1.0 2014). Professional observers have observed that

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1.0  Introduction&

The literature review will provide an evidence based justification
for the selected topic. An outline of the search strategy used to generate
literature in depth from appropriate databases will be implemented. Methods of
each individual study and a summary of the key findings will be identified and
outlined. Thereafter, the methodical strengths and limitations will be
identified and critically appraised. An appendix of the selected studies will
be summarised and included. A conclusion and synthesis of literature will be
discussed. The clinical complications and identifiable gaps in knowledge will
be discussed to inform future research.

Chronic Kidney Disease (CKD) is defined by Gulanik and
Myers (2017) as a condition characterised by an irreversible and progressive
impairment of kidney function lost over a long period of time. Moreover, the kidney
function impairment will cause chronic abnormalities thus affecting every
system of the body. The kidneys fail to maintain electrolyte and metabolic
balance due to a mass destruction of nephrons therefore causing a metabolic
acidosis, endocrine disorders and electrolyte imbalances (Gulanik And Myers,
2017). The main causes are diabetes, high blood pressure, glomerulonephritis
and renal vascular disease with diabetes and high blood pressure accounting for
two thirds of CKD cases (Thomas, 2014). Professional observers have observed
that CKD is a global public health problem associated with high prevalence of
8%-16% worldwide, high morbidity and mortality (Faria et al., 2013).
Additionally, over 2 million people are currently receiving treatment worldwide
hence posing a heavy burden on the healthcare system. Also, millions die every
year thus making it an important heath issue worldwide (National Kidney
Foundation, 2015).  

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CKD symptoms often manifest at an advanced stage thereby
making it problematic to control the damage and offer sufficient treatment (Kidney
Research UK, 2016). Various clinical interventions such as urine tests and
bloods are in existence to have efficient diagnosis as the condition is often
asymptomatic (NHS Choices, 2014). However, scan of the kidney and biopsy may be
conducted to rule out other similar conditions (Carville, Stevens and
Wonderling, 2014). The kidney function level has five stages and in order to
determine the stage and decide the appropriate treatment the which are measured
by the Glomerular Filtration rate (GFR) is used to measure. (National Kidney Foundation,2017).

The risk of kidney dysfunction or damage increases with age
affecting 50% of people aged 75 and above. Additionally, the risk is also due
to decreased knowledge and awareness regarding CKD (Kidney Disease Improving
Global Outcomes, 2009). Haemodialysis is the most frequent treatment for CKD.
However, Stravroula and Fotoula, (2014) argued that haemodialysis affects the
psychological well-being as well as impacting on the quality of life as the
treatment has many restrictions and modifications. Psychological impact for
adults with CKD affect their quality of life hence reducing their life
expectancy (Chen et al., 2010). Equally important, the main common
psychological impacts explored were depression, anxiety, fatigue, increased
suicide risk and decreased quality of life. Indeed, the psychological symptoms
like depression and anxiety increase patient suicide risk. Research questions
for further investigation might include: Are the patients with CKD presenting
with psychological symptoms screened for mental health issues and offered
psychological support?  What are the
interventions that increase knowledge and psychological interventions to
improve the quality of life for patients? What treatment strategies are in
place to help the patients on haemodialysis to have a better treatment outcome
hence maintaining their work?

2.0  Search
Strategy Process:

A search strategy was
conducted in English language for this literature review using a range of
subject headings for the topic. The electronic databases used to conduct the
search were CINHAL, MEDLINE, Cochrane and PubMed. CINHAL was used because it is
the most common used nursing database and yielded in depth relevant documents.
MEDLINE yielded relevant journals and Cochrane yielded meta-analysis and
systematic reviews. However, PubMed did not yield any relevant results. The
search terms used in combination with each other to guide the search included
‘chronic kidney disease and/or psychological impact and /or quality of life’,
renal insufficiency and/or haemodialysis. As part of the search refinement, the
search inclusion criteria were conducted within a search parameter between
2007-2017 to ensure the most contemporary data. However, the exclusion criteria
outside parameters from 2000-2017 can be used to allow for a comparison for the
nursing intervention which was developed between the last two decades except
for seminal works. Non-evidential sources will be excluded. Other professional
websites including National Kidney Foundation, Kidney Research, journals of nursing
produced significant policies and guidelines. The search inclusion focused on
UK studies only because it relates to current clinical protocols.

However, international data
was incorporated in the search inclusion to widen the search because of the
dearth of research in UK and for comparison purposes of worldwide findings. Also,
the use of international research might incorporate private healthcare settings.
The validity of the British nursing practice may be affected as the literature
fails to identify the psychological impact of CKD in details. The international
research included China, United Sates of America, Asia, Australia, Korea and
Canada. Quantitative and qualitative studies were the main types of studies found.
There was a disproportion number between quantitative and qualitative with the latter
being the largest. This indicates that there may be gap in research knowledge
exploring the psychological impacts on patients and their families in groups
due to the dearth of quantitative studies.

3.0  Evaluation
& Integration of the Evidence:

The integrative review total number of studies included
amounted to 10 of which 8 were quantitative and 2 qualitative. Refer to table
1overleaf for the studies areas of investigation and overview.

Table 1: Studies Selected for Integrative Review


Study Design/Approach

Study Aim/Purpose

Tang et al., (2017)


Examined the effects of a 12-week exercise on
psychological dimensions for patients with CKD and health related quality of
life for a group of Chinese participants.

Llywellyn et al., (2014)

Phenomenological study

Examined the lived experiences of adults with
stage 5 CKD receiving dialysis focusing on continuity and disruption.

Lee et al., (2013)

Correlational Study

Analysed the association of reduced quality
of life with anxiety and depression at Samsung Changwon Hospital in Korea.

Zalai, Szeifert & Novak ((2012)


Examined and analysed psychological distress
and depression faced by people living with CKD

Bonner, Caltabiano & Berlund (2013)

Correlational Study

Examined the relationship between the quality
of life, activity levels and fatigue for people living with CKD over a 12-month

Mie-Chen et al. (2016)


Analysed 8 studies from 3 databases
investigating depression and quality of life among people with CKD.

Stanon et al., (2015)


Examined depression and anxiety prevalence
and patterns in dialysis patients from 13 dialysis centres.

Clarke, Read & & SIM (2017)

Phenomenological study

Analysed symptoms experienced with non-dialysis
depend CKD patients.

Stavroula & Fotoula (2014)

Systematic review

Explored the psychological impact for CKD
people undergoing dialysis on their quality of life

Low et al., (2008)

Literature Review

Analysed the psychological impact of CKD on
patients and their families using 20 studies.


3.1  Psychosocial
and psychological impact of CKD (Low et al., (2008), Zalai, Szeifert &
Novak (2012), Tang et al., (2017).

3.2  The impact
of dialysis and lived experiences on CKD patients (Llywellyn et al., (2014),
Stavroula & Fotoula (2014M, Stanon et al., (2015), Clarke, Read & Sim

3.3  Reduced
quality of life due to depression and anxiety for CKD patients.  Bonner, Caltabiano & Berlund (2013), (Lee
et al., (2013), Mie-Chen et al., (2016).


Me-Chen et al., (2016) conducted a meta-analysis which
analysed depression and the quality of life for adults living with CKD in
clinical trials or RCT between 8 studies from 3 different databases used to
conduct the search in Korea.  A non-probability
convenience sampling method was used and comprised of (n-22) of which 18 research
papers identified depression and knowledge of disease and 4 papers identified
the quality of life when living with CKD for patients aged over 35 years old. The
Beck Depression inventory and the medical outcome study were used to measure
the depression condition of the CKD patients. Also, the short form (SF-36)
developed by Ware et al.; (2011) which is in two distinct groupings was used to
examine the quality of life of patients including their mental and physical aspects.
The key findings showed a higher significance of (p<0.001) on depression, 75.2% on physical and p<0.001) on mental quality of life. Furthermore, it was observed that depression affect the quality of life hence reduce the life expectancy of patients. Depression will increase the risk of committing suicide therefore, it is important to screen the patients for mental health illness by developing a systematic approaches and planning treatment strategies thereby improving the quality of life. The methodological strength was the use of meta-analysis which is a very powerful study that obtains data from relevant clinical questions and relevant trials hence gaining a robust understating (Ellis,2013). The methodological limitations were the use of the Beck inventory and the short form (SF-36) which are structured and does not provide open ended questions. Moreover, the participants might leave the forms uncompleted and skew the results leading to publication biases.   Tang et al., (2017) conducted an RCT which examined the effects of a 12-week exercise on psychological dimensions for patients with CKD and health related quality of life between November 2015 and May 2016 at the Nephrology department in China. A non-probability method of purposive sampling comprised of (n-90) of the selected participants, 45 were in the experimental group and 45 were in the control group. Guidance and exercise education was provided while the patients were in hospital for 3 times and home based aerobic exercise was implemented. Adults aged 20-70 years with CKD stages 1 to 5 were included in the trial. Individualised exercise programme was provided to the exercise group and the control group received the usual care. A six-minute walk (6MWT) was used to measure the physical function whilst the hospital anxiety and depression scale assessed the psychological dimensions. Also, the ability to perform exercises was measured using the self-efficacy for exercise scale. A demographic form collected details of age, gender and causes of CKD. The Kidney Disease Quality of Life Scale evaluated the health-related related quality of life. The key findings showed (ns) no significant differences between the 2 groups. The physical function of the participants was strengthened by exercise and the nursing staff promoted the exercise education to patients with CKD. However, nursing staff should take some strategies and pay attention to CKD patients' psychological stress and limitations to their physical function. The methodological strength for the study was the one to one exercise education and guidance offered to the control group as they fully adhered to the programme. Equally important, the RCT was a true experiment. The methodological limitations were that the study was only conducted for 3 months and it remains unknown whether after the programme the positive results were maintained, Secondly, For the home-based exercise there were no measures of the completes exercises due to no direct supervision. 

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