Nephrologists’ Attitudes Regarding Psychosocial Care in Hemodialysis Units

Introduction

Nephrology patient care is a complex, chronic, and multifaceted task that requires an interdisciplinary approach to maximize survival and quality of life. Psychosocial care is one aspect, encompassing patient’s mental, spiritual, and emotional well-being through quality-of-life metrics such as happiness, social support, and self-perception. However, psychosocial care requires the physician to invest additional time despite limited empirical data that show better outcomes.

Nephrologists in hemodialysis units, as in many other health fields, are faced with ever-increasing administrative and patient time constraints.^1,2 Consequently, increased physician demand compounded with diminishing resources and direct patient time has led to a higher prevalence of physician burnout with deleterious effects on patient care. ³

Due to the invasive and demanding nature of treating patients with kidney failure, a greater emphasis might be placed on nephrologists to address the psychosocial aspects of patient care, such as depression, anxiety, happiness, and self-image. ⁴ However, there is limited available research on the prevalence and provision of renal patient psychosocial care.

Consequently, we developed and administered a survey instrument to Canadian nephrologists that was intended to gather their opinions and attitudes about psychosocial care provided within in-center hemodialysis units. Our objective was to study the relative importance placed on psychosocial care and discern which factors influence nephrologists’ ability to provide this type of care.

Methods

The research design was a self-administered survey sent to almost 500 members of the Canadian Society of Nephrology. The target respondents were practicing nephrologists who work primarily in clinical care with adult in-center hemodialysis patients on a regular basis. The survey was initially sent via e-mail, with a cover letter, in November 2018, with 2 follow-up e-mails sent in late November 2018 and December 2018.

The survey questionnaire was designed to gather opinions and attitudes on psychosocial care delivery as well as potential factors that influence nephrologists’ ability to provide this care. The survey included questionnaire themes such as the responding physicians’ demographics, their role in administering psychosocial care, potential administrative and patient time constraints, availability of other health care workers for this activity, and factors that influence or impede physicians’ ability to address the patients’ psychosocial needs. Survey respondents were kept anonymous. The initial survey instrument was pilot tested for face validity and leading questions on a sample of 5 nephrologists and modified accordingly. All respondents provided consent prior to the initiation of the survey.

The e-mailing and administration of the survey instrument were done by the Canadian Society of Nephrology. Design of the survey, data entry, and data analysis were undertaken entirely by the authors at Humber River Hospital. Data were collected using Survey Monkey. A univariate statistical analysis was used to analyze survey responses. The research project was approved by the Research Ethics Board of Humber River Hospital, Toronto, ON, Canada.

Results

The survey was sent to approximately 500 members of the Canadian Society of Nephrology, with 30 nephrologists responding (6% response rate). Respondents’ demographic data are depicted in Table 1.

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Table 1.

Demographics of Survey Respondents.

Demographics	n (%)
Location
Ontario	12 (40)
Quebec	4 (13)
Manitoba	4 (13)
Alberta	3 (10)
British Columbia	3 (10)
Nova Scotia	3 (10)
New Brunswick	1 (3)
Current role
Staff nephrologist	24 (80)
Medical director	4 (13)
Dialysis director	1 (3)
All of the above	1 (3)
Role in PS care of patients
Lead initiatives	9 (40)
Participate in initiatives	18 (78)
Expertise in developing initiatives	1 (4)
Received training in aspects of PS issues	2 (9)

Note. PS = psychosocial.

Proportional to sample population, respondents were distributed fairly evenly across the Canadian provinces. The greatest proportion of respondents (80%) comprised practicing staff nephrologists with medical/dialysis directors making up 17% of the sample. Only 40% of the respondents led initiatives in psychosocial care of patients while the majority (78%) participated in the psychosocial care of patients.

As demonstrated in Figure 1, more than 94% of respondents either strongly agreed or agreed that focus on psychosocial aspects of patient care significantly improves patient outcomes, whereas only 2 respondents (7%) strongly disagreed with the statement.

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Figure 1.

Responses to: “In my opinion, focus on psychosocial aspects of patient care (eg, quality of life, support network, depression, anxiety, general satisfaction) significantly improves patient outcomes.”

Figure 2 illustrates that only 43% of respondents felt that staff nephrologists were the providers best equipped to focus on the psychosocial issues of their patients. Comparatively, more than 97% of respondents felt that social workers were the most suitable health care members to focus on these issues. In addition, 53% of respondents chose dialysis nurses or psychiatrists as the best-equipped health care members to provide this psychosocial care. These data correspond to more than 70% of respondents indicating that their opinion regarding supporting patients dealing with psychosocial issues is “best provided by other health care members” (Supplemental Figure 1). Only 17% were very comfortable addressing these psychosocial needs (Supplemental Figure 1).

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Figure 2.

Responses to: “Which health care members are best equipped to focus on the psychosocial issues of patients? (select all that may apply).”

Moreover, although the vast majority of respondents believed social workers are the best-equipped health team members to address psychosocial issues, 47% of respondents disagreed with the statement that “in [their] hemodialysis unit, social workers are able to provide personalized and sufficient psychosocial care” (Supplemental Figure 2). Indeed, 89% indicated that the “ratio of patients per social worker is too high” (Supplemental Figure 3).

When asked how “psychosocial issues of patients [could] be best served,” respondents (97%) selected having “additional health care support workers (nurses, social workers, etc)” available, whereas 45% of nephrologists indicated that “doctors [should receive] more training to adequately address psychosocial issues” (Supplemental Figure 4).

The respondents’ opinions varied concerning factors that interfere with their ability to provide optimal psychosocial care to their patients. As depicted in Figure 3, the majority of respondents (67%) felt there is “insufficient time to suitably address psychosocial issues in a hemodialysis unit due to high volume of administrative paperwork/follow up.” Both an absence of available resources for psychosocial issues and other staff members being better equipped to handle psychosocial issues were indicated by 57% of respondents (Figure 3). Opinions concerning receiving inadequate training in psychosocial care, the choices of psychosocial care expanding nephrologists’ role too much, and that other staff on the team should specifically focus on psychosocial issues were each chosen by 40% of the respondents (Figure 3).

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Figure 3.

Responses to: What “following factors interfere with my ability to provide the PS care needed for optimal results (select all that may apply).”

Discussion

This survey was conducted to assess Canadian nephrologists’ attitudes and opinions concerning psychosocial care in hemodialysis units. Our goal was to elucidate the roles nephrologists have in treating psychosocial issues, their attitudes on the significance of psychosocial care delivery, and what barriers, if any, prevent these physicians from providing such care to their patients.

From the responses, several main themes emerged. It was found that the majority of respondents agreed or strongly agreed that focus on psychosocial issues significantly improves the clinical outcome of patients. Despite this, there is limited available research demonstrating psychosocial care influencing clinical outcomes of renal patients. Furthermore, there is a discordance between nephrologists understanding the importance of patient psychosocial care and having the mechanisms in place to actually provide this care to patients. As demonstrated in Figure 3, insufficient time resulting from large volumes of administrative work coupled with high patient-to-doctor ratios were 2 barriers that prevented adequate psychosocial care. With the number of patients on dialysis increasing by almost 31% since 2005, time constraints on patient-physician interactions pose significant barriers to the overall quality of patient care in hemodialysis units. ⁵ Yet, unless systematic changes to the current health care model can occur to address these issues, other solutions must be proposed.

Data from a 2014 national survey of Canadian chronic kidney disease (CKD) clinics demonstrated that the majority of CKD clinical members felt that more health care staff, in addition to more time available to spend with patients, had the greatest need for improvement. ⁶ In our survey, 70% of respondents felt that “dealing with psychosocial issues is an integral part of patient care that is best provided by other trained health care members” (Supplemental Figure 1). Consequently, the majority of respondents believed that other health care members, particularly social workers, were best equipped to address the psychosocial needs of patients. However, less than half of respondents reported social workers being able to provide sufficient psychosocial care in their hemodialysis units (Supplemental Figure 2). This disparity between the perceived importance of social workers in administering psychosocial care, yet being unable to effectively deliver it, indicates that certain barriers may be impeding social workers in hemodialysis units. For instance, data have demonstrated that renal disease patients’ satisfaction is greater when social workers’ caseloads are lower. ⁷ With 90% of the respondents stating that social workers are impeded in optimally delivering this care by the high volumes of patients, it is reasonable to infer that additional social workers might address the current time constraints on other hemodialysis clinical staff members while also improving the psychosocial care of the patients. ⁸ Future research is necessary to assess social workers’ attitudes on psychosocial care delivery in hemodialysis units in addition to what barriers are currently impeding social workers from adequately providing this care.

However, by placing too much emphasis on psychosocial care provided by CKD staff members, we risk minimizing the importance of the nephrologists’ own roles in addressing the psychosocial needs of their patients. Data have demonstrated that many primary care CKD patients believed there are barriers to how their psychological symptoms are addressed and treated by nephrologists. ⁹ Results from our survey support this. More than 40% of respondents were not adequately trained in psychosocial care delivery while more than half felt there were a lack of adequate resources available for them (Figure 3). In addition, more than half the respondents reported being uncomfortable addressing topics such as depression, anxiety, sexual issues, and suicide/self-harm (Supplemental Figure 5).

This study applied a survey methodology to explore the perspectives of Canadian nephrologists regarding psychosocial care for people on hemodialysis. However, there were some limitations. Despite 3 reminders by e-mail, the response rate for the survey was roughly 6%, effectively reducing our ability to draw definitive conclusions. The e-mail list provided by the Canadian Society of Nephrology does not include every nephrologist in Canada, and, without an exact number of practicing nephrologists, differences in the demographics of respondents compared with those who did not participate cannot be made. As with any survey, the answers by respondents may be entirely different from those by nonrespondents. In addition, answers may be subject to social desirability bias and not reflect true opinions. The very low response rate requires further comment. One of the authors has published several surveys of Canadian nephrologists^10-18 with quite higher response rates than this study. We hypothesize that the low response rate suggests a discomfort and/or unfamiliarity among Canadian nephrologists with psychosocial care. Comparatively, this could likewise suggest a selection bias toward respondents who are more familiar and/or motivated by the topic. It should therefore be considered that the survey responses are potentially over-/underestimated. In spite of these limitations, we believe this study, and the topics it addresses, should serve as a stimulus for creating more effective patient care in hemodialysis units.

Conclusion

Data from previous studies, ¹⁹ in conjunction with these survey results, indicate that both nephrologists and patients believed that the treatment of psychosocial issues in hemodialysis units is inadequate. Due to the low survey response rate, further research is necessary to conclusively determine what barriers nephrologists and the health care team face in providing psychosocial care. It is tempting to speculate, but not yet conclusively established, that nephrologists should receive more education around psychosocial care during their years of training and/or once in practice. Additional investigation is necessary to establish what training and resources concerning psychosocial care is needed in hemodialysis units, as well as how this may differ among hospitals and nephrology training programs. Furthermore, this survey should be expanded to assess the views of multidisciplinary team members concerning renal patient psychosocial care compared with those of nephrologists. Likewise, renal patient–reported quality-of-life metrics would provide useful data indicating which psychosocial domains require the greatest attention. Outcomes of this future research, combined with further inquiry into how to increase and empower non-nephrologist dialysis support workers with the skills required to address psychosocial issues, will potentially establish a more multifaceted and enlightened team-based care of patients with kidney failure than currently exists.

Supplemental Material