Contributor: Bruno Alexandre Silva
Chronic Kidney Disease (CKD) is one of the chronic diseases that can impact people’s everyday lives most. According to (Hill et al., 2016), it is estimated that this disease has an incidence of 11 – 13% in the global population. This disease can be classified as in several stages, and the last stage of development of this disease places patients on hemodialysis and depending on a kidney transplant. Without hemodialysis, patients with CKD may not survive. Patients with CKD may be treated hospitals or clinics prepared for hemodialysis. These sessions last four hours for most Renal Insufficient Patients and are usually performed three times a week.
From a nursing perspective, it is essential for people going through this experience to adapt to this new stage of their lives. I have been working in dialysis since 2017 and in Nursing Theories, a unit during my Master’s Degree, I decided to do a more profound reflection on my patient’s situation. When developing new knowledge and deepening what I already had, regarding Nursing Theory, I asked myself a question: what would be the theory that I could carry to my clinical practice? My answer: the Theory of Transitions according to Afaf Meleis.
For the author of this theory, Afaf Meleis (2010), it is important to define some key concepts, namely transition – which, in a certain type of transition, refers to the passage from a health condition to a disease condition or from another disease, condition/life stage to a new situation. This change in your life implies a change in behavior or the inclusion of new knowledge. Several types of transition are applicable in the context of transitions nurse theory, however, in my work there is no doubt that most applied is the health-illness transition. For Meleis (2010), transitions depend on personal characteristics and experiences already lived and integration with others – environment and people (family members and health professionals). This process of change develops to reach a new stage of life.
I reflected several times on what the individuals I care for experienced at the beginning of hemodialysis treatment and all the adaptations they must make. From the water and food restriction that is essential for these individuals, through the transformation to treatment schedules and their day-to-day routines to constructing an Arteriovenous Fistula and carrying out the appropriate and necessary procedures for the effectiveness of haemodialysis treatment. The way of going through this transition is different for everyone with Chronic Kidney Disease. Each person’s experience is unique, making this disease experience different from individual to individual. Therefore, the change at the beginning of these treatments is usually complex and tricky and can be experienced in several ways. The nurse’s role is essential for these transitions to be carried in the best possible way. It is us, the nurses, who have an active and decisive role in the success of these processes to ensure what these individuals with chronic kidney disease need to do to guarantee a significant improvement in the ‘ ‘people’s life affected by this disease.
In the course of my professional practice, I have noticed that most individuals with chronic kidney disease, in the first haemodialysis sessions, have an enormous need to speak and be heard, to clarify their doubts and fears regarding haemodialysis. They are attentive to everything we do and everything around them, showing the need to absorb all the information they can. All these processes of change generate anxiety and fear. This is where the nurse’s role is crucial. As a nurse and based on the Theory of Transitions, it is here that I try to have a facilitating posture during the transition processes that this population specifically needs. The fear of feeling bad during the treatment or even the fear of being punctured for the first time are reasons for anxiety and that need to be clarified by nurses.
I remember a specific case in which our performance was essential for the transition from the situation of “I don’t need haemodialysis” to the situation of “now I have to do haemodialysis three times a week”. In this specific case, the patient in the beginning of haemodialysis treatment was very anxious and nervous with the course of treatment, even having episodes of generalized tremor associated with the anxiety he had. The same individual was afraid of feeling bad during the treatment, that the puncture of the arteriovenous fistula would result in a hematoma, that he would carry too much weight for the treatment, etc. All this proved essential importance for the patient, so it would be necessary to watch him properly to promote adherence to the treatment so that it would not be a moment of suffering. Therefore, the performance of all nurses was essential for this patient to get used to it and feel comfortable and less anxious about the treatment. As nurses, we talked to the individual, completed some crucial teachings, and reassured him as much as possible. Through humour, we established a therapeutic relationship, guaranteeing the necessary trust between the professional and the individual so that, after some time, gradually, he could adapt to the treatment, to the care we provided.
At the end of this transition, the individual already had less fear anxiety about the treatment itself, with a more cheerful and relaxed face during the treatment. Often it was the patient himself who, together with the other individuals undergoing haemodialysis, discussed football games or even the news. With a much more relaxed attitude, he was always grateful for the care we had given and the help we provided him throughout the process of moving to this new reality. After three years of treatment, this patient was transplanted and is now experiencing a unique transition process. Once again, changes in our lives appear several times throughout our time.
As a haemodialysis nurse and dealing almost daily with patients transitioning to this new health condition, I see how difficult these processes become for some patients. The suffering they go through until they manage to adapt is often incalculable. Haemodialysis improves the quality of life of these individuals with chronic kidney disease. However, the transition process to this reality is often consuming and challenging and causes suffering for most individuals. Some of them reject entirely their condition of life, taking months to know how to deal with the disease and its limitations. I try in my daily practice to listen to patients, clarify doubts or questions that arise regarding their disease, I try to establish a therapeutic relationship of trust so that the transition processes in these contexts carry out in the best possible way.
Hill, N. R., Fatoba, S. T., Oke, J. L., Hirst, J. A., O’Callaghan, C. A., Lasserson, D. S., & Hobbs, F. D. R. (2016). Global prevalence of chronic kidney disease – A systematic review and meta-analysis. In PLoS ONE (Vol. 11, Issue 7). Public Library of Science. https://doi.org/10.1371/journal.pone.0158765
Meleis, A. (2010). Transitions Theory Middle-Range And Situation-Specific Theories In Nursing Research And Practice. Springer Publishing Company.
Gabriela, L., & Costa, F. (2016). Visitando a teoria das transições de Afaf Meleis como suporte teórico para o cuidado de enfermagem. In Enfermagem Brasil (Vol. 15, Issue 3).
Meleis, A. (2019). Facilitating and Managing Transitions: An Imperative for Quality Care. Investigación en Enfermería: Imagen y Desarrollo, 21(1).
Meleis, A., & Bond Simon Dean, M. (2012). Theoretical Nursing Development and Progress (5th Edition).
About Bruno Alexandre Silva
I finished Nursing School in July 2016 at the Escola Superior de Saúde da Cruz Vermelha Portuguesa. I started working at Hospital Beatriz Ângelo in the Operating Room, and after a few months, I started working at a Hemodialysis Clinic in Almada. I completed the Post-graduation course in Clinical Supervision in 2020 at the Escola Superior de Saúde da Cruz Vermelha Portuguesa, where I currently collaborate. In terms of nursing, my areas of most significant interest are: Person on hemodialysis, Person in critical condition and Person in surgical condition. During the follow-up of students and integration of new colleagues, I also developed a taste for clinical supervision.
I am currently in the Master’s Course in Medical-Surgical Nursing: person in a critical situation, where I made this post in the curricular unit of Nursing Theories under the pedagogical guidance of Prof. Zaida Charepe (PhD)