mentoring program for in-center hemodialysis can benefit both mentees and mentors. ..... use on its own (Bowling, 2005; ..... patients on maintenance hemodialy-.
A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A PatientCentered Quality Improvement Program Jennifer St. Clair Russell Shiree Southerland Edwin D. Huff
oth psychological theory and empiric evidence (Heisler, 2006; Heisler, Vijan, Makki, & Piette, 2010; Knox et al., 2015; Krause, Herzog, & Baker, 1992; Long, Jahnle, Richardson, Loewenstein, & Volpp, 2012; Riegel & Carlson, 2004; Sandhu et al., 2013; Thom et al., 2013) suggest that peer mentoring programs can increase self-management and improve outcomes in chronic disease; however, little research has examined the use of peer mentoring for this purpose among patients receiving in-center hemodialysis. This appears to be a gap, and because patients on in-center hemodialysis face significant disease management and self-care burden, an opportunity for quality improvement (Curtin, Sitter, Schatell, & Chewning, 2004; Denhaerynck et al., 2007; Hakim & Collins, 2014; Leggat, 2005; Matteson & Russell, 2010; Obialo, Hunt, Bashir, & Zager, 2012; Richard, 2006; Saran et al., 2003).
B
Jennifer St. Clair Russell, PhD, MSEd, MCHES, is a Medical Instructor, Duke University School of Medicine, Durham, NC, and a member of ANNA’s Cardinal Chapter. Shiree Southerland, PhD, RN, is a Health Insurance Specialist, the Centers for Medicare and Medicaid Services, Baltimore, MD. Edwin D. Huff, PhD, MA, is a Science Officer, Contracting Officer Representative III, the Centers for Medicare and Medicaid Services, Boston, MA.
Continuing Nursing Education
Maria Thomson Klemens B. Meyer Janet R. Lynch
Copyright 2017 American Nephrology Nurses Association. St. Clair Russell, J., Southerland, S., Huff, E.D., Thomson, M., Meyer, K.B., & Lynch, J. (2017). A peer-to-peer mentoring program for in-center hemodialysis: A patientcentered quality improvement program. Nephrology Nursing Journal, 44(6), 481-489, 496. A patient-centered quality improvement program implemented in one Virginia hemodialysis facility sought to determine if peer-to-peer (P2P) programs can assist patients on in-center hemodialysis with self-management and improve outcomes. Using a single-arm, repeatedmeasurement, quasi-experimental design, 46 patients participated in a four-month P2P intervention. Outcomes include knowledge, self-management behaviors, and psychosocial health indicators: self-efficacy, perceived social support, hemodialysis social support, and healthrelated quality of life (HRQoL). Physiological health indicators included missed and shortened treatments, arteriovenous fistula placement, interdialytic weight gain, serum phosphorus, and hospitalizations. Mentees demonstrated increased knowledge, self-efficacy, perceived social support, hemodialysis social support, and HRQoL. Missed treatments decreased. Mentors experienced increases in knowledge, self-management, and social support. A P2P mentoring program for in-center hemodialysis can benefit both mentees and mentors. Key Words: Hemodialysis, mentor, mentee, peer to peer, social support.
Patients receiving in-center hemodialysis are advised to follow a complex self-management regimen and to practice behaviors that promote treatment efficacy, such as monitoring fluid intake, adhering to dietary restrictions, and managing a complex medication
schedule (Centers for Medicare & Medicaid Services, 2007). However, the more complex and the lengthier a treatment regimen, the lower the probability of adherence (McDonald, Garg, & Haynes, 2002). Further, end stage renal disease (ESRD) self-manage-
Acknowledgements: The authors would like to thank the patients and staff at the University of Virginia Lynchburg Dialysis facility, as well as members of the Community Advisory Committee for their participation and contributions to this project. Support: The intervention and analyses reported were performed under Special Innovation Project (SIP) contract HHSM-500-2013-NW05C funded by The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.
Maria Thomson, PhD, is a Assistant Professor, Virginia Commonwealth University School of Medicine, Richmond, VA.
Statement of Disclosure: Klemens B. Meyer’s salary is supported in part by payments to his employer from Dialysis Clinic, Inc.
Klemens B. Meyer, MD, is Director of Dialysis Services, Tufts Medical Center, Boston, MA.
All other authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.
Janet R. Lynch, PhD, CPHQ, is Corporate Science Officer, Quality Insights, Richmond, VA.
Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 490.
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A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A Patient-Centered Quality Improvement Program
ment may be especially challenging because the diagnosis and its associated functional limitations constitute a profound physical, social, and financial loss for patients and families. For example, many patients are unable to continue working, and some require the assistance of a caregiver (Kutner, Bowles, Zhang, Huang, & Pastan, 2008; Muehrer et al., 2011; van Manen et al., 2001). The theoretical basis for peer mentoring in chronic disease may be found in Bandura’s Social Cognitive Theory (SCT), which emphasizes the critical role of self-efficacy, one’s confidence in his/her ability to perform a behavior (Bandura, 1977, 1978, 1986, 1997, 2004). Self-efficacy is enhanced by learning through observation and role-modeling (Glanz, Rimer, & Viswanath, 2015). SCT also recognizes the importance of social support in behavior change, including it as a major construct within the theoretical model (Glanz et al., 2015). Peer programs provide patients with ongoing disease self-management information and emotional support, and foster mutual reciprocity, with the goal of improving health-related quality of life (HRQoL), healthy behaviors, and chronic disease control, while reducing hospitalizations and costs (Clark & Nothwehr, 1997; Heisler, 2006; Lorig et al., 1999). Self-management support goes beyond traditional knowledgebased patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support patients’ application of knowledge to manage their chronic disease. Research suggests that the act of helping others also benefits peer mentors (Inagaki et al., 2016; Krause et al., 1992; Schwartz & Sendor, 1999). Self-management is particularly relevant among the ESRD population because controlling diet and fluid intake plays a crucial role in treatment and outcomes. Patients on in-center hemodialysis congregate for treatment three times a week, and to some extent, constitute a community. These circumstances foster social interaction and lower social and logistical barriers to peer mentoring.
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Table 1 Inclusion Criteria for Peer Mentees and Mentors Mentees
• Diagnosed by a physician with end stage renal disease and receiving in-center hemodialysis treatment at this hemodialysis facility. • Adults (over 18 years of age). • Able to provide consent. • Able to comprehend English without the aid of a support person. • Willing to commit for the duration of the program, through June 30, 2015 (e.g., willingness to complete surveys and other program-related forms such as a confidentiality agreement and meeting logs). • No evidence, as documented in the electronic health record and/or a physician diagnosis, of mental illness (e.g., major depression, dementia, Alzheimer’s disease, schizophrenia, bipolar disorder, alcoholism, or drug abuse), or intellectual disability. Mentors
• In addition to the mentee requirements, mentors must have received treatment at this hemodialysis facility for one or more years, with at least six months of their treatment performed in-center, as confirmed by the patient’s electronic health record. (This time-related treatment requirement increased the likelihood that mentors were familiar with the facility, its staff, and its policies.) • Patients on home dialysis and former patients of this hemodialysis facility (those transplanted) are eligible to serve as mentors. • Complete all training activities associated with the program. • Willing to dedicate the time necessary to provide ongoing one-on-one support to another patient in the facility.
The primary goal of this quality improvement program was to evaluate the feasibility and impact of a four-month P2P program on physiological and psychosocial health outcomes of patients on in-center hemodialysis at one hemodialysis center. We hypothesized that a peer mentoring program would positively impact the self-management behaviors of patients on hemodialysis, resulting in improvements in physiological and psychosocial outcomes.
Methods Context The intervention site was a 249patient hemodialysis facility affiliated with an academic medical center in western Virginia. Most patients receive three weekly treatments. Three patient shifts are treated six days a week in five treatment bays, each accommodating eight to nine hemodialysis chairs.
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Intervention The intervention was conducted from March through June 2015. It included mentor trainings, mentee and mentor pairing, kick-off mixers, ongoing meetings, mentor booster trainings, and a final celebration mixer. The intervention was preceded by a social marketing effort, which included flyers and posters throughout the facility, bulletin boards and television announcements in the waiting area, recruitment brochures, and a program naming contest. The contest resulted in naming the intervention Peer Up! Together Makes Us Better. Participant recruitment. Table 1 shows participant inclusion criteria. All patients interested in participating were asked to submit an application, which was also used to match the participant into mentor/mentee dyads. Mentor training. Mentors completed a five-hour training before being matched with mentees. The training curriculum was skills-based
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• • • • • •
Table 2 Sample of Mentor Training Topics
Basic kidney disease information. Leadership. Communication skills and relationship building. Active listening. Difference between medical information and medical advice. Privacy and confidentiality.
and experiential, enabling mentors to learn content through demonstration and role-playing. Table 2 lists training topics. We also gave mentors a sample outline they could take with them and follow during an interaction with their mentee. These included greeting and welcome, asking about self-care in the past week, pointing out and congratulating good self-care, checking in about expectations, and asking for and working together on one concern or challenge. Mentee and mentor pairing. Mentees were paired with mentors on the same shift so they could meet at the facility before or after hemodialysis treatment. This was the initial factor for pairing because many patients relied on medical transport or relatives for transportation. If transportation was not an issue or multiple participants were available for pairing during a particular shift, additional considerations and characteristics were taken into account using information from the program application, such as age, sex, and hobbies. Facility social workers and nurses reviewed the suggested pairings and provided input so participants were not paired with someone who may not be compatible because of personalities or previous interactions. Pairs were finalized, and participants were invited to the kick-off mixers. Kick-off mixers. The kick-off mixers served as the official program launch and provided participants an opportunity to meet their assigned mentor/mentee. During the mixers, a program overview was provided, including a review of the program length, the suggested number of interactions, and suggested places to meet (e.g., at the facility or off-site). The importance of confidentiality as well as
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cautions against providing medical advice versus medical information were also reviewed. All participants were asked to sign a confidentiality agreement. Participants received Peer Up! program branded giveaways, including hand sanitizer, grocery bag, t-shirt, and notebook. Finally, participants whose mentee/mentor also attended were introduced and held their first meeting. Three mixers were held to accommodate participants’ availability. Ongoing meetings. Participants were asked to meet approximately four times per month, or once per week. Meetings could be in-person or by phone, email, or text; however, patients were encouraged to hold at least two face-to-face meetings each month. The content discussed and length of the meetings was not dictated by the intervention. Participants were free to discuss their individual self-management needs at the time of the interaction. Fidelity was assessed through the use of meeting logs, which were to be completed at the end of each dyad meeting. Pairs who met the suggested number of times each month were entered into the monthly drawing for a $25 gift card for each individual. Pairs also earned an entry into the grand prize drawing each month they met the suggested number of times. The grand prize, a $100 gift card per individual, was awarded during the final celebration. These prizes encouraged participants to complete and submit their logs. Mentor training boosters. Mentor training boosters were also conducted two months after the intervention began. Mentors were asked to attend one two-hour session. Kidney disease and hemodialysis information
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was reviewed, and mentors could discuss any problems they might have encountered, such as difficulty scheduling or connecting on a personal level with their mentees. Final celebration mixer. The final celebration mixer was held at a restaurant, and transportation was provided, as necessary. Certificates of recognition were awarded to participants, and the grand prize drawing was held. This event served as the last meeting for dyads present; however, participants were free to continue meeting.
Measures Assessing Intervention Feasibility This was a single-arm pilot intervention study with repeated measurements over three time periods to evaluate the program’s feasibility and impact on patients’ physiological and psychosocial health. To assess program feasibility, we tracked overall patient interest, participants’ attendance at events, and the number of peer interactions. A program log created in Microsoft Excel® was used to track the number of applications received, the number deemed ineligible to participate with the corresponding reason, and the final number of participants enrolling in the program. Additionally, the number of participants completing the mentor training was documented, and each mentor was asked to complete a training evaluation at the end of the training session. Peer interactions were also tracked via meeting logs. Mentors were asked to complete a meeting log after each meeting with a mentee. Data, including the date, location of the meeting, length of interaction, topics discussed, educational materials used, and referrals to staff, were documented by the mentor immediately following each visit. The total number of interactions per pair, as well the total number for the overall project, was documented.
Assessing Intervention Impact Data abstracted from participants’ electronic health record (EHR) were
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Table 3 Data Collection Timeline by Data Type and Participant Role EHR Time Points
Pre-intervention
Participant Role
Post-intervention
Survey Time Points Pre-train
Post-train
Pre-intervention
Mid-intervention
Post-intervention
01/01/15 – 02/28/15
Mentors
02/25/15 – 03/08/15
All
03/01/15 – 04/30/15
All
Mentors
Mentees Mentees
Mentors and mentees
Note: EHR = electronic health record.
used to assess physiological health indicators, including missed treatments, shortened treatments, interdialytic weight gain (IDWG), serum phosphorus, and hospital admissions. Physiological variables under consideration were deemed to be clinical measures of self-management behaviors that patients on hemodialysis are encouraged to follow (Curtin et al., 2004; Richard, 2006). Psychosocial health indicators, including disease management self-efficacy and perceived social support, as well as hemodialysis self-management knowledge, were assessed using paper surveys. Time periods for data collection are outlined in Table 3. The survey, administered at three distinct time points, was composed of four validated scales, with additional questions relating to demographics and vascular access. Because limited health literacy has been documented within the hemodialysis patient population, we sought to use validated scales with a readability level at or below 6th grade, as assessed by the Flesch-Kincaid Grade Level Formula (Cavanaugh et al., 2010; Green et al., 2011) Whenever possible, surveys were administered during events (i.e., mixer, mentor training, and celebration). Participants not attending an event completed their assessments when they arrived for their next scheduled treatment or within 30 minutes of beginning their treatment
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Data Collection
All
Mid-intervention
•
05/01/15 – 06/30/15
•
02/25/15 – 03/08/15 03/04/15 – 03/07/15 05/07/15 – 05/09/15 06/28/15 – 06/30/15
because of concerns with hemodialysis-associated cognitive impairment (Murray, 2008; Murray et al., 2006) All mentees completed the mid-point assessment when they arrived at the facility for treatment or within 30 minutes of beginning their treatment. One member of the project team coded and entered data using the coding manual. Once entered, a second member of the project team reviewed the coding and checked the hard copy against the electronic entry. Data entry errors were minimal (less than 1%) and corrected. Missing survey data were examined for patterns. Minimal survey data were missing (less than 1%) and exhibited no patterns. We used person-mean imputation to estimate missing values for survey responses. Electronic clinical data were received monthly from the facility’s information technology group and were examined for completeness and accuracy. Any implausible values, as pre-defined by nephrologist advisor (KM), were flagged, and the project team worked directly with facility staff to determine the accurate value.
•
•
•
•
Specific Measures The following specific measures were used. • Self-efficacy was measured using Self-Efficacy for Managing Chronic Disease 6-item Scale (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2000).
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•
Perceived social support was measured using the Social Support Subscale (Emotional/Informational) from the Medical Outcomes Study (MOS) (Sherbourne & Stewart, 1991). Hemodialysis social support: A unique aspect of this program is peer support offered by other patients on hemodialysis; however, no validated scale appears to exist to capture perceived social support within the hemodialysis setting. A four-item scale was created specific to the hemodialysis setting, using a 5-point Likertscale, with responses ranging from “none of the time” to “all of the time.” A mean score was generated, with a higher mean indicative of higher perceived social support within the hemodialysis population. Knowledge was measured using the multiple choice Chronic Hemodialysis Knowledge Survey (CHeKS) (Cavanaugh, Wingard, Hakim, Elasy, & Ikizler, 2009). Self-management behaviors were measured using a 7-item scale that asked participants to rate how frequently they have carried out a specific behavior on a 5-point Likert-scale ranging from “none of the time” to “all of the time.” A mean score was generated, with a higher mean indicating higher frequency of self-care behaviors. Intentions to have a consultation with a vascular surgeon to have an arteriovenous fistula (AVF) placed were assessed among mentees who, at the time of enrollment, had a central venous catheter and no other access, per the EHR. Missed hemodialysis treatments were summed per individual and then divided by the total number of prescribed hemodialysis treatments for each time period. A missed hemodialysis treatment was defined as any treatment a patient was scheduled for but did not receive and did not reschedule. Shortened treatments were summed per individual for each time period
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Table 4 Demographic Characteristics of Peer Up! Participants (as of March 1, 2015) Mentee Count (%) (n = 23)
Demographics
Current modality In-center hemodialysis Home hemodialysis Transplant Sex Female Male Race African American Caucasian More than one race Ethnicity Not Hispanic or Latino Hispanic or Latino Marital status Single/never married Married/cohabiting Divorced Separated Widowed Education Less than high school High school diploma Some college (no degree) Associate degree (e.g., Cosmetology, LPN) More than associate degree (no bachelor’s degree) Bachelor’s degree Some graduate school (no degree) Master’s degree Employment Unemployed Employed (full-time) Employed (part-time) Annual Income $0 – $19,999 $20,000 – $39,999 $40,000 – $59,999 $60,000 – $79,999 $80,000 – $99,999 $100,000 or more Don’t Know
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23 0 0
(100.00%) (0.00%) (0.00%)
21 2 0
(91.30%) (8.70%) (0.00%)
11 12
22 1 7 3 4 5 4 7 8 4 2 2 0 0 0
21 0 2 17 3 1 0 0 0 2
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(47.83%) (52.17%)
(95.65%) (4.35%)
(30.43%) (13.04%) (17.39%) (21.74%) (17.39%) (30.43%) (34.78%) (17.39%) (8.70%) (8.70%) (0.00%) (0.00%) (0.00%)
(91.30%) (0.00%) (8.70%)
(73.91%) (13.04%) (4.35%) (0.00%) (0.00%) (0.00%) (8.70%)
Mentor Count (%) (n = 23) 21 1 1 16 7 17 5 1
(91.30%) (4.35%) (4.35%)
(69.57%) (30.43%) (73.91%) (21.74%) (4.35%)
23 (100.00%) 0 (0.00%) 9 5 2 3 4
(39.13%) (21.74%) (8.70%) (13.04%) (17.39%)
22 0 1
(95.65%) (0.00%) (4.35%)
2 11 3 1 1 2 2 1
10 8 1 1 1 0 2
(8.70%) (47.83%) (13.04%) (4.35%) (4.35%) (8.70%) (8.70%) (4.35%)
(43.48%) (34.78%) (4.35%) (4.35%) (4.35%) (0.00%) (8.70%)
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A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A Patient-Centered Quality Improvement Program
•
•
•
•
then divided by the total number of prescribed treatments for each time period. (A shortened treatment was defined as a treatment shortened by 30 minutes or more.) Mean IDWG was calculated for each time period using the available observations, which varied by patient. Serum phosphorus was calculated at three time points using the available observations, which varied by patient. All-cause hospitalizations were summed per individual and divided by the number of months in the time period. Hospitalizations were defined as any hospital admission. HRQoL was assessed using the single item from the MOS to measure participants’ perceived health status. This item has been deemed to be a valid measure to use on its own (Bowling, 2005; Cunny & Perri, 1991; Ware & Sherbourne, 1992).
Analysis We prepared descriptive statistics to answer our questions related to program feasibility. Hypotheses related to patients’ physiological and psychosocial health were tested using repeated measures ANOVA (analysis of variance) in the case of parametric data and Friedman’s test in the case of non-parametric data. All analyses were performed using SAS® 9.2. Twenty dyads (n = 40) were needed to detect a change in self-efficacy, our primary outcome. We used G*Power 3.1.9.2 to calculate this based on an effect size of 0.30, at 80% power and an alpha level of 0.05 for a repeated measures ANOVA (within subjects). An effect size of 0.30 (considered a medium effect size) was selected because it is regarded as a clinically significant change in self-efficacy for patients with chronic disease (Lorig et al., 2001; Sandhu et al., 2013). Intentto-treat analysis was used so every participant enrolled in the program was analyzed.
Ethical Considerations This study was reviewed and
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deemed exempt by Institutional Review Board for the University of Virginia.
Results Intervention Feasibility In total, 30 mentor applications and 27 mentee applications were received. Twenty-three mentors completed training, and the program launched with 23 mentors and 23 mentees. A total of 21 mentors and 22 mentees completed the program. The mean age of mentees was 56 years (SD = 12.85) and mentors was 57 years (SD = 15.49). Fifty-two percent of mentees had been receiving hemodialysis for a year or less as of March 1, 2015. More females served as mentors, whereas the distribution of gender was about equal among mentees (see Table 4). Most of the Peer Up! participants were AfricanAmerican, which is consistent with the overall demographics of the center. Very few individuals were married or were cohabiting; primarily, participants lived alone. The majority of mentees and mentors had a high school diploma or less, although some mentors had some college, with one reporting a master’s degree. Few individuals were employed, and those who were employed worked part time. All mentors met at least once with their mentee. A total of 416 logs were submitted by mentors, and the mean number of interactions per month was 4.52. The most popular meeting location was the treatment area, at 26%, followed by the clinic lobby, at 12%. When not meeting in person, participants preferred to meet by phone. The length of contacts ranged from 2 minutes to 9.5 hours. The mean length of interaction was 39.14 minutes (SD = 45.96), and the median was 28.5 minutes. Longer interactions were associated with dining out and other more time-consuming activities, including grocery shopping and cleaning out a mentee’s pantry.
Intervention Impact Results for mentees’ measures meeting parametric and nonparamet-
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ric test criteria are provided in Table 5. Peer Up! had a statistically significant impact on many of the psychosocial variables examined. Repeated measures one-way ANOVAs (within subjects) demonstrated significant increases between the means for self-efficacy, F(2,22) = 8.15, p < 0.01; knowledge, F(2,44) = 6.62, p < 0.01; perceived social support, F(2,22) = 7.30, p < 0.01; and hemodialysis social support, F(2,44) = 4.79, p = 0.01. The nonparametric Friedman’s test showed a statistically significant increase in HRQOL, c2(2) = 12.46, p < 0.01. Missed treatments decreased significantly over the time periods, c2(2) = 7.85, p = 0.02. It was hypothesized that mentees who had a central venous catheter only would report greater intention to consult with a vascular surgeon to have an AVF or arteriovenous graft (AVG) placed over the course of the program. Three participants entered the program with only a central venous catheter. When asked about their intentions to consult with a vascular surgeon at the three time points of the program, all three showed movement along the continuum. Peer Up! also had a statistically significant impact on some psychosocial variables examined among mentors, as shown in Table 6. A repeated measures one-way ANOVA (within subjects) demonstrated a significant increase between the means for knowledge, F(2,22) = 11.88, p < 0.01, and hemodialysis social support, F(2,42) = 3.19, p = 0.05. Friedman’s test showed a statistically significant increase in hemodialysis self-management, c2(2) = 7.65, p = 0.02. No statistically significant results were found in analyses of the mentors’ clinical measures.
Discussion This program demonstrates that peer mentoring implemented among patients on in-center hemodialysis may be beneficial for both mentees and mentors, and adds to the growing body of evidence examining peer mentoring as a treatment intervention in chronic disease. Mentees reported
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Table 5 Comparison of Psychosocial and Physiological Measures across Time Periods, Mentees (n = 23) Measures
Baseline
Repeated measures ANOVA Psychosocial Self-efficacy Knowledge Perceived social support
Mean
Dialysis social support Physiological Phosphorus IDWG Friedman’s Test Psychosocial Health-related quality of life† Dialysis self-management Physiological Missed treatments Shortened treatments Hospitalization
SD
Interim
Mean
SD
Mean
Final
SD
7.29 13.22 3.84
2.10 3.67 0.99
7.65 14.87 4.15
1.83 4.16 0.94
8.31 15.87 4.32
1.45 3.84 0.79
5.85 2.20a Median
1.53 1.35 IQR
5.54 2.43 Median
1.26 1.00 IQR
5.61 2.35b Median
1.53 0.83 IQR
7.14a 11.54a 0.00a
14.29 8.31 0.00
0.00 11.54 0.00
2.00 8.24 0.00
0.00 b 13.46 b 0.00
3.85 11.54 0.00
2.17
4.00 3.33b
1.18
1.00 0.50
2.60
1.11
3.00 3.50
1.00 0.50
3.12
3.00 3.67
0.98
2.00 0.34
p -Value < 0.01 < 0.01 < 0.01 0.01
0.52 0.39 p-Value < 0.01 0.09 0.02 0.13 0.55
Scale: Excellent = 1; Very Good = 2; Good = 3; Fair = 4; Poor = 5. n = 21 (Baseline data not available for two patients because they began dialysis shortly before Peer Up! program started.) b n = 22 (Data missing/final data not available for one patient because he transitioned to home modality.) † a
Table 6 Comparison of Psychosocial and Physiological Measures across Time Periods, Mentors (n = 23) Measures
Repeated measures ANOVA Psychosocial Self-efficacy Knowledge Perceived social support Dialysis social support Physiological Phosphorus IDWG Friedman’s Test Psychosocial Health-related quality of life† Dialysis self-management Physiological Missed treatments Shortened treatments Hospitalization
Baseline
Mean
8.36 15.96 3.82a 3.00a
SD
1.53 4.31 0.76 0.89
Interim
Mean
8.33 17.74 4.18a 3.09a
SD
1.69 3.05 0.84 0.91
8.11 18.35 3.83 3.34
Final
SD
1.60 3.56 0.86 0.89
5.34a 2.44b Median
1.48 0.89 IQR
5.66a 2.57b Median
1.36 0.84 IQR
5.71a 2.45b Median
0.97 0.92 IQR
0.00b 12.00b 0.00
0.00 20.00 0.00
0.00b 11.54b 0.00
3.85 12.09 0.00
0.00b 7.69b 0.00
3.85 11.54 0.00
3.00 3.43a
1.00 0.83
3.00a 3.57a
0.00 0.43
Scale: Excellent = 1; Very Good = 2; Good = 3; Fair = 4; Poor = 5. n = 22 (Data missing/not applicable for transplant patient.) b n = 21 (Data unavailable/not applicable for home patient and transplant patient.) †
Mean
3.00 3.71a
0.0 0.43
p -Value 0.60 < 0.01 0.60 0.05
0.14 0.26pValue 0.33 0.02 0.29 0.08 0.07
a
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A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A Patient-Centered Quality Improvement Program
improved self-efficacy, increased knowledge, higher perceived social support, and increased hemodialysis social support. Mentors benefited as well, reporting improved hemodialysis self-management behaviors, increases in knowledge, and increased hemodialysis social support. Patients may help each other in ways that health care providers may not be able to by sharing lived experiences and support. Participants in this study were committed to the program and enjoyed helping each other. This is further supported by anecdotal evidence that some peer pairs were still in contact or meeting after the intervention. Peer Up! was associated with improved scores for mentees in most psychosocial measures. Only hemodialysis self-management was unchanged over the time periods. These behaviors may take longer to improve. Approximately 52% of mentees had been on hemodialysis a year or less and were facing the tremendous challenge of managing ESRD in the early stages when there is much to learn and adjust to while possibly coping with profound feelings of grief and loss. Consistent with SCT, perhaps once participants experience social support and improved self-efficacy, improved selfmanagement will occur in time. However, we cannot rule out response bias. Participants, either knowingly or unknowingly, may have reported they were doing a “better” job at their selfmanagement behaviors at baseline. Whether biased or unbiased, high average scores at baseline may have created a “ceiling effect,” with little room for improvement. Peer Up! was also associated with improved scores in three psychosocial measures among mentors – knowledge, hemodialysis social support, and hemodialysis self-management. The increase in knowledge is consistent with our hypothesis. Mentors received seven hours of training, so it seems logical that knowledge would increase. While providing support to others has been shown to help oneself (Inagaki et al., 2016; Krause et al., 1992; Schwartz & Sendor, 1999), nothing specifically within the intervention focused on psy-
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chosocial health indicators for mentors. Nevertheless, hemodialysis social support and hemodialysis self-management both showed statistically significant increases. Some increase in mean scores related to the hemodialysis social support measure may be related to meeting other patients during the trainings and mixers. The improvement in hemodialysis selfmanagement may be related to mentors feeling accountable to their mentees. When project staff spoke with various mentors while at the facility, many mentioned they felt they led by example because they were rolemodels for their mentees. Nevertheless, response bias is possible because this was self-reported data. While most clinical measures did not change over time, possibly due to the short-term nature of the intervention, the reduction in missed appointments among mentees is promising. Missed appointments have been associated with higher rates of hospitalizations and mortality (Obialo et al., 2012); thus, if the intervention and this trend continued, a change in hospitalization as well as survival might have been observed. While steps were taken to limit threats to validity, this pilot quality improvement project had limitations. Because information examining the use of peer mentoring in the hemodialysis setting is limited, it was thought best to begin with one study site to determine program feasibility. External validity, or the generalizability of findings, is limited because we were only able to test Peer Up! at one site. However, it could be argued that every hemodialysis facility has its own unique organizational culture and conditions, and generalizability of findings, even in multiple study sites, may be limited. Threats to internal validity, such as maturation or selection bias, may also be an issue because a control or comparison group was not available. Finally, although adequately powered to detect a change within subjects, the sample was not large enough to conduct post hoc analyses to determine the exact time periods when the changes occurred.
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Conclusion A peer mentoring program for patients on in-center hemodialysis may be beneficial for both mentees and mentors, even when conducted on a trial basis over a short period of time. This program was successful, in part, because it used one of the most underutilized resources within the healthcare system – patients. The evaluation of this intervention starts to fill the void observed in the literature related to peer mentoring within the in-center hemodialysis setting. It also begins to build on the limited evidence available within ESRD for using peers to increase self-management behaviors and provide support. Future efforts should focus on programs extending over longer time periods with larger groups of patients and a control group. These might include testing the program at multiple sites across the country, both rural and urban locations, and ultimately, conducting randomized controlled trials. Longitudinal studies could also be conducted to determine if peer mentoring affords benefits beyond the intervention period. References Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33(4), 344-358. Bandura, A. (1986). Social foundations of thought and action: A social cognitive perspective. Englewood Cliffs, NJ: Princeton-Hall. Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Macmillan. Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31(2), 143-164. Bowling, A. (2005). Just one question: If one question works, why ask several? Journal of Epidemiology and Community Health, 59(5), 342-345. Cavanaugh, K.L., Wingard, R.L., Hakim, R.M., Eden, S., Shintani, A., Wallston, K.A., … Ikizler, T.A. (2010). Low health literacy associates with increased mortality in ESRD. Journal of the American Society of Nephrology, 21(11), 1979-1985.
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Cavanaugh, K.L., Wingard, R.L., Hakim, R.M., Elasy, T.A., & Ikizler, T.A. (2009). Patient dialysis knowledge is associated with permanent arteriovenous access use in chronic hemodialysis. Clinical Journal of the American Society of Nephrology, 4(5), 950-956. Centers for Medicare & Medicaid Services. (2007). You can live: Your guide for living with kidney failure. Baltimore, MD: U.S. Department of Health and Human Services. Clark, N.M., & Nothwehr, F. (1997). Selfmanagement of asthma by adult patients. Patient Education and Counseling, 32(1, Suppl), S5-S20. Cunny, K.A., & Perri, M. (1991). Single-item vs multiple-item measures of healthrelated quality of life. Psychological Reports, 69(1), 127-130. Curtin, R.B., Sitter, D.C.B., Schatell, D., & Chewning, B.A. (2004). Self-management, knowledge, and functioning and well-being of patients on hemodialysis. Nephrology Nursing Journal, 31(4), 378386, 396. Denhaerynck, K., Manhaeve, D., Dobbels, F., Garzoni, D., Nolte, C., & De Geest, S. (2007). Prevalence and consequences of nonadherence to hemodialysis regimens. American Journal of Critical Care, 16(3), 222-235. Glanz, K., Rimer, B.K., & Viswanath, K. (2015). Health behavior: Theory, research, and practice. San Francisco, CA: John Wiley & Sons. Green, J.A., Mor, M.K., Shields, A.M., Sevick, M.A., Palevsky, P.M., Fine, M.J., … Weisbord, S.D. (2011). Prevalence and demographic and clinical associations of health literacy in patients on maintenance hemodialysis. Clinical Journal of the American Society of Nephrology, 6(6), 1354-1360. Hakim, R.M., & Collins, A.J. (2014). Reducing avoidable rehospitalization in ESRD: A shared accountability. Journal of the American Society of Nephrology, 25(9), 1891-1893. Heisler, M. (2006). Building peer support programs to manage chronic disease: Seven models for success. Oakland, CA: California Health Care Foundation. Heisler, M., Vijan, S., Makki, F., & Piette, J.D. (2010). Diabetes control with reciprocal peer support versus nurse care management: A randomized trial. Annals of Internal Medicine, 153(8), 507-515. Inagaki, T.K., Bryne Haltom, K.E., Suzuki, S., Jevtic, I., Hornstein, E., Bower, J.E., & Eisenberger, N.I. (2016). The neurobiology of giving
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versus receiving support: The role of stress-related and social reward– related neural activity. Psychosomatic Medicine, 78(4), 443-453. Knox, L., Huff, J., Graham, D., Henry, M., Bracho, A., Henderson, C., & Emsermann, C. (2015). What peer mentoring adds to already good patient care: Implementing the carpeta roja peer mentoring program in a well-resourced health care system. The Annals of Family Medicine, 13(Suppl. 1), S59-S65. Krause N., Herzog, A.R., & Baker E. (1992). Providing support to others and well-being later in life. Journal of Gerontology, 47(5), 300-311. Kutner, N., Bowles, T., Zhang, R., Huang, Y., & Pastan, S. (2008). Dialysis facility characteristics and variation in employment rates: a national study. Clinical Journal of the American Society of Nephrology, 3(1), 111-116. Leggat, J.E., Jr. (2005). Psychosocial factors in patients with chronic kidney disease: Adherence with dialysis: A focus on mortality risk. Seminars in Dialysis, 18(2), 137-151. Long, J.A., Jahnle, E.C., Richardson, D.M., Loewenstein, G., & Volpp, K.G. (2012). Peer mentoring and financial incentives to improve glucose control in African American veterans: A randomized trial. Annals of Internal Medicine, 156(6), 416-424. Lorig, K.R., Ritter, P., Stewart, A.L., Sobel, D.S., Brown, B.W., Jr., Bandura, A., … Holman, H.R. (2001). Chronic disease self-management program: Twoyear health status and health care utilization outcomes. Medical Care, 39(11), 1217-1223. Lorig, K.R., Sobel, D.S., Ritter, P.L., Laurent, D., & Hobbs, M. (2000). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4(6), 256262. Lorig, K.R., Sobel, D.S., Stewart, A.L., Brown, B.W., Jr., Bandura, A., Ritter, P., … Holman, H.R. (1999). Evidence suggesting that a chronic disease selfmanagement program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1), 5-14. Matteson, M.L., & Russell, C. (2010). Interventions to improve hemodialysis adherence: A systematic review of randomized controlled trials. Hemodialysis International, 14(4), 370-382. McDonald, H.P., Garg, A.X., & Haynes, R.B. (2002). Interventions to enhance
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patient adherence to medication prescriptions: Scientific review. JAMA, 288(22), 2868-2879. Muehrer, R.J., Schatell, D., Witten, B., Gangnon, R., Becker, B.N., & Hofmann, R.M. (2011). Factors affecting employment at initiation of dialysis. Clinical Journal of the American Society of Nephrology, 6(3), 489-496. Murray, A., Tupper, D.E., Knopman, D.S., Gilbertson, D.T., Pederson, S.L., Li, S., … Kane, R.L. (2006). Cognitive impairment in hemodialysis patients is common. Neurology, 67(2), 216-223. Murray, A.M. (2008). Cognitive impairment in the aging dialysis and chronic kidney disease populations: An occult burden. Advances in Chronic Kidney Disease, 15(2), 123-132. Obialo, C.I., Hunt, W.C., Bashir, K., & Zager, P.G. (2012). Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: Observations from a US dialysis network. Clinical Kidney Journal, 5(4), 315-319. Richard, C.J. (2006). Self-care management in adults undergoing hemodialysis. Nephrology Nursing Journal, 33(4), 387-394. Riegel, B., & Carlson, B. (2004). Is individual peer support a promising intervention for persons with heart failure? Journal of Cardiovascular Nursing, 19(3), 174-183. Sandhu, S., Veinot, P., Embuldeniya, G., Brooks, S., Sale, J., Huang, S., … Bell, M.J. (2013). Peer-to-peer mentoring for individuals with early inflammatory arthritis: Feasibility pilot. BMJ Open, 3(3), 1-9. doi:10.1136/bmjopen2012-002267 Saran, R., Bragg-Gresham, J.L., Rayner, H.C., Goodkin, D.A., Keen, M.L., Van Dijk, P.C., … Port, F.K. (2003). Nonadherence in hemodialysis: Associations with mortality, hospitalization, and practice patterns in the DOPPS. Kidney International, 64(1), 254-262. Schwartz, C.E., & Sendor, R.M. (1999). Helping others helps oneself: Response shift effects in peer support. Social Science & Medicine, 48(11), 1563-1575. Sherbourne, C.D., & Stewart, A.L. (1991). The MOS social support survey. Social Science & Medicine, 32(6), 705714. continued on page 496
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Peer-to-Peer Mentoring Program continued from page 489 Thom, D.H., Ghorob, A., Hessler, D., De Vore, D., Chen, E., & Bodenheimer, T.A. (2013). Impact of peer health coaching on glycemic control in lowincome patients with diabetes: A randomized controlled trial. The Annals of Family Medicine, 11(2), 137-144. Van Manen, J.G., Korevaar, J.C., Dekker, F.W., Reuselaars, M.C., Boeschoten, E.W., & Krediet, R.T. (2001). Changes in employment status in end-stage renal disease patients during their first year of dialysis. Peritoneal Dialysis International, 21(6), 595-601. Ware, J.E., Jr., & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30(6), 473-483.
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A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A Patient-Centered Quality Improvement Program
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Nephrology Nursing Journal Editorial Board Statements of Disclosure In accordance with ANCC governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below. Paula Dutka, MSN, RN, CNN, disclosed that she is a coordinator of Clinical Trials for the following sponsors: Amgen, Rockwell Medical, Keryx Biopharmaceuticals, Akebia Therapeutics, and Dynavax Technologies. Norma J. Gomez, MBA, MSN, CNNe, disclosed that she is a member of the ZS Pharma Advisory Council. Tamara M. Kear, PhD, RN, CNS, CNN, disclosed that she is a member of the ANNA Board of Directors, serves on the Scientific Advisory Board for Kibow Biotech, Inc., and is employed by Fresenius Kidney Care as an acute hemodialysis RN. All other members of the Editorial Board had no actual or potential conflict of interest in relation to this continuing nursing education activity. This article was reviewed and formatted for contact hour credit by Beth Ulrich, EdD, RN, FACHE, FAAN, Nephrology Nursing Journal Editor, and Sally Russell, MN, CMSRN, CPP, ANNA Education Director.
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