the first time, considered the role of family-centered self-care in the management of death anxiety in hemodialysis patients. Considering that hemodialysis patients often experience depression and death anxiety therefore, health care quality policymakers should consider the self-care as an important part of nursing care and improving the level of self-care should always be a part of the nursing care quality evaluation. There are no conflicts of interest.

In summary, the results showed that the self-care training could improve death anxiety in hemodialysis patients. A review of the available literature shows that researchers have limited focus on the role of self-care training in death anxiety managing in hemodialysis patients. However, other interventions have been suggested by researchers to address death anxiety in hemodialysis patients. Saki et al .[ 24 ] showed in 2022 that cognitive-behavioral interventions are significantly effective in improving the level of hope and death anxiety in hemodialysis patients. In another study Oshvandi et al .,[ 25 ] in 2018, reported the positive effect of a spiritual care program on reducing death anxiety in hemodialysis patients with end-stage renal disease. However, researchers have also shown the positive role of such interventions in managing death anxiety in other settings. Studies have shown that spiritual well-being[ 26 ] psychological[ 27 ] and psychosocial treatments, particularly cognitive behavioral interventions, have a significant impact on reducing death anxiety.[ 28 ] Reviewing the results of studies in the role of self-care in management of death anxiety shows the contradictory results. So that, in Farshi et al .’s[ 16 ] 2020 study, self-care counseling in women with endometriosis was able to reduce their anxiety. Also in another study Dejange et al .’s[ 17 ] 2018, showed that, the self-care training could able to manage the anxiety in women with breast cancer. Similarly, Soleimanpour Manzari et al .,[ 29 ] 2024 in the results of a study concluded the telenursing psychological/spiritual self-care training could reduce the elderly death anxiety of during the Covid-19 pandemic. However, it can be acknowledged that the nature and severity of death anxiety among the elderly may be different from those who face life-threatening conditions and complex complications in hemodialysis patients. In contrast to the above results, Soleimani et al .[ 18 ] 2017. showed that the intervention of illness perception alleviation, which was self-care as part of this program, could not reduce the death anxiety of hemodialysis patients. These researchers’ intervention program had a wide scope, even though their focus was not solely on self-care. Finally it can be claimed that, self-care and death anxiety seem to have a reciprocal relationship. So that the self-care reduces death anxiety, and then, cyclically, the reduction of death anxiety leads to the improvement of self-care in hemodialysis patients.[ 30 31 ] Evidence shows that the ability to self-care increases illness perception[ 32 ] and is associated with a reduction in negative psychological problems, positive psychological changes,[ 33 ] and treatment adherence.[ 34 ] Nemati and et al .[ 35 ] 2023, in the result of a study showed that the self-care training in hemodialysis patients leads to increased awareness, improvement of quality of care and finally their hope. So it can be expected that improving self-care abilities can help hemodialysis patients to improve their psychological conditions such as death anxiety. One of the strengths of this study was the involvement of family members of hemodialysis patients in the self-care program of hemodialysis patients. Previously, the important and inevitable role of family members of patients involved in chronic conditions such as chronic renal failure in self-care was shown. and the positive effects of the family-centered empowerment model on the level of death anxiety and depression among hemodialysis patients have been confirmed in several studies.[ 36 37 ] It should be accepted that in order to protect patients from psychological harm, working in the field of death, especially in the presence of life-threatening diseases such as chronic kidney failure, requires its own difficulties and special considerations. This study also has limitations in this regard, but with the presence of researchers (nurses and nephrologists) alongside the patients and their support, help manage this problem.

This double-blind randomized controlled trial was performed from November 2023 to April 2024 to determine the effect of self-care training on death anxiety in hemodialysis patients in Rafsanjan, in Kerman province, Iran. The sample size was calculated to be 23.87, according to previous study[ 19 ] and the following formula with a standard deviation of 1.6 and, and the effect size of 1.5 based on the minimum expected difference between the means at the confidence level of 95% and power of 90%. To ensure the power of the study, 50 patients (25 in each group) were included in the study. n = 2(z 1- α + z 1- β ) 2 σ 2 /d 2 Sampling was initially purposeful, and based on inclusion criteria, the eligible patients who met the inclusion criteria were assigned to study groups using the random minimization method. The assignment was based on the level of the death anxiety, which was categorized into three groups (low death anxiety with a score of 0-6, moderate death anxiety with a score of 7-9, and severe death anxiety with a score of 10-15). The first samples were assigned to different categories by lottery, and for subsequent samples, the sum of samples in each group and category was taken into consideration. so that the total number of samples in each category of different groups was equal.[ 20 ] Inclusion criteria were: age over 18 years, being in an advanced stage of the kidney disease confirmed by a nephrologist, receiving at least two dialysis sessions per week, absent known mental illness and cognitive problems, not experiencing a crisis during the last 6 months, physical ability to do personal daily activity. Exclusion criteria include: occurrence of any condition that violates the entry criteria, unwillingness to participate in study. The data collection tool included a demographic characteristics questionnaire (age, gender, marital status, education level, duration of hemodialysis) and the Templer Death Anxiety Scale (DAS). Templer et al .[ 21 ] in 1970 designed this scale. Templer Death Anxiety Questionnaire includes 15 items with total score rang of 0-15 (Score of 0-6 indicate the low death anxiety, score of 7-9 moderate, and score of 10-15 high. In Iran, the reliability coefficients of the DAS using test-retest, split-half, and Cronbach’s alpha were reported to be 0.87, 0.59, and 0.75, respectively.[ 22 ] For the intervention group and one of their family members- who had the most role in patient care- the self-care program training was given in at least three 1 hour sessions, during two weeks (2 sessions in the first week and one session in the second week) implemented at the department of Ali Ebn Abitaleb hospital during hemodialysis ward. The training seasons were conducted by the first researcher in person and through question and answering method. The objectives of the first training session were to introduce all aspects of chronic kidney failure, including physical and psychosocial changes during this disease. The topics covered include depression, stress, death anxiety, treatment principles, follow-up, and self-care in hemodialysis patients. The focus of the second session was on teaching principles of self-care skills to hemodialysis patients. The goals, which included diet compliance, weight control, fluid consumption, exercise and physical activity, sleep and rest, daily weighting, and skin and fistula care, were followed. At the last session, all the items of the previous sessions reviewed and the questions answered. The discussion revolves around the patients’ specific conditions and the way to apply self-care principles based on their needs, abilities, and individual life styles.[ 23 ] In addition, a booklet containing educational tips on self-care of hemodialysis patients was presented to the patients of the intervention group. After completing the training sessions, the subjects were followed up for 4 weeks in order to check the implementation of the self-care program. The quality of self-care implementation was monitored by one of the researchers who was in charge of the training, in the hemodialysis department and by phone calls, and while solving probable problems, necessary guidance was provided to adapt the patient’s life style to the self-care principles. No intervention was applied for the control group except the routine cares. At the end of the sixth week, the DAS questionnaire was completed again for both groups, in the form of a face-to-face interview by a researcher’s colleague who was blinded about the allocation of subjects in groups. Considering that the patients who participated in the study were given hemodialysis in fixed beds throughout all sessions, coordinated by the head of the hemodialysis department. Due to the L-shaped design of the dialysis department building, the arrangement of the patients’ beds in both groups was designed in such a way that the control and intervention groups were located in two almost separate section of hemodialysis ward. So the patients in the control group were also blinded to receive the intervention program. In order to observe the ethics in the research, the proposal was approved by the research council and ethics committee in biomedical research of Rafsanjan University of Medical Sciences with (code of ethics: IR.RUMS.REC.1402.016), the project was registered at the Iranian Clinical Trial registry with Code of: IRCT (IRCT20230610058437N1), while obtaining the informed written consent from patients, the confidentiality respected. Also patients were assured that their participation or non-participation in the study would not effect on their quality of care. Data were analyzed by SPSS version 22 software, Shapiro and Wilk test (to determine the normality of the data), Chi-square test or Fisher’s exact test (to compare ratios),‎ Independent t -test and Paired t -test (to compare the mean scores within and between groups) at the 95% confidence level.