The effect of spiritual intervention on self-esteem of hemodialysis patients: A semi-experimental study

Introduction

Today, with increasing life expectancy, chronic diseases have become a major health concern (Weisz 2016). Chronic renal failure is recognized as a debilitating and life-threatening condition. This disease forces individuals to constantly assume the role of a patient due to their health status and illness (Chen et al. 2019; Hashmi et al. 2023). Patients with chronic renal failure experience various challenges. Changes in nutrition and fluid intake are implemented to prevent the accumulation of waste products and electrolytes. Consequently, complex treatment regimens impose restrictions on patients’ activities, leading to increased dependence, financial stress, family issues, lifestyle adjustments, and alterations in self-confidence and self-image (Gagnon and Desai 2013; Asti et al. 2006; Imamah and Lin 2021). Although hemodialysis is considered an acceptable treatment option for patients with chronic renal failure (Bello et al. 2022), dialysis presents challenges due to its requirements and potential complications. Patients undergoing dialysis must contend with fistulas, vascular grafts, and catheters. These methods can cause anxiety and discomfort when patients encounter them (Al-Arabi 2006; Suprapti et al. 2019; Rasyid et al. 2022). In addition to the physiological changes, patients face significant psychological stress. Anxiety, depression, low self-confidence, and diminished self-esteem are common behavioral responses (Tian et al. 2021; Cohen et al. 2016; Shahgholian et al. 2012). Lack of self-esteem leads to anxiety, depression, and distrust in oneself, resulting in feelings of absurdity and futility in life (Büssing et al. 2008; Sowislo and Orth 2013; Nguyen et al. 2019). However, spirituality and religious practices serve as crucial resources in the battle against chronic diseases. These spiritual and religious coping strategies contribute to maintaining and promoting the patient’s self-esteem, creating a sense of purpose and meaning in life, and increasing psychological comfort and hope (Büssing et al. 2008). Studies have shown that spiritual beliefs enhance a patient’s ability to cope with disease occurrence and expedite recovery (Saeedi 2013). Despite the growing attention to spirituality and the substantial evidence supporting its effectiveness in coping with chronic medical conditions, spiritual issues are not yet fully integrated into routine care. According to the holistic model, humans possess biological, psychological, social, and spiritual dimensions, all of which should be considered in comprehensive care (Sulmasy 2002). Given the importance of high self-esteem in patients undergoing hemodialysis and the historical role of spirituality in our Iranian-Islamic culture, researchers aim to study the effect of the spiritual dimension on the self-esteem of these individuals, with the hope of improving care and enhancing self-esteem among hemodialysis patients.

Material and methods

This research is semi-experimental. The research population consisted of all patients undergoing hemodialysis referred to the hemodialysis ward of Imam Reza (AS) Hospital in Kermanshah in 2016. In this study, the sampling was first done by the convenience method.
The sample size was determined using a formula for comparing a quantitative trait in two groups. The parameters considered were: 95% confidence coefficient (α-1), 90% test power (β-1). These parameters were based on the results of a similar study (Tajbakhsh et al. 2014). The sample size calculation followed the specified formula:

α = 0.05, β = 0.1, µ1 = 10.35, µ2 = 8.06, σ1 = 2.96, σ2 = 2.91

To account for the possibility of participant falls during the study stages, 10% was added to the sample size. Consequently, the minimum required sample size for each of the groups, intervention and control, was 22 (totaling 44 people). These 44 individuals met the inclusion criteria, which were as follows: undergoing hemodialysis, scoring 26 or less on the Cooper-Smith Self-Esteem Questionnaire, voluntarily willing to participate in the study, not having physical disabilities such as deafness or blindness, being over 18 years old, having the ability to read and write, believing in Islam and absence of other physical and mental illnesses as per the doctor’s diagnosis. Exclusion criteria included: non-participation of volunteers in more than two training sessions, individual dissatisfaction with continuing participation in the study, presence of other diseases during the study, migration or receiving drugs affecting the nerves system.
Questionnaire description: The self-esteem questionnaire comprises 58 items that explore feelings, beliefs, or reactions experienced by an individual. Respondents answer these items by marking either “resembles me (yes)” or “does not resemble me (no)”. The questionnaire is divided into several subscales: General Scale: consists of 26 items. Social Scale: comprises 8 items. Family Scale: contains 8 items. Career Scale: includes 8 items. False Scale: comprises 8 items.
Scoring method: The scoring system is binary: zero and one. For some questions: “Yes” responses receive a score of one. “No” responses receive a score of zero. For the remaining questions, the scoring is reversed. Specific questions with scoring: The following questions receive a score of one for “yes” and zero for “no”: 2, 4, 5, 10, 11, 14, 18, 19, 21, 23, 24, 28, 29, 30, 32, 36, 45, 47, and 57. Interpreting scores: Poor self-esteem: a total score of 26 or less. Moderate self-esteem: a score between 23 and 27. High self-esteem: a score of 44 or higher.
Reliability and validity: Researchers in Iran and abroad have found this test to have acceptable reliability and validity (Coopersmith 1965; Taghibaygi et al. 2015).
To collect research data, after giving the necessary explanations and obtaining informed consent, the Cooper-Smith Demographic Characteristics and Self-Esteem Questionnaire was completed by the participants and the mean score of self-esteem was calculated and those who obtained a score less than 26 entered the study and were randomly divided into intervention and control groups. Then in the intervention group, spiritual intervention was performed. In order to reduce congestion and make optimal use of group meetings, the intervention group was divided into two groups of 11 people to participate in the meetings. An 8-session spiritual intervention was held with 11 people in each group twice a week for 50 to 70 minutes. Again, after the last session of spiritual intervention, both Cooper and Smith questionnaires were completed by both intervention and control groups. Since spiritual cares arise from the religious spirituality and commands of Islam, the four dimensions of human communication were considered: communication with God, communication with oneself, communication with others, and communication with nature. Data analysis was done by SPSS software version 18.0. Descriptive statistics were used to describe the variables. To compare the two groups in terms of qualitative and quantitative demographic characteristics, we used Fisher’s exact test, the chi-square test, and the independent t-test. To compare the self-esteem in patients between the two groups before and after the intervention, we used the independent t-test. P-values of < 0.05 were considered statistically significant.
The topics discussed in each session are summarized in Table 1.

Ethical consideration

This study has been approved by the Ethics Committee of Kermanshah University of Medical Sciences (KUMS.REC.1395.445).

Results

Table 2 shows the status of qualitative demo-graphic variables of patients. As the results of the table show, 54.5% of patients were married, 47.7% were unemployed and 45.5% had undergraduate education. Also, 72.7% of the patients lived in urban areas.
The results of comparing the frequency of demographic variables in the intervention and control groups show the similarity of the mentioned variables in the intervention and control groups (Table 3). Also in this study, the independent t-test was used to evaluate the homogeneity of age variables in the intervention and control groups. The mean age in the intervention group was 46.95 with a standard deviation of 19.92 and in the control group was 51.86 with a standard deviation of 12.60, which were not statistically significantly different between groups.
According to Table 4, the mean score of total self-esteem and its dimensions (general, family, social and occupational self-esteem) before and after spiritual intervention in the control group did not show a significant difference (p > 0.05), but the mean score of total self-esteem and its dimensions (general, family, social and occupational self-esteem) before and after the spiritual intervention in the intervention group showed a significant difference at the 95% confidence level (p < 0.05), which shows that spiritual intervention has caused the self-esteem of these patients to increase in the intervention group. Also, the analysis of data related to the mean score of total self-esteem and its dimensions (general, family, social and occupational self-esteem) before the spiritual intervention between the intervention and control groups showed no significant difference (p > 0.05). The mean score of total self-esteem and its dimensions (general, family, social and occupational self-esteem) after spiritual intervention between the intervention group and the control group showed a significant difference at the 95% confidence level (p < 0.05). Also, in this study, a statistically significant relationship was found between self-esteem and demographic variables in each group, including gender, marital status, education level, employment status, and place of residence before and after the intervention (p < 0.05), and the effect of the intervention on self-esteem was not significantly different between the two groups (p > 0.05) (Table 5).

Discussion

In this study, we investigated the effect of spiritual intervention on the self-esteem of patients undergoing hemodialysis. Combining spiritual intervention with other nursing approaches will create a balance between the body, mind, and spirituality, ultimately contributing to complete and comprehensive health. Therefore, nurses should prioritize the study of spiritual needs as part of community-based care (Tajbakhsh et al. 2014). Regarding the main purpose of the study, the findings showed that spiritual intervention has a positive effect on the self-esteem of patients undergoing hemodialysis. The findings indicate that spiritual intervention leads to improvement in various dimensions of self-esteem, including general self-esteem, family self-esteem, social self-esteem, and occupational self-esteem in hemodialysis patients. This finding aligns with the results of a study by Saeedi, which examined the effect of spiritual care based on a healthy heart model on the spiritual experience of coronary artery patients hospitalized in the cardiac intensive care unit in Tehran. The scores of the intervention group were significantly lower than those of the control group (Saeedi 2013). Additionally, the results of the present study align with Ghahari et al.’s research, which examined the effectiveness of cognitive-behavioral and spiritual-religious interventions in reducing anxiety and depression among women with breast cancer. Their findings demonstrated that religious-spiritual interventions effectively safeguard the psychological well-being of cancer patients by mitigating depression and anxiety through the inhibitory influence of spirituality and religion on psychological disorders (Ghahari et al. 2012). Similarly, Tajbakhsh et al.’s study revealed that spiritual-religious care can reduce anxiety levels after coronary artery bypass transplant surgery, consistent with the results of the current study (Tajbakhsh et al. 2014). Furthermore, Bamdad et al.’s investigation into the impact of spiritual care on spiritual health was consistent with the results of the current study (Bamdad et al. 2013). Likewise, Ghorbani et al.’s study, which explored the effect of spiritual interventions on anxiety reduction in mothers of children with cancer, was in concordance with our present study (Ghorbani et al. 2021).
In summary, our study indicates that spiritual-religious interventions effectively reduce anxiety among family members, corroborating findings from other studies. Research has consistently shown that spirituality and spiritual beliefs enhance individuals’ ability to cope with disease occurrence and accelerate recovery. Since a person’s complete health depends on the interaction between all dimensions of their well-being, namely, physical, mental, social, and spiritual, it is essential to consider the spiritual dimension. Without acknowledging the spiritual aspect, we cannot fully understand an individual’s physical health, psychological well-being, or social personality. In fact, spiritual interventions play a crucial role in achieving balance for overall health and combating diseases (Saeedi 2013). Therefore, integrating spiritual intervention with other nursing approaches will foster equilibrium among the body, mind, and spirituality, ultimately contributing to comprehensive health. Nurses should prioritize addressing spiritual needs as part of community-based care (Tajbakhsh et al. 2014). Furthermore, the findings of this study demonstrated an increase in self-esteem among the samples after the intervention, irrespective of gender, marital status, education level, occupation, and place of residence. In simpler terms, the intervention proved effective regardless of these demographic factors. Other studies have also shown that spiritual intervention positively impacts both male and female gender groups (Akbari et al. 2021; Khaledian et al. 2017; Sheikhzakaryaie et al. 2023). Additionally, spiritual intervention is effective for all individuals, regardless of their marital status. Various studies have highlighted the efficacy of spiritual interventions across different marital histories (Borji et al. 2020; Safara et al. 2020; Shaygannejad and Mohamadirizi 2020). Moreover, research has investigated the effect of spiritual interventions on people with varying levels of education, revealing positive outcomes at different educational levels, employment statuses, and places of residence (Singh and Bandyopadhyay 2021; Ghasemi 2023; Currier et al. 2015; Caton 2021; Ilyas et al. 2020; Farmanesh et al. 2021; Amiruddin et al. 2021).

Implications for practice

For end-stage kidney disease patients undergoing hemodialysis who require long-term or even lifelong regular treatment, self-esteem is critical to their health outcomes. This study confirms that spiritual intervention on self-esteem can improve their health. Healthcare professionals should consider spiritual intervention when designing interventions to enhance self-esteem in hemodialysis patients. These results reinforce the importance of promoting spirituality teaching in clinical and outpatient environments.

Limitations

One of the limitations highlighted in the study is related to the psychological state of patients when completing the questionnaires. Although the study focused on self-esteem, it acknowledges that psychological factors, such as mood or emotional state, could influence how patients respond. However, these variables were not explicitly considered during the study. Future research should take into account the psychological context of patients to gain a more comprehensive understanding of their self-esteem.
Additionally, no similar research was found for comparison. The absence of comparative studies limits the ability to contextualize the findings and understand how they compare to existing literature. Researchers should explore related studies to validate and build upon their results.

Conclusions

The study concludes that spiritual care has a positive impact on the self-esteem of hemodialysis patients. By incorporating spiritual care into the patients’ care program, their self-esteem improved. This finding suggests that addressing spiritual needs alongside medical care can enhance hemodialysis patients’ self-esteem.

Acknowledgements

This study is extracted from the master’s thesis of a nursing student at Kermanshah University of Medical Sciences. The researchers thank the Vice Chancellor for Research of Kermanshah University of Medical Sciences and all the patients, colleagues and officials who helped us in this research.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Ethics Committee of Kermanshah University of Medical Sciences (Approval No. KUMS.REC.1395.445).
The authors declare no conflict of interest.

References