Promoting self-directed hemodialysis: measurement and cognitive-behavioral intervention.

Approximately 98% of hemodialysis patients who are treated in hemodialysis units currently use staff-directed treatment. This may well be the most expensive and most dependent mode of hemodialysis treatment. If an effective strategy were developed to enhance degree of self-directed care, millions of public health dollars might be saved while patients reap potentially substantial psychological benefits. The present research took two steps in the direction of promoting increased self-directed treatment of hemodialysis. First, a reliable and easily used behavioral observation system was developed to define and measure degree of self-directed treatment of hemodialysis. Second, a five-step cognitive-behavioral strategy to improve degree of self-directed treatment was developed and tested preliminarily. The strategy includes an initial rationale, decisional counseling, behavioral contracting, self-monitoring, and staff support/problem solving. Four nurses used this approach with 4 elderly patients (mean age = 70.5 years). A multiple-baseline-across-subjects design revealed substantial and relatively rapid improvements in degree of self-directedness associated with the intervention for the 3 patients who remained healthy throughout the study. The discussion focuses on the implications of the results for future research.