The Effect of the Training on Adaptation to Treatment Provided to Hemodialysis Patients According to the Neuman Systems Theory on Self-Esteem and Perceived Social Support

Nursing care and education are of great importance in solving the existing or potential problems of individuals dependent on hemodialysis due to chronic kidney failure and in patients' adaptation to living with their diseases and treatment (Velioğlu 2012, Pektekin 2013). In this process, nurses benefit from nursing theory-based models to protect and improve the health of sick/healthy individuals, to ensure that they receive optimal care, and to accelerate their recovery process. One of these models is the Neuman Systems Model. The Neuman Systems Model, a well-being-oriented holistic approach that considers patients an open system, is a suitable model for holistic evaluation of patients and guiding nursing practices, as it includes five variables characterizing the individual, namely physiological, developmental, spiritual, psychological, and socio-cultural variables (Uysal et.al.2009). The model concretely defines the nursing activities and the areas in which the nurse provides service; facilitates the planning and implementation of the interventions, and can be used in most of the working areas of nursing (Özer and Gökçe,2015).

Patients undergoing hemodialysis treatment go to dialysis centers, get connected to hemodialysis machines, and fear death due to the illness, all of which cause them to feel lonely. Under this circumstance, the social support systems perceived by the individual come into play, and in case of deficiency, they experience difficulties in coping (Atik et.al.2015). National and international literature has proven that hemodialysis patients receive high social support from family, friends, and special people, which contributes positively to their treatment process, quality of life, social appearance anxiety, and self-esteem. (Atik et.al.2015; Alexopoulou et.al.2016; Silva et.al.2016; Theodoritsi et.al.2016; Karadağ et.al.2013) Many patients undergoing hemodialysis treatment for chronic kidney failure see the dialysis machine as an extension of their own body, consequently leading to deterioration in their self-esteem. Skin, bone, digestive system, nervous system changes, and fistulas related to uremia are factors that increase the loss of body image and self-esteem (Yılmaz,2014). Interventions to be implemented by the nurse to increase self-esteem help hemodialysis patients to use problem-focused coping strategies. Accordingly, improving the role of nurses in boosting patients' self-esteem increases patients' adherence to treatment and enables them to cope with problems more easily (Rezaei and Salehi,2016). National and international studies show that hemodialysis patients' beliefs about their disease and treatment play a significant role in their autonomy and self-esteem, education to improve quality of life affects/increases patients' self-esteem, hemodialysis patients with high self-esteem use problem-focused coping strategies, and individuals receiving hemodialysis treatment have lower self-esteem levels than healthy individuals (Yılmaz ,2014; Soltani-Nejad and Zeighami 2018; Rezaei and Salehi,2016; Jansen et.al.2014; Theofilou 2012).

There are studies in which nursing care and case presentations are made in line with the Neuman Systems Model in our country and the international literature (Uysal et.al.2009; Özer and Gökçe 2015; Braga et.al.2018; Ahmadi and Sadeghi 2017; Luz Omaria et.al.2016; Angosta et.al.2014; Yarcheski et.al.2010; Sultan 2018; Özkan and Öztürk 2013; Mert and Barutçu 2013; Güner and Kavlak 2015; Eren and Çalışkan 2018). These studies have shown that the integration of the model into these case presentations and nursing care reflects positively on the results and serves as a holistic guide in nursing practice. The use of models in the education program that the nurses plan within the scope of their educator role increases the effectiveness of the education, and these educational interventions reflect on the patient behaviors. Neuman Systems Model, which defines the individual as an open system, is preferred for more systematic and effective patient education in hemodialysis patients as it allows the evaluation of many stressors affecting the individual during the hemodialysis treatment process. The stages and content of the education process planned to eliminate the effects of these stressors are compatible with the nursing intervention stages of the model. Accordingly, this study aims to evaluate the effect of Neuman Systems Model guided therapeutic training given to individuals receiving hemodialysis treatment on self-esteem and perceived social support.

MATERIALS AND METHODS Type of the Research This research has a pretest-posttest comparative controlled quasi-experimental design.

Place and Time of the Research The research was carried out at Kahramanmaraş Sütçü İmam University Research and Application Hospital Hemodialysis Service and Necip Fazıl City Hospital Hüsnü Öksüz Dialysis Center between 15.04.2017 and 15.10.2017.

Universe and Sample of the Research All patients registered and treated in Kahramanmaraş Sütçü İmam University Research and Application Hospital Hemodialysis Service (Experimental group) and Necip Fazıl City Hospital Hüsnü Öksüz Dialysis Center (Control group) constituted the research universe (N:108). Experimental and control groups were formed by purposive sampling. The entire universe was included in the sample without selecting a sample. The study was carried out with 84 patients, experimental (n:42) and control (n:42). Inclusion criteria for the study;

• Being over 18 years old
• Being literate
• Not being deaf
• Being able to communicate in Turkish
• Continuing hemodialysis treatment for at least 6 months
• Not receiving a medical diagnosis of psychiatric illness
• Being conscious, cooperative

Data Collection Tools Patient Information Form The patient information form used in the study consists of a total of 23 questions. It was prepared under the guidance of the relevant literature (Özdemir and Taşçı 2013; Biçer et.al.2013; Davaridolatabadi and Abdeyazdan 2016; Mutlu ve Duyan,2012,Neuman 1996, Fawcett 2001, Alligood and Tomey 2006, Horigan and Barroso 2016) and includes questions about the patient characteristics and hemodialysis treatment characteristics.

Neuman Systems Evaluation Form The form consisting of 21 questions prepared by a thorough literature review (Velioğlu 2012, Uysal et.al.2009, Özer and Gökçe 2015, Mert and Barutçu 2013, Güner and Kavlak 2015, Alligood 2014, Fawcett and Madeya 2013, Turner and Kaylor 2015, Neuman and Fawcett 2011, Neuman 1996, Fawcett and Gigliotti 2001, Alligood and Tomey 2006) allows the patients to be evaluated based on their internal, interpersonal, and external stressors, in line with Neuman's model, which refers to the patient as an open system that interacts with these stressors.

Neuman Systems Model-Based Patient Education Guidelines After the literature review, the education topics of patients receiving hemodialysis treatment were created by the researchers within the scope of primary, secondary, and tertiary prevention intervention modes outlined in the Neuman system model (Velioğlu 2012, Özer and Gökçe 2015, Arreguy-Sena et.al.2018, Karadakovan and Kaymakçı 2011). This Neuman Systems Model-based training guideline prepared for the individuals in the experimental group was published as a training booklet called "Let's Learn Hemodialysis" and distributed to the patients. At the end of the research, the training booklet was also distributed to the individuals in the control group.

Scale of Perceived Social Support from Family (PSS-FM) and Friends (PSS-FR) The study used the "Perceived Social Support from Family and Friends Scale" developed to determine the social support score perceived by the patients from their family and friends, which was adapted into Turkish by Eskin (Eskin 1993), and confirmed for validity and reliability. The scale is two independent scales, each including 20 items (Kahriman and Polat 2003).

Coopersmith Self-Esteem Inventory (Adult Form) (SEI) The "Coopersmith Self-Esteem Inventory" consisting of 25 items was used to evaluate the self-esteem level of the patients. The reliability study in our country was conducted by Turan and it was determined as a valid and reliable scale (Turan and Tufan,1987).

Hemodialysis Stressor Scale (HSS) The hemodialysis stressor scale was adapted to Turkish society by Kara (Kara 2006). Hemodialysis Stressor Scale is a five-point Likert-type scale consisting of 23 items. An increase in the score obtained from the scale indicates an increase in the perceived stress level (Kara 2006).

Data Collection First of all, the patients in the research group were informed about the purpose and importance of the study, and their written and verbal consents were obtained for voluntary participation. Data were collected from the patients in the experimental group in four stages. In the first stage, data were collected through scales and forms. In the second stage, the patients received training prepared in line with the Neuman Systems Model at their homes on a day when they did not go to the hemodialysis unit, and a printed model-based training guide was distributed. The third stage included training repetition and question-answer steps in the dialysis center. In the fourth and final stage, data were collected once again for the last time. Data collection for individuals in the control group included two stages, one at the beginning and one at the end of the study.

Data Analysis Data analysis was performed in a computer environment using SPSS 20 software. Descriptive statistical methods (number, percentage) and chi-square test were used. Parametric tests were used as the scales had normal distribution. In the comparison of quantitative data for scales with normal distribution, independent t-test was used for the difference between the two groups, paired t-test for the pre-test post-test comparative analysis in the same group, and one-way analysis of variance for the comparison of the means of more than two groups.

Ethical Aspect of the Research Following the approval of Atatürk University Faculty of Health Sciences Ethics Committee (Number: 2016/12/04, Date: 09.01.2017), written permission was obtained from the Chief Physician of KSU Research and Application Hospital and the General Secretariat of Kahramanmaraş Public Hospitals Union to conduct the research. The purpose of the study was explained to the participating patients. Verbal and written informed consent forms were obtained.