Improving Treatment Adherence in Hemodialysis Patients


Those patients who have chronic renal disease need regular hemodialysis procedures. However, the problem is that these patients often demonstrate non-adherence to treatment regimens because of certain barriers. The purpose of this literature review is to explore the phenomenon of non-adherence and identify obstacles that can be faced by patients. A review of the literature was conducted as a result of searching such databases as PubMed, CINAHL, PsycINFO, Ovid MEDLINE, and ProQuest. 54 articles published in 2008-2017 were found to be associated with the topic, and 18 articles were retrieved for further review. Four key themes were determined as related to the problem determined for this project: the discussion of the phenomenon of adherence to treatment, various barriers experienced by patients, different interventions to address these barriers, and the concept of self-care associated with the issue. The literature review indicates that those patients who receive certain education and support regarding their disorder and hemodialysis adhere to treatment regimens more actively, and interventions to address barriers are effective in many cases, as is stated in recent studies.

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Those patients who suffer from severe chronic kidney disease or an end-stage renal disease can require regular hemodialysis procedures to overcome the kidney dysfunction and contribute to their life expectancy. The continuous decrease in the number of nephrons in kidneys, which is associated with these diseases, usually results in impossibilities to improve patients’ state without hemodialysis because of 90% destruction in kidneys’ functioning (Rostami, Badr, & Falah, 2015). According to recent statistics in the field, chronic kidney deficiency is diagnosed in more than 240 people per million, and this number can increase by about 8% annually (Rostami et al., 2015). In the United States, these numbers also grow, and in 2010, more than 650,000 patients required hemodialysis (Zolfaghari, Sookhak, Kashfi, Sekhavati, & Tabrizi, 2017). Among them, about 400,000 patients are diagnosed with end-stage renal disease, and about 300,000 patients need permanent hemodialysis (Rostami et al., 2015). To support their organisms’ functions and improve their physical health, hemodialysis patients are expected to follow strict treatment regimens. Therefore, it is extremely significant for clinical practice to address possible challenges associated with patients’ access to hemodialysis procedures. Certain obstacles can be identified as important to prevent treatment adherence in hemodialysis patients, and this literature review will indicate typical barriers and ways proposed to overcome them.

Problem Identification

The specific problem associated with the topic of treatment adherence in hemodialysis patients is that many patients who require regular dialysis procedures do not follow the prescribed treatment regimens because of certain barriers, resulting in decreases in dialysis adequacy or effectiveness and increases in patients’ mortality. According to Chan, Thadhani, and Maddux (2014), some patients who require hemodialysis procedures can refuse to attend dialysis sessions, ignore scheduled procedures, and violate treatment regimens. As a result, risks of complications and hospitalizations increase, as well as the overall risk of mortality because of the missed hemodialysis procedure (Cukor et al., 2014). Thus, according to Zolfaghari et al. (2017), more than 50% of people with chronic kidney disorders choose not to adhere to prescribed regimens and hemodialysis sessions. Such non-adherence to specific treatment plans prescribed for patients with chronic renal diseases is viewed as a significant clinical problem that requires its immediate solution to decrease the percentage of deaths in cases when patients ignore hemodialysis procedures because of certain barriers.

Therefore, the improvement of treatment adherence for patients with chronic kidney disease should be based on finding ways to overcome barriers that can prevent patients from following their schedules of hemodialysis procedures (Ahmed et al., 2013; Nobahar & Tamadon, 2016). According to researchers, such barriers can include depression, patients’ lack of knowledge and education, safety concerns, demographic aspects, and the lack of control and motivation among other factors (Chan et al., 2014; Cukor et al., 2014; Nobahar & Tamadon, 2016). Thus, it is important to study what barriers can provoke hemodialysis patients’ non-adherence to treatment and what procedures to use to increase the quality of nursing services and decrease these patients’ mortality.

Search Strategy

The PICO(T) question that guided the procedure of searching the literature to review can be formulated the following way: In hemodialysis patients (P), does the presence of education regarding possible barriers (I) compared to the absence of such education (C) increase treatment adherence (O) during the first two years of dialysis (T)? To find the literature related to this question, five databases, such as PubMed, CINAHL, PsycINFO, Ovid MEDLINE, and ProQuest, were searched. The following keywords for searching were formulated concerning the topic and identified the problem: “hemodialysis,” “hemodialysis patients,” “treatment adherence,” “treatment non-adherence,” “regimen,” “barriers,” “education,” “patient compliance,” “care,” and “self-care.” The keywords were combined with the help of AND as a Boolean search connector to find the most relevant articles on barriers typical of hemodialysis patients who do not adhere to treatment regimens, as well as on interventions to apply to solve the problem.

It is important to note that the search was limited with the focus on articles that were published within the past ten years (2008-2017). Thus, 54 articles were found to be associated with the topic, 18 articles were determined to be directly related to the problem and research question, and they were reviewed for this DNP project. 10 articles represented results of quantitative studies, and 8 articles offered results of qualitative studies and reviews. After completing the search procedure, it is possible to identify the following themes reflected in the literature to review: adherence to treatment, possible barriers to treatment adherence, interventions to address barriers, and particular features of self-care for hemodialysis patients.

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Adherence to Treatment

Adherence to treatment in those patients who require hemodialysis is characterized by their readiness to follow physicians’ recommendations and change their lifestyles to participate in regular dialysis sessions (Ahmed et al., 2013; Chan et al., 2014; Nobahar & Tamadon, 2016). In their quantitative study, Chenitz, Fernando, and Shea (2014) noted that patients with kidney diseases understand that ignoring hemodialysis sessions can have extremely negative effects on their health, and threats of complications are high. Still, according to the researchers, even if patients understand this fact, they can non-adhere to hemodialysis treatment (Chenitz et al., 2014). Findings by Cukor et al. (2014) indicated that non-adherence to treatment can be both intentional and non-intentional. Vardanjani, Parvin, and Mahmoodi Shan (2016) also stated that many patients claim that they intentionally try to decrease the duration of hemodialysis sessions and avoid following a therapeutic regimen. Furthermore, when patients ignore hemodialysis, they also violate regimens regarding taking medications and keeping a diet (Chan et al., 2014; Vardanjani et al., 2016). Thus, many patients do non-adhere to therapies because of a range of factors that influence their intentional and non-intentional choices regarding hemodialysis.

Despite the character of adherence or non-adherence to treatment, studies on the topic can illustrate the idea that the percentage of those patients with chronic kidney disease who do not follow physicians’ recommendations regarding hemodialysis is extremely high. Thus, only about 20% of patients adhere to their therapies and dialysis regimens strictly (Zolfaghari et al., 2017). As a result, risks of complications, further readmissions to hospitals, and even mortality increase (Vardanjani et al., 2016; Zolfaghari et al., 2017). Patients’ choices to adhere or not to treatment can also depend on the complexity of regimens, and persons can choose not to follow hemodialysis schedules because they do not realize positive changes in their physical state (Guerra-Guerrerro, Plazas, Cameron, Salas, & González, 2014). Thus, the literature suggests that patients’ non-adherence to treatment is provoked by certain factors or obstacles, and these barriers need to be discussed in detail.

Barriers to Treatment Adherence

The literature on the topic of adherence to hemodialysis treatment suggests that many obstacles can prevent patients with kidney disease from following their regimen. One of the problems that can be faced by patients with chronic kidney disorders is depression, which is a result of the decreased quality of life, associated health problems, and thoughts about death (Chan et al., 2014; Guerra-Guerrerro et al., 2014; Nabolsi, Wardam, & Al‐Halabi, 2015). Thus, depression can also be viewed as one of the barriers to treatment because patients do not see or understand the positive results of hemodialysis therapy, and they do not want to follow a regimen while discussing it as lacking any sense (Cukor et al., 2014). Clark, Farrington, and Chilcot (2014) also paid attention to the role of mood and patients’ self-efficacy in their study. From this point, the emotional state of patients plays a key role in influencing their treatment adherence.

One more group of barriers is determined in studies on the problem. This group includes problems with adaptation to a new situation. Patients experience challenges while accessing healthcare centers to participate in a dialysis procedure, they do not accept a new diet, and they do not want to change their lifestyle (Clark et al., 2014; Nabolsi et al., 2015). Individuals with chronic renal disease can resist accepting their disease and become non-motivated to follow therapies. According to the results of the study conducted by Chenitz et al. (2014), those patients who require regular hemodialysis procedures experience such obstacles as the lack of effective transportation and the lack of support to receive adequate transportation. As a result, these patients become limited in their access to nursing services and hemodialysis, and they require assistance.

Therefore, the next group of barriers identified by researchers includes the lack of support, assistance, and education. Yau, Carver, Alvarez, Block, and Chertow (2016) stated that much attention should be paid to the role of nurses in this case because they are expected to provide patients with the care and knowledge required for their adaptation and effective treatment. These ideas are in line with findings by Vélez‐Vélez and Bosch (2016), who noted that many patients accentuate the necessity of education sessions to overcome the lack of understanding regarding their state and required treatment. Nabolsi et al. (2015) also paid attention to the fact that, when patients experience such barriers as the lack of knowledge regarding their disease and hemodialysis, they also suffer from such barriers as poor communication with nurses, the lack of control, and the lack of motivation. Furthermore, depending on their age, gender, ethnicity, social status, and education, patients can view treatment as complicated, problematic, expensive, painful, and non-effective (Barnett, Li Yoong, Pinikahana, & Si‐Yen, 2008; Yokoyama et al., 2009). Thus, the literature indicates that there are many barriers that can prevent patients from following their hemodialysis regimens, and it is important to examine possible interventions which can be applied to address this problem.

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Interventions to Address Barriers to Treatment

In their practice, nurses can follow certain recommendations and participate in implementing definite interventions in order to address barriers typical of patients with chronic kidney disease (Barnett et al., 2008; Chan et al., 2014; Guerra-Guerrerro et al., 2014). According to Cukor et al. (2014), one of the interventions appropriate to help patients adapt to their new life circumstances is behavioral therapy and associated education oriented to eliminating barriers connected with depression and anxiety in patients. Chan et al. (2014) also supported this idea and stated that when people with chronic kidney disease receive support, education, and guidelines regarding treatment procedures, their adherence to the plan increases. Thus, there are many interventions described in the literature that are oriented to improving the psychological state of individuals with kidney disease.

Patients require continuous and high-quality education regarding risks of non-adherence to hemodialysis sessions and regimens. According to Yokoyama et al. (2009), patient education is important to address the problem of poor dialysis attendance and remove possible barriers. These views are in line with ideas by Barnett et al. (2008) who found that improvement in adherence to treatment can be observed concerning building strong relationships with nurses to receive their support and encouragement. Chenitz et al. (2014) also stated in their study that patient education should be connected with communication and nurses’ support to overcome patients’ barriers to treatment. Patients need to improve their knowledge regarding hemodialysis and increase their motivation to achieve high results.

Furthermore, researchers state that positive results on adherence to treatment can be observed regardless of the used intervention, and the focus should be on applying some techniques to overcome patients’ barriers (Vélez‐Vélez & Bosch, 2016; Zolfaghari et al., 2017). Nabolsi et al. (2015) noted in their study that positive outcomes can be associated with using interventions oriented to developing patients’ self-evaluation and self-control in the context of self-care. It is possible to state that recent studies provide a range of evaluations of interventions to improve patients’ adherence to treatment, and the role of self-care should be discussed in more detail in this context.

Self-Care for Hemodialysis Patients

Self-care is a significant concept to be discussed with the focus on the problem of adhering to treatment in hemodialysis patients. According to Rostami et al. (2015), if patients are focused on self-care, they participate in treatment procedures willingly, and their health outcomes can improve. The researchers made this conclusion concerning applying Dorothea Orem’s self-care model to support patients. In their study, Jahanpeyma and Akbari (2016) were also interested in examining how patient education regarding the concept of self-care could improve their treatment adherence. It was found that those patients who understand the idea of self-care are more responsible for their treatment (Jahanpeyma & Akbari, 2016). Self-care is viewed in this context as patients’ readiness to control their treatment, use coping strategies, and adhere to the prescribed regimen (Vélez‐Vélez & Bosch, 2016). The regulatory character of self-care provides patients with chronic kidney disease with opportunities to monitor their state and follow treatment depending on their needs.

However, Queirós, Vidinha, and Almeida (2014) noted that, when patients receive more control over their treatment, they can ignore physicians’ prescriptions regarding dialysis procedures, and the focus should be not on control, but self-control in order to guarantee that patients receive the required cure. Thus, the number of patients who are able to concentrate on self-care and follow home hemodialysis sessions is comparably low because patients also face barriers to this approach in spite of their benefits determined by healthcare providers (Queirós et al., 2014; O’Shaughnessy, 2014; Yau et al., 2016). Therefore, the literature suggests that barriers to different forms of treatment for dialysis patients can be observed by researchers.

Strength of Evidence and Conclusions

Different types of articles were reviewed for this project. Evidence provided in the literature represents levels II-VI, with the focus on evidence retrieved from randomized controlled trials (level II) and quasi-experimental studies (level III). As a result, it is possible to state that the evidence provided in this literature review is comparably strong, but it can be improved by adding systematic reviews. Still, the presented literature is appropriate to be used in order to support the need for change and propose interventions that can be applied in order to address the formulated problem.

The literature review indicates that key themes discussed in recent studies on the problem of treatment adherence for hemodialysis patients are the following ones: non-adherence to regimens, barriers that cause non-adherence, interventions that are effective to address these barriers, and the idea of self-care in the context of providing treatment and education for patients with chronic kidney disease. Referring to the reviewed literature, it is possible to recommend implementing a certain intervention in order to address patients’ barriers to treatment adherence because studies demonstrate positive results in those cases when healthcare providers integrate interventions in their work with patients.


A review of literature is important to provide the background for the project and the intervention selected to solve the identified problem. Recent articles on the topic include the discussion of such themes as adherence to treatment, barriers to treatment, interventions to address obstacles, and self-care for hemodialysis patients. Those patients who are diagnosed with chronic kidney disease can resist adhering to treatment regimens because of some barriers, and this situation is frequently observed in the United States and worldwide. The literature indicates that these barriers include emotional or cognitive ones, obstacles associated with adaptation, and barriers associated with the lack of education and understanding. To address these barriers, healthcare professionals use cognitive therapies, support, and education as interventions. The application of these interventions is connected with the concept of self-care, as it is presented in the literature.


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