Patient--staff interactions and mental health in chronic dialysis patients.
Abstract: Chronic dialysis imposes ongoing stress on patients and staff and engenders recurring contact and long-term relationships. Thus, chronic dialysis units are opportune settings in which to investigate the impact of patients' relationships with staff on patient well-being. The authors designed the present study to examine the degree to which perceptions of open communication between patients and staff affect patient mental health. A one-year, two-wave longitudinal survey assessed patient (N = 109) perceptions of the interpersonal environment and mental health. Assessments included sharing personal reformation (open disclosure), assisting one another (helping), staff respect for patients (respect), and hierarchical patient--staff relations (formal staff authority). Cross-sectional and longitudinal regression analyses examined how these characteristics of the interpersonal environment relate to depression and subjective well-being among patients. Multivariate analysis showed that open disclosure correlated independently with lower levels of depression at baseline (N = 109) and a predicted significant decrease in depression over time (N = 64). Other interpersonal characteristics did not correlate with depression or subjective well-being at baseline or longitudinally. The interpersonal climate in chronic dialysis units influences patient well-being. Contrary to traditional views, open disclosure in patients' relationships with staff is not detrimental and contributes to well-being.

KEY WORDS: chronic dialysis; depression; interpersonal relationships; mental health; professional boundaries
Subject: Medical personnel and patient (Research)
Hemodialysis patients (Care and treatment)
Hemodialysis patients (Social aspects)
Authors: Swartz, Richard D.
Perry, Erica
Brown, Stephanie
Swartz, June
Vinokur, Amiram
Pub Date: 05/01/2008
Publication: Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2008 National Association of Social Workers ISSN: 0360-7283
Issue: Date: May, 2008 Source Volume: 33 Source Issue: 2
Topic: Event Code: 290 Public affairs; 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 179158811
Full Text: In the United States, nearly 450,000 individuals now undergo chronic dialysis, with more than 50,000 new patients appearing each year (United States Renal Data Service [USRDS], 2005). Complications are common, and there is predictable and relentless attrition from the population, with an annual mortality rate of 15 percent to 20 percent (USRDS, 2005). On a day-to-day basis, dialysis treatment substantially alters normal lifestyle, including large amounts of time several days per week spent on treatment and related activities, multiple prescription medications, multiple dietary restrictions, and residual symptoms that interfere with full participation in work, school, or household management (USRDS, 2005). It is no surprise that patients are often depressed and that interpersonal interactions are affected (Rhodes, 1981). In fact, clinically significant depression affects as many as 30 percent or more of dialysis patients and is associated with higher mortality (Christensen & Ehlers, 2002; Deoreo, 1997; Kimmel, Peterson, Weihs, Simmens, et al., 2000; Lopes et al., 2002; Watnick, Kirwin, Mahnensmith, & Concato, 2003) and lower levels of adherence to the medical regimen (Kimmel et al., 1995, 1998; Kimmel, Peterson, Weihs, Simmens, et al., 2000).

Dialysis treatment is ongoing, often lasting many years, virtually until the end of life; thus, the chronic dialysis unit presents a unique opportunity to observe specific psychosocial phenomena (Rhodes, 1981; Wuerth, Finkelstein, Kliger, & Finkelstein, 2000), including the quality of interpersonal relationships formed between patients and staff. Yet, the influence of such interpersonal phenomena on mental health is not emphasized in the dialysis literature. It is important to address this oversight because quality relationships are associated with improved general health and well-being (House, Landis, & Umberson, 1988) and may be particularly so in chronically in individuals such as dialysis patients.

Although patient--staff relationships have not been studied in depth, several studies have examined the importance of social support in the dialysis setting. In one early study, social support appears to predict sociability and correlates to some degree with the presence of anxiety in chronic dialysis patients at baseline but does not predict longer term outcomes in mental health (Burton, Kline, Lindsay, & Heidenheim, 1988). McClellan and colleagues (1993) reported that patients' perceptions of support from family or dialysis staff did not correlate with mortality, but this study did not evaluate other clinical or mental health outcomes. Other researchers reported that dyadic family relationships correlate with mortality and with social support but that social support does not independently predict outcome (Kimmel, Peterson, Weihs, Shidler, et al., 2000). In a study from a large international dialysis database, Saran and colleagues (2003) reported that adherence (as a surrogate) is worse in larger dialysis units, which might have less patient--staff interaction, but did not report on social support in particular or on mental health outcomes in general.

We hypothesized that quality interpersonal relationships between dialysis patients and staff have a beneficial effect on patient mental health. In particular, the present study was designed to test whether patients who perceive interactions to be more open and personal also have higher well-being and less depression. We have focused on open communication (open disclosure in this study) as indicative of these perceptions because Christensen and Ehlers have (2002) suggested that perceived social support among dialysis patients is conducive to more open expression in interpersonal communications and that open expression is associated with less depression and anxiety (Christensen & Ehlers, 2002). This construction is supported by others who have suggested that clearer and more honest communication in the dialysis setting reduces anxiety and enhances the perceived quality of service (Giancchino, Manzato, DePiccoli, & Ponzetti, 2000), that patient satisfaction is influenced by perceptions of the interpersonal atmosphere (Wuerth et al., 2000), and that breast cancer patients who participate in support groups report better quality of life and less chronic pain, although participation does not appear to alter survival (Goodwin et al., 2001). In addition, we focused on other aspects of the dialysis unit environment that also might increase or decrease the quality of interpersonal communications between patients and staff, namely the helpfulness of individuals on the unit, staff respect for patients, and the perception of professional boundaries or formality (Gabbard & Nadelson, 1995: Pilette, Berck, & Achber, 1995; Sabey & Gafner, 1996). To this purpose, we surveyed patients at baseline and one year later, assessing the impact that these components of the interpersonal climate have on patient depression and subjective well-being.



Patients came from diverse settings that included urban, suburban, and semirural communities in the Detroit--Ann Arbor vicinity. This study was undertaken during 2000 and 2001. Hemodialysis (HD) was undertaken in two separate locations, one 20 miles from the central hospital site in which approximately 60 percent of HD patients were treated, and a second within the central hospital complex that was relocated four miles off-site at the one-year follow-up. Peritoneal dialysis (PD) patients did home-based care and came to clinic at least once per month at the second location. Physicians were common to all patients, but nursing personnel were distinct for each HD location and for PD.

A total of 109 patients (49 men and 60 women; 80 HD and 29 PD), representing 70 percent of all patients within the maintenance dialysis program at the University of Michigan participated in this study. Patients volunteered to fill out a 30-minute survey concerning dialysis patients, stress, and coping. An incentive of a lottery ticket, good for a chance at winning a gift certificate, was provided. At the one-year follow-up, 64 patients were still available for the second survey, and 60 patients (27 men and 33 women; 43 HD and 17 PD) provided answers to a shorter 15-minute survey. Among the 49 patients not completing the second survey, 20 had died, 12 had received transplants, nine had transferred their care to other facilities, and four chose not to complete the survey.

Demographic and Clinical Data

For patients, demographic data included age, gender, race and ethnic identity, and education level. In the final analysis, patients ranged in age from 23 to 81 (mean = 54) years, 55 percent were women, 54 percent were white, and 38 percent were black; 84 percent had a least a high school diploma. Eighty patients were treated with HD, 29 at location 1 and 51 at location 2, and 29 were treated with PD and seen once per month at location 2.

Survey Administration

Self-administered questionnaires were given to patients at their dialysis sessions. The patients were asked to fill out the questionnaires at the center or to complete them at home and bring them back later. For patients who could not read the questionnaires, readers (authors Perry, J. Swartz, and other staff) were available to help them complete the survey. The questionnaires included coded identification numbers to protect the anonymity of the patients and were collected by personnel of the Institute for Social Research, where data were collated and analyzed.


Predictor variables in the interpersonal environment were assessed at baseline using select questions from the Ward Atmosphere Scale (WAS) (Moos & Houts, 1968). The WAS was created, in part, to characterize individual responses to a treatment program and to measure dimensions of the program, including staff control, support, and autonomy. Perceptions of formal staff authority in the dialysis unit were measured using the following three statements: "In this program, everyone knows who is in charge;" "It is a good idea to let the doctors know that they are in charge;" and "Once a schedule is arranged, the patient must follow it." Perceptions of open disclosure between patients and staff included patients' perceptions of openness and ease of sharing feelings with staff on the dialysis unit. This variable was measured using the following two statements: "Patients tend to hide their feelings from staff" (reverse scored), and "Patients are careful about what they say when staff are around" (reverse scored). Perceptions of respect from staff was measured using the following two statements: "Staff sometimes do not show up for their appointments with patients" (reverse scored) and "Patients are rarely kept waiting when they have appointments with staff." Finally, perceptions of helpfulness was measured using the following four items: "Staff go out of their way to help patients," "The staff help new patients get acquainted here," "The healthier patients here help take care of the less healthy," and "Patients rarely help each other" (reverse scored). Patients indicated their agreement or disagreement with the statements using a five-point scale ranging from 1 = strongly disagree to 5 = strongly agree. All composites were formed by taking the mean of the respective items.

Patient outcomes were assessed at baseline and at follow-up and included level of depressive symptoms, indicated by 11 items adapted from the Hopkins Symptom Checklist (Derogatis, Lipman, Rickles, Uhlenhuth, & Covi, 1974; Horwath, Johnson, Klerman, & Weissman, 1992) that included dysphoria, somatic symptoms, hopelessness, and suicidal ideation. The severity of each symptom was rated by the patients for the previous two-week period using a five-point scale ranging from 1 = not at "all to 5 = extremely. The Satisfaction with Life Scale was used to measure subjective well-being (Diener, Emmons, Larsen, & Griffin, 1985). Patients' current level of life satisfaction was measured using five statements, including "The conditions of my life are excellent" and "I am satisfied with my life." Patients responded to the statements using a five-point scale ranging from 1 = strongly disagree to 5 = strongly agree.

Data Management and Statistical Methods

Personal identifiers were removed from the data. The statistical analysis progressed in three stages. First, product moment correlations were computed to examine the relationships among the variables that were assessed at baseline. Second, least square regression analyses were conducted to examine the extent to which the predictor variables explain significant unique variance in the assessed outcomes at baseline when controlled for the effects of demographics and the other variables. Third, longitudinal analyses with least square regressions were conducted to examine the extent to which the predictor variables explain changes in the outcomes from baseline to follow-up.

Power analysis for the population available to us and for regression models that we employed, which controlling for baseline measures of mental health, shows greater than 95 percent chance of detecting a strong trend ([r.sup.2] = .10) and greater than 70 percent chance of detecting a smaller effect ([r.sup.2] = .05), thus supporting conclusions regarding factors that correlate significantly as well as those that do not. Given the limited sample size available and the fact that some patients were not available for the later follow-up survey, we also did an attrition analysis comparing responders to nonresponders and found no differences in demographic or baseline mental health characteristics.


The prevalent correlations at baseline between depression or subjective well-being and patient perception of interpersonal characteristics in the dialysis setting, and several demographic characteristics are presented in Tables 1 and 2, respectively. At baseline, only open disclosure correlated inversely with depression and directly with subjective well-being, whereas other characteristics, such as formal staff authority, respect from staff, and helpfulness, did not correlate significantly. Among the demographic characteristics, only age correlated significantly (and directly) with depression and with subjective well-being at baseline.

The correlation between interpersonal characteristics or demographic factors and the change in depression and subjective well-being from baseline to follow-up one year later are presented in Tables 3 and 4, respectively; all data controlled for baseline mental health characteristics. In this analysis, open disclosure predicted a decrease in depression over time (see Table 3), with other interpersonal characteristics not independently predicting any change in depression. Subjective well-being over time was not correlated significantly with the interpersonal characteristics. Among the demographic factors, age, location, and modality appeared to have some independent predictive value, specifically less depression over time for older patients, for PD (compared with HD) and for attendance at one of the clinics (in fact, the one at which PD was administered) rather than the other.


In the present study, patients' perceptions of the interpersonal environment in the dialysis unit were associated with patient mental health. These results in Table 3 are unique, showing that the degree to which patients perceive open communication and shared feelings (open disclosure) correlates with less depression, both at baseline and over time, whereas perceptions of more formal boundaries, helpfulness, and respect did not correlate. Among mental health indicators, depression is most consistently associated with clinical comorbidity and mortality (Christensen & Ehlers, 2002; Deoreo, 1997; Kimmel et al., 1993; Kimmel, Peterson, Weihs, Simmens, et al., 2000; Lopes et al., 2002; Watnick et al., 2003), and perceptions of openness help to ameliorate depression, for example, by reducing the feelings of dependency and of being a burden (Brown, Dahlen, Mills, Rick, & Biblarza, 1999). Subjective well-being, on the other hand, is more difficult to predict, and whether patients feel better or worse may depend more on their health status than on their perception of relationships, especially in chronic dialysis wherein patients are constantly in jeopardy of treatment complications or symptoms from metabolic, bone, cardiovascular, or neurologic disease. Thus, it is not surprising that depression appears to be a more specific indicator and that the openness patients perceive influences mental health outcome through its impact on the time course of depression.

Our results contribute to existing studies that suggest the importance of interpersonal relationships in medical settings and support more open communication in chronic dialysis units. As already noted, receiving social support in general is associated with less depression and better adherence to the medical regimen, and providing support is associated with better survival among older adults in the general medical setting (Brown, Nesse, Vinokur, & Smith, 2003), perhaps the result of underlying quality of interpersonal relationships. Burton and colleagues (1988) have suggested that social support is a "buffer" against the stress of illness, and others have suggested more specifically that more empathy in the physician-patient relationship engenders more human and more humane interactions (Gianakos, 1996; Spiro, 1992). It is not unusual to hear patients or caregivers say that the dialysis unit is "just like family," and we have characterized the relationship that develops in this setting as a "medical family" in which patients sometimes have interactions with dialysis unit caregivers that may be more frequent and trusting than those with their own family members (Swartz & Perry, 1999). The present study supports the notion that patients" perception of their ability to interact openly with caregivers (including physicians, nursing personnel, social workers, and dietitians) has a substantial impact on their mental well-being.

The results of the present study have certain limitations that should be noted. First, the results are based on a single dialysis program with a relatively small number of patients. Although statistically significant results were realized, future research is needed to examine whether patient--staff open disclosure is beneficial for other patient outcomes, and in other samples of dialysis patients. Second, the present study is correlational in nature; therefore, caution must be used in interpreting results. For example, our baseline correlations may simply reflect the fact that more depressed patients are naturally less open with staff. However, the longitudinal design of this study increases our confidence that open disclosure is beneficial, even more so because our results were obtained after controlling for baseline mental health levels. Third, the present results apply largely to the patient side of the patient--staff relationship and bear only on baseline characteristics for staff because we did not have sufficient staff numbers for an adequate longitudinal study. Even so, the results are unique and prompt the need for further investigation in this area.

Chronic illness inherently requires repeated contacts between patients and caregivers, often in circumstances that demand flexibility, empathetic understanding, and sharing of personal feelings. The present results support the notion that when these relationships take a more personal character with more open communication they may enhance the mental health of the patients and may possibly influence staff stress and job satisfaction. We trust that our results help to stimulate future research efforts to explore the untapped healing potential of interpersonal relations in the dialysis unit.

Original manuscript received December 20, 2005

Final revision received March 12, 2007

Accepted May 16, 2007


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Richard D. Swartz, MD, is professor, Division of Nephrology, Department of Internal Medicine, University of Michigan, 3914 Taubman Center, Box 0364, University of Michigan, Ann Arbor, MI 48109-0364; e-mail: Erica Perry, ACSW, is a social worker, Division of Nephrology, and Stephanie Brown, PhD, is assistant professor, Institute for Social Research, University of Michigan, Ann Arbor. June Swartz, MA, BA, is school counselor and research consultant, National Kidney Foundation of Michigan, University of Michigan, Ann Arbor Amiram Vinokur, PhD, is professor, Institute for Social Research, University of Michigan, Ann Arbor. The authors gratefully acknowledge all the staff and patients who participated, as well as the staff of the Institute for Social Research who assisted with data collection and analysis. There are no financial conflicts to declare with respect to this work. Send correspondence to Dr Richard D. Swartz.
Table 1: Relation between Interpersonal
Characteristics and Depression or
Subjective Well-Being at Baseline (N = 109)

                          Mental Heath outcome

Interpersonal         Depression            Well-Being
Characteristics    [beta]   95%(CI)       [beta]   95%(CI)

Open disclosure     -.27 (-.19, -.35) *     .32 (+.22, + .42) *
Limited equality    -.07 (-.17, +.03)       .06 (-.06, +.18)
Respect             -.06 (-.15, +.03)      -.03 (-.13, +.07)
Helpfulness         -.07 (-.22, +.08)       .02 (-.16, +.20)

Notes: The descriptive statistics for interpersonal characteristics
at baseline were as follows: open disclosure 3.309 +0.969, limited
equality 3.800 + 0.904, respect 3.976 + 1.001, and helpfulness
3.460 +0.613. CI = confidence interval.

* p < .05.

Table 2: Relation between Demographic
Characteristics and Depression or
Subjective Well-Being at Baseline (N- 109)

                        Mental Health Outcome

Demographic              Depression            Well-Being
Characteristics       [beta]   95%(CI)       [beta]  95%(CI)

Age                     .03 (+.02, +.04) *      33 (+.32, +.34) *
Gender                  .05 (-.11, +.16)        18 (-.01, +.37)
Dialysis (HD or PD)    -.05 (-.28, +.18)        20 (-.06, +.46)
Location (1 or 2)      -.03 (-.23, +.17)        07 (-.16, +.30)

Notes: HD = hemodialysis; PD = peritoneal dialysis. CI = confidence

* p < .05.

Table 3: Relation between Interpersonal
Characteristics and Depression or
Subjective Well-Being over Time at
One-Year Follow-Up (N = 64)

                             Mental Health Outcome (a)

Interpersonal          Depression              Well-Being
Characteristics     [beta]  95%(CI)        [beta]  95%(CI)

Open disclosure      -.35 (-.27, -.43) *     .03 (-.12, +.18)
Limited equality     -.06 (-.18, +.06)       .22 (-.01, +.45)
Respect              -.04 (-.13, +.05)      -.04 (-.20,+.12)
Helpfulness           .18 (-.01, +.37)       .25 (-.07, +.57)

(a) All correlations are controlled for baseline level of the mental
health outcome. See attrition analysis in Methods section. CI =
confidence interval.

* p < .05.

Table 4: Relation between Demographic
Characteristics and Depression or
Subjective Well-Being over Time at
One-Year Follow-Up

                              Mental Health Outcome *

Demographic               Depression             Well-Being
Characteristics       [beta]   95%(CI)       [beta]   95%(CI)

Age                     .08 (+.07, +.09) *    -.05 (-.15, +.05)
Gender                 -.20 (-.41, +.01)       .00 (-.29, +.29)
Dialysis (HD or PD)    -.27 (-.48, -.06) *     .18 (-.22, +.58)
Location (1 or 2)      -.24 (-.42, -.06) *     .05 (-.29, +.39)

(a) All correlations are controlled for baseline level of the
mental health outcome. See attrition analysis in Methods section.

* p < .05.
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