Globally, chronic kidney disease has become a health burden and Saudi Arabia is not an exception. Scientist Ayman Karkar cites uncontrolled blood pressure, sugar levels and lipids among others as factors, which hasten the development of End Stage Renal Disease (ESRD) (2011, pp. 419). In addition, kidney failure may occur due to accident, which inflicts injuries to the organs. Consequently, the victims have to undergo either dialysis or kidney transplant in order to implement the functions of the kidney. Statistically, according to Shaheen and Souqiyyeh the ESRD affects at least 100 to 120 million people in the total population of Saudi Arabia (2004, pp.125). Subsequently, the government established about 144 centres, which specialize in dialysis and a transplant centre called Saudi Centre for organ transplant. However, the cost of dialysis is very high thus, remaining as the main challenge in reducing deaths, which arise from kidney failure (Barsoum, 2006). Nevertheless, in comparison to kidney transplant, most people opt for dialysis because it does not only seem affordable but also because the acquisition of a kidney either from a cadaveric donor or from any other source is always a challenge to the patients.
Dialysis is a detoxification process, which involves the removal of harmful wastes like mineral, water and excessive fluids from the body system (Cooper, 2004). The implementation of dialysis is either through peritoneal dialysis or through haemodialysis. The worst part of it is that, it only provides temporary treatment and a patient has to repeat the same procedure every now and then. On the other hand, Kidney transplant involves the replacement of the patient’s kidney with a new one from a donor, which is of course done through an operation (Geist-Martin, Ray, & Sharf, 2003). A major problem that faces people who would like to go for a kidney transplant is finding a willing donor and sometimes, the donor’s kidney may not be compatible with that of the patient (Nazroo, 2006). Despite the fact that kidney transplant provides a permanent solution to ESRD, most patients rely on dialysis hence the urgent need of pre-dialysis education (Mason et al., 2008). Therefore, pre-dialysis improves the treatment of renal failure.
Therefore, it can be very traumatizing to find out that one is suffering from such a condition (Goovaerts, Jadoul, and Goffin, 2005). It is difficult for a patient to accept that he or she will be undergoing dialyses until death in the event that kidney transplant is not possible. The costs involved could give the patient, friends, and relatives quite a difficult time. Settling the payment for the next dialysis gives all of them and more so the victim a lot of psychological torture (Nazroo, 2006). In addition to this, the whole procedure of dialysis keeps the patient wanting no more. The general expenditure, pain and psychological torture the patients undergo remains in the implementation of dialysis. However, the construction and implementation of pre-dialysis education may prepare the patients to engage acceptably in the process (Parahoo, 1999; Pereira, 2005). According to, Staley, pre-dialysis education reduces the need for ‘urgent start’ dialysis as well as improve short-term survival (Staley, 2009). It also improves the quality of life after the initiation of the dialysis. In Saudi Arabia, there are socio-economic and political factors, which either positively or negatively affect the implementation of pre dialysis education in patients with end stage renal disease (Burrows and McLeash, 1995). Intuitively, pre-analysis education hastens the process of recovery especially, during dialysis.
Inhibitors (political and organizational factors)
There are various factors, which work in hand during the implementation or research in pre-analysis education. Although SA has put more emphasis on developing dialysis services, the inclusion of nurses as principal researchers in the medical sector remains a challenge. For instance, according to Toity Deave, nurses only hold positions such as research assistants, data collector or nurse researcher (2005, pp.671). Therefore, they rarely have the mandate to carry out research. More over, some of them discard the element of research as part of their career. This situation will therefore hinder the implementation of the proposal in SA. Furthermore, although most nurses may be competent to carry out research they hold lower position in the sector, which may affect both the motivation and research skills (Geist-Martin et al., 2003). According to Tanner and Hale, nurses lack the experience, knowledge and time to carry out research (2002, pp.33). More over, most of them spend more time caring for patients and thus, they may not have adequate time to implement research programs (Sitzia, 2002). Family and clinical commitments may hinder the implementation of the proposal because most of the nurses will be unavailable to assist in carrying out the research (Tanner and Hale, 2005). Therefore, the unavailability of human resource may hinder the implementation of pre-dialysis education as part of treatment in renal failure.
On the contrary, doctors have a higher chance of carrying out research projects in SA. In addition, according to Deave, only doctors have a higher chance of receiving funds from both Non-governmental organizations and the government (2005, pp.649). Therefore, the implementation of the proposal may not be smooth because of lack of funding or extra source of income. Consequently, the lack of faith or value in nurses and other clinical practitioners, who are not doctors, instils a negative attitude towards implementing the proposal. Eventually, the aforementioned, situation leads to a deficit in skilled personnel during implementation of pre-dialysis education.
According to Gallagher and Searle, the Saudi Arabian’s culture plays a vital role in hindering the implementation of health services (1985, pp.255). For instance, the two researchers’ write that the political culture combined with the Islamic culture must influence the technology and human progress in the health system (Gallagher and Searle, 1985). Therefore, in varying levels the segregation against female especially during appearance in public varies widely in the Middle East and SA is not an exception. For example, according to a research done by Lee, female physicians have to treat female patients while the culture also forbids women studying independently abroad (Le May, 1998; Lee, 1982). Geographically, the distribution of the research is in 25 hospitals. However, the culture of Saudi Arabia prohibits women from travelling independently an issue, which may negatively affect the implementation of the project. Therefore, the articulation of health care system with the Islamic culture will hinder the implementation of the proposal.
Authentically, there is no prior study or research, focussing on the implementation of pre-dialysis education to patients with end stage renal disease. Consequently, the implementation of the research may seem unimportant to both patients and other clinicians (Crombie and Floreu, 1998). According to researchers, the clinical environment views pre-dialysis education as not vital during the care of renal failure. Therefore, most patients receive dialysis without prior counselling or psychological preparation (Lee et al., 2008). Therefore, this notion will remain a challenge to the implementation of the project.
Promoters (Border political factors)
According to Shaheen and Souqiyye, due to increases levels of renal failure in SA, the Kingdom has set up thirteen renal transplant centres and at least more than a hundred dialysis centres (2004,pp.127). The services have spread to various parts of the country through the efforts of the government and other non-governmental organizations (SCOT, 2010). The total number of dialysis machines in the country is 4,264 (Golper, 2001; Law, 2008). Giving them this kind of information will enable them and their loved ones to select the best treatment option, which best suits them economically (Goovaerts, Jadoul & Goffin, 2005). In addition, although the machines may not tally with the population in SA, the existence of a few of them can positively initiate/implement the project (Almgren, 2007). Therefore, the popularity of dialysis in SA will hasten the implementation of the research. Furthermore, the availability of renal dialysis centres within the government hastens the implementation of the project. The uniformity of healthcare system in regards to renal failure quickens the research process.
Contemporarily, the health practitioners and policy makers are encouraging the nurses to adopt research as part of their career (Tanner and Hale, 2002). According to researchers, a combination of evidence-based practice or practice-based research with motivation will lead to an improvement in the health systems (Crombie and Floreu, 1998). Consequently, the aforementioned idea may propel many nurses to engage in research projects ((Mehrotra et al., 2005, p.379). Although Gallagher and Searle cite that most of physicians in SA are foreigners, the participation of nurses in research work contributes to a positive implementation of the project (1985, pp.253). Combination of both clinical experience and research skills leads to positive contribution to the research (Muir, 2009; Thompson, 2005). Clinically, nurses have a defined role in monitoring and implementing treatment procedures among patients. Therefore, their inclusion in the study will hasten the development of the project ((Cropper, 2004). Nurses play the centre role in treatment of patients including pre-analysis education if it exits (Devins et al., 2005). Consequently, the Faisal specialist Hospital established the Saudi society of nursing research, which motivates nurses to take part in research work. This step motivates and instils a positive effect in nurses whose aim is to focus on research work (Gómez, et al., 1999; Lewis, 1998). Therefore, the establishment of nurse-oriented research programs contributes positively to implementation of pre-analysis education in health facilities (Tanner and Hale, 2002). There has been increased number of patients on dialysis over the years and it is expected that the number will exceed fifteen thousand by the end of 2015 (SCOT, 2010). Thus, all clinicians including nurses will have to collaborate in order to implement pre-dialysis education in the large population.
The area of study is in the western part of SA; therefore, this is an amicable solution on the cultural issue regarding the movement of women (Bowman and Gross, 1986). Secondly, the uniformity of health policy and clinical practices makes it easier to implement the program (Cheater and Closs, 1994). The similarity in Islamic culture in SA will assist in analysis and data collection leading to a positive implementation of the study (Veeramah, 2007). Bowling cites exclusion and inclusion criteria as the major factors, which influence a research project (2002, pp.10). Finally, according to Mehrotra et al., there is no study, which has solely investigated the element of pre-dialysis education and subsequent choice of treatment (2005, pp.10). Therefore, this is an independent research, which will not contravene or allude from the results of any other project.
Situational analysis of the location of research
In terms of development, Saudi Arabia falls under developing countries. Subsequently, poverty, poor health services/education, inequality and political upheavals are some of the socio-economic and political factors, which affect it (Lee, 1982; Parkin and Bullock, 2005). However, economically Saudi Arabia heavily relies on oil reserves to generate income. Thus, the government and other stakeholder should fund the education of nurses and other medical practitioners especially in relation to pre-dialysis education. Consequently, this will lead to faster implementation of the proposal. In terms of health quality, the situation analysis is similar to most development countries. For instance, a study conducted at King Faisal Hospital of the University shows that 42.9% of patients with ESRD arose from failure in glomerular infiltration, 27.9% originated from diabetes and 27% hypotension (Al-muhanna, Saed, Al-Muelo, Larbi and Rubaish, 1999). Consequently, the survival rate depends on the age, for instance 95% for patients below twenty-nine years old, 84% for patients who are in the middle age and 27% for old people that is, 60 years and above (AlSuwaida, Farag and Alsayyari, 2010). For survival, maintenance haemodialysis (MHD) is the primary care medical experts apply in case of renal failure (Al-muhanna, Saed, Al-Muelo, Larbi and Rubaish, 1999). However, when compared to the developed countries, the research on pre-dialysis education is minimal in SA. Luckily, according to Hann, the political environment and technological advancement is constantly improving both the health policy and implementation in the region (2007, pp.40). Eventually, with the aforementioned facts on treatment of renal failure, the implementation of the research project becomes easier.
Practice Development and research agendas
For the success of the research and implementation of the project, different parties like the hospital administration that is, the hospital director and head nurses more so, in the dialysis unit have to grant permission to carry out the project. Secondly, the Head of Dialysis unit plays a role in both research and implementation of the project. Finally, through attending conferences like Birmingham EURO PD, the presence of Saudi nephrologists and subsequent communication of the research agenda plays a positive role in development of pre-dialysis education program.
Nurses need to make tangible developments in their practice in order to improve the provision of health care. They need to learn that pre dialysis education to patients with end stage renal disease is very important. Saudi Arabia should only seek the services of experienced nurses, as they are less likely to leave any issue unattended to (Hörl, 2003). This paper has looked at the various political, organizational, and practical factors that have hindered the implementation of pre dialysis education in Saudi Arabia. It provides a reason for a change in the country’s administration of health care to kidney disease patients.
In conclusion, renal failure is among health problems SA is fighting to control. Although the management of the disease lies within dialysis, the issue on pre-dialysis education seems to be a challenge among the professionals. End stage renal disease is the last stage of chronic kidney disease. At this level, there are only two options for treatment, dialysis, or kidney transplant. However, patients should undergo pre- dialysis education before they can decide on the form of treatment they would like to take. Saudi Arabia has not been able to implement fully this policy due to various political, organizational, and practical factors. The fact that nurses have no significant role in carrying out research work, challenges the implementation of the project. The implementation of pre-dialysis education faces both pros and cons although it is also vital in the treatment (Narva and Briggs, 2009). In terms of organization, the society neglects the nurses in research issues and eventually they are not only demoralized but lack support, financial assistance, knowledge/experience and enough personnel to carry out research (Holloway & Wheeler, 2010). Culturally, most nurses have family responsibilities and thus, discard research issues. However, the establishment of a nurse oriented research institute, the situational analysis in SA and uniformity in the health policy makes it is easier to carry out pre-dialysis education. For implementation of pre-dialysis education in the government facilities, nurses should resort to clinical research as part of their career programme. Finally, the establishment of many dialysis centres in SA together with the relevant equipment hastens the research and implementation of pre-dialysis education. Government and stakeholders in Saudi Arabia should unify in order to ensure patients receive pre-dialysis education before undergoing dialysis.
Almgren, GR 2007, Health care politics, policy, and services: a social justice analysis. Springer Pub, New York.
Al-Muhanna, F.A., Saed I., Al-Muelo, S., Larbi, E., & Rubaish, A 1999. ‘Disease profile, complications and outcome in patients on maintenance haemodialysis at King Faisal University Hospital, Saudi Arabia’. East African Medical Journal, vol. 6, no. 12, pp.664-667
Alsuwaida, A.O., Farag, Y.M., and Al Sayyari, A.A 2010, ‘Epidemiology of chronic kidney disease in the Kingdom of Saudi Arabia (SEEK-Saudi Investigators): a pilot study’. Saudi Journal Kidney Dieases Transplantation, vol.21, no.6, pp.66-72
‘Arabia’. Social scientific medical journal, vol.21, no.3, pp.251-265.
‘Audit of a clinical standard for research and its impact on an NHS trust’. Journal of Clinical Nursing, vol.14, no.1, pp.418-425.
Barsoum, R 2006, ‘Chronic Kidney Disease (CKD) in the Developing World’. The New England Journal of Medicine, vol.354, no.10, pp.997-999.
Bowman, M & Gross, M.L 1986, ‘Overview of research on women in medicine – issues for public policymakers’. Public Health Rep, vol.101, no.5, pp.513-521.
Burrows, D & McLeash, K 1995, ‘A model of research-based practice’. Journal of Clinical Nursing, vol.4, no.1, pp. 243-247.
Closs, S.J & Cheater, F.M 1994, ‘Utilization of nursing research: culture, interest and Support’. Journal of Advanced Nursing, vol.19, no.1, pp.762-773.
Crombie, I & Floreu, D 1998, The pocket guide to grant applications: a handbook for health care research. BMJ publishers, London.
Cropper, L 2004, Service development- Extending choice to patients needing dialysis. Web.
Deave,T 2005, ‘Research nurse or nurse researcher: How much value is placed on research undertaken by nurses?’ Journal of research in nursing, vol.10, no.6, pp. 649-657.
Devins, G.M., Mendelssohn, D.C., Barre, P.E., Taub, K & Binik, Y.M 2005, ‘Predialysis psychoeducational intervention extends survival in CKD: A 20-year follow-up’. American Journal of Kidney Disease, vol.46, no.4, pp.1088-98.
Gallagher, E.B., Searle, M., 1985. ‘Health services and the political culture of Saudi Arabia’ Social Sciences, Med. Vol.21, No.3, pp. 262-265.
Geist-Martin, P., Ray, E. & Sharf, B 2003, Communicating health: personal, cultural, and political complexities, Wadsworth, Belmont, Calif.
Golper, T 2001, ‘Patient education: can it maximize the success of therapy?’ Nephrol Dial Transplant, vol.16, no.7, pp.20-24.
Gómez, C., Valido, P., Celadilla, O., Bernaldo de Quirós, A., and Mojón, M 1999, ‘Validity of a standard information protocol provided to End-Stage-Renal Disease patients and its effect on treatment selection’, Peritoneal dialysis international, vol.19, no.5, pp. 471-477.
Goovaerts.T., Jadoul, M., Goffin, E 2005, ‘Influence of Pre-Dialysis Education Programme (PDEP) on the mode of renal replacement therapy’. Nephrology Dialysis Transplantation, vol.20, no.9, pp.1842-1847.
Hann, A 2007, Health policy and politics Aldershot, England. Ashgate, Burlington VT.
Holloway, I & Wheeler, S 2010, Qualitative research in nursing. Blackwell Science, Oxford.
Karkar, A., 2011.The value of pre-dialysis care. Saudi Journal of kidneydiseases and transplantion, 22(3), pp 419-427
Law, M., 2008.Evidence-Based Rehabilitation. A Guide to Practice. New Jersey: Slack Incorporated.
Le May, A., 1998. Bridging the research-practice gap: exploring the research cultures of practitioners and managers. Journal of Advanced Nursing, 28(2), pp.428-437
Lee R. P., 1982. Comparative studies of health care systems.”Social science Medical Journal, 16(1), pp.629-642
Lee, A., Gudex, C., Povlsen, J., Birgitte, B., and Nielsen, C., 2008. Patients views regarding choice of dialysis modality. Nephrology Dialysis Transplantation, 23(12), pp.3953-3959.
Lewis, S.L., 1998. Nephrology nurses’ perceptions of barriers and facilitators to using research in practice. ANNA-Journal, 25(4), pp.397-406.
Mason, J., Khunti, K., Stone M., Farooqi, A., and Carr, S., 2008. Educational interventions in kidney disease care: A systematic review of randomized trials. American Journal of Kidney Disease, 51(6), pp.933-51
Mehrotra, R., Marsh, D., Vonesh, E., Peters, V., and Nissenson, A., 2005. Patient education and access of ESRD patients to renal replacement therapies beyond in-center haemodialysis. Kidney International, 68(3), pp.378–390.
Muir Gray, J., 2009. Evidence Based Healthcare. Edinburgh: Churchill Livingstone.
Narva, A.S., and Briggs, M.,2009. The national kidney disease education program: improving, understanding, detection, and management of CKD. American Journal of Kidney Diseases, 53(3), pp.115-20
Nazroo, J., 2006. Health and social research in multiethnic societies. New York: Routledge.
Parahoo, K., 1999. A comparison of pre-Project 2000 and Project 2000 nurses’ perceptions of their research training, research needs and their use of research in clinical areas. Journal of Advanced Nursing, 29(1), pp.237-245
Parkin, C., and Bullock, I., 2005. Evidence-based health care: development and Pereira, B.J., 2000. Optimization of pre-ESRD care: the key to improved dialysis outcomes, Kidney International journal, 5(7), pp.351-65
SCOT,2010. Annual Report: Peritoneal Dialysis. Web.
Shaheen, F.A., and Souqiyyeh, M.Z., 2004. Current status of renal transplantation in the Kingdom of Saudi Arabia. Transplantation proceedings, 36(1), pp.125-127
Sitzia, J.,2002.Barriers to research utilization: the clinical setting and nurses themselves. Intensive & Critical Care Nursing, 18(4), pp.230-243
Staley, K., 2009. Exploring impact: public involvement in NHS, public health and social care research. Eastleigh: Involve
Tanner, J., and Hale, C., 2002. Why are nurses reluctant to undertake research in practice? Journal of clinical research, 98 (48), pp.33
Thompson, C., 2005. Barriers to evidence-based practice in primary care nursing – why viewing decision-making as context is helpful”, Journal of Advanced Nursing, 52 (4) pp.432-444
Veeramah,V.,2007. Use of research findings in nursing practice. Journal of advanced nursing, 103(1), pp.32-33.