Cognitive Learning of Adult Kidney Transplant

Teaching on the Cognitive Learning of Adult Kidney Transplant Recipients

The aim of this study was to investigate the effects of individual and group teaching on the cognitive learning of adult kidney transplant recipients on an inpatient transplant unit.

Kidney transplant recipients have an abundance of learning needs after receiving their transplants. Patient education is a crucial aspect of the transplant nurse’s role. Transplant recipients must learn follow-up instructions, signs of rejection and infection, medications and their side effects, urine testing procedures, and dietary and lifestyle modifications in order to ensure transplant viability and increased quality of life. It is important that the most effective method is used to teach this critical information. Patient education is widely documented in the literature, however little is known about the effects of individual and group teaching on the cognitive learning of adult kidney transplant recipients.

Design. A true experimental design.

Methods. The research will take place in a large east coast teaching hospital in the adult kidney transplant unit. A total of 100 participants will be randomly assigned to the experimental individual teaching sessions or the control group that will attend group teaching sessions. Each subject in both groups will take the Evaluation of Transplant Teaching Test prior to the onset of the study and again 48 hours prior to discharge from the hospital. The experimental and control groups will receive the same postoperative teaching using verbal, visual, and written literature by an RN. The experimental group will attend scheduled group teaching sessions in the patients’ solarium. A paired t-test will be used to analyze the collected data. The results of the study will be statistically significant at the.05 level.

Results. The findings will indicate there will be an increase in cognitive learning from individual patient teaching compared to group teaching in postoperative adult kidney transplant recipients.

Conclusion. Individual patient teaching in adult postoperative kidney transplant recipient patients results in increased cognitive learning.

Relevance to clinical practice. As indicated by the results of this study, individual patient teaching in the postoperative adult kidney transplant patient is superior to group teaching in the adult kidney transplant patient. The patient will be able to maximize organ vitality and improve overall quality of life.



Problem Statement

Definition of Terms

Inclusion Criteria


Significance of Study


Literature Review Related to an Overview of Renal Failure

Definition and Types of Renal Failure

Chronic Kidney Disease

Treatment Options

Dialysis vs. Transplantation

Literature Review Related to Renal Transplantation

Graft Survival

Quality of Life

Organ Rejection

Economic Outcomes

Literature Review Related to Transplant Teaching in Post-Op Patients

Individual Teaching in Renal Postoperative Patients

Group Teaching in Renal Postoperative Patients

Literature Review Related to Emotional Acceptance of Chronic Illness

Theoretical Framework: Dorothea Orem’s Theory of Self-Care





Selection of Participants


Data Collection Procedure

Data Analysis






The issue of chronic renal failure is one that has been misunderstood for many years. There are many individuals that study it and discuss how significant it is, and there are others that do not realize the seriousness of the issue. Chronic renal failure is a serious issue. However, there are treatments available for it and there are many different thoughts and theories as to what causes it in some people and not others, and how it should be handled when it does occur so that the patient can get the maximum amount of benefit from the treatment or treatments that are offered to him or her. For a study such as this one, it is important to discuss these treatments.

Problem Statement

The main problem statement for this study is designed to address whether group learning or individual learning is the best choice when it comes to teaching patients how they must care for themselves when they have kidney failure. For purposes of this study, care is limited to after the individuals have been through a kidney transplant.

Definition of Terms

Group learning – Individuals are taught something new or given instructions in a group setting.

Individual learning – Individuals are taught something new or given instructions in a one-on-one atmosphere.

Inclusion Criteria

In order to be eligible for this particular study, the patients must:

Be either a first time cadaveric or first time living related recipient of a kidney transplant.

Be between 18 and 64 years of age and possess at least a high school education.

Have a functioning renal allograft.

Be both oriented and alert mentally.


Individuals that have had kidney transplants are able to comprehend what they are taught, provided the teaching methods are effective.

Having a teaching methods that is structured helps to promote information, and this also encourages independent functioning, compliance with what is needed for treatment, and self-care.

Patients that are properly informed and included in the process of their own education are less likely to be readmitted to the hospital, and if they are their stays are not as long.

A better knowledge of what is wrong and what must be done to help make it better is generally associated with having a higher level of patient compliance.

Significance of Study

Being successful with a renal transplant allows the recipient of the kidney to function well without the need for continued hemodialysis. However, there are postoperative issues that must be addressed and a standard of care must be accepted and continuously undertaken in order for the patient to stay as healthy as possible. New knowledge of care, health problems, diet, and many other issues must be addressed for the individual to have a complete understanding of how best to remain healthy after a kidney transplant.

Many factors are available that actually effect the health outcome of individuals that have received a new kidney from a donor.

The fact that a transplant recipient must take medication for the rest of his or her life means that there is a higher chance of specific medical problems. While this increased risk cannot be avoided, there are things that can be done in order to help minimize these particular risks. Patients must be informed, however, so that they can continue to maintain a high standard of self-care as much as possible. They also need to be aware of what problems they might face so that they can see their doctor if issues arise. Professional nurses are the ones that have the responsibility of patient education.



Literature Review Related to an Overview of Renal Failure

Chronic renal failure, also sometimes called chronic kidney failure, is a serious disease that can be fatal if not treated, and can lead to many other significant health problems as well. The disease progresses slowly, and can take months or years before it gets to the point where it is noticed, but there are other changes in the body that can be seen earlier on, if they are being looked for, and these changes can make physicians aware of the problem so that it can be treated as early as possible (Vernon & Pfeifer, 2003).

If the disease progresses far enough, it is known as end-stage renal disease, and when this takes place, a renal replacement therapy such as kidney dialysis is required to keep the patient alive (Rogers, 2004). When the kidneys do not function properly, they do not remove the toxins from the blood, and this can result in the person not being able to remain healthy (Rogers, 2004).

In the beginning of the disease, there are virtually no symptoms, unless the serum creatinine is studied (Rogers, 2004). However, the progression of the disease can cause an increase in blood pressure, an accumulation of potassium in the blood, an accumulation of urea, anemia, fatigue, an overload of fluid volume, cardiac arrhythmias, and vascular calcification (Rogers, 2004).

In addition to these symptoms, those that have chronic renal failure also have a high incidence of atherosclerosis, or hardening of the arteries, usually at a more accelerated rate, and also a high incidence of cardiovascular disease with a prognosis that is not as good as this disease in someone that does not have chronic renal failure as well (Rogers, 2004).

Usually, there is a previous renal disease or some other kind of underlying disease that is the cause of the chronic renal failure. There are some patients, however, where a cause for the problem cannot be found (Rogers, 2004). Sometimes, this cause is identified in retrospect (i.e. At a later date) but cannot be discovered when the diagnosis of chronic renal failure is first made. It is important to be aware, however, that chronic renal failure is not the same disease as acute renal failure, as acute renal failure can sometimes be corrected or even reversed (Rogers, 2004).

In order to diagnose chronic renal failure, there are several tests. Generally, there is an abdominal ultrasound that is performed, and during that time the size of the kidneys are measured. The kidneys of someone that has chronic renal failure are generally smaller than average kidneys, with some notable and important exceptions (Rogers, 2004). Two of these exceptions would be polycystic kidney disease and diabetic nephropathy (Rogers, 2004). Another diagnostic tool that is used, that of the study of the serum creatinine levels, can not only diagnose chronic renal failure, but also help to distinguish it from acute renal failure, as the acute version would see a rapid and sudden spike in the serum creatinine levels over several days or several weeks, as opposed to a gradual rise that is seen over months or even over years (Rogers, 2004).

Sometimes, the levels of serum creatinine have not been measured in the past, and therefore the patient is often first treated as having acute renal failure. Only when blood tests continue to show elevated serum creatinine levels and it is determined that the renal failure is irreversible will the diagnosis be made as chronic renal failure as opposed to the previously assumed acute renal failure (Rogers, 2004). A numerous amount of uremic toxins also accumulate in individuals that have chronic renal failure and are involved in the treatment of standard dialysis, which cannot be avoided (Rogers, 2004).

There are many cytotoxic activities that these toxins have, and these are seen through studying the serum. They have different weights, molecularly, and they also bind to various proteins, although they seem to have a preference for albumin (Rogers, 2004). Many scientists are studying these toxin-bound proteins, because they feel that – through a better understanding of the issue – there may be a way to improve the dialysis that patients are undergoing now and therefore prolong not only these patients’ lives, but the quality of their lives as well (Rogers, 2004).

In Europe and North America, there are some causes of chronic renal failure that are considered to be the most common. These are: hypertension, diabetic nephropathy, and glomerulonephritis (Rogers, 2004). When taken together, the three diseases mentioned above account for approximately 75% of the cases of chronic renal failure in adults. There are certain geographic areas, however, that also have a very high rate of chronic renal failure that is caused by HIV nephropathy (Rogers, 2004).

It is also important to understand how chronic renal failure and kidney disease is classified, as well, because it is often classified based on the part of the renal anatomy that is involved (Rogers, 2004). The vascular kind of kidney disease involves large vessel disease and small vessel disease (Rogers, 2004). The large vessel variety includes bilateral renal artery stenosis, and the small vessel disease includes problems such as hemolytic-uremic syndrome, vasculitis, and ischemic nephropathy (Rogers, 2004). In addition to the vascular kidney disease, there is also glomerular, tubulointerstitial, and obstructive kidney disease (Rogers, 2004).

Glomerular kidney disease involves a very diverse group of problems that is usually classified into primary and secondary glomerular disease (Rogers, 2004). The primary type of this disease involves problems such as IgA nephritis and focal segmental glomerulosclerosis, while the secondary type of the disease involves problems such as lupus nephritis and diabetic nephropathy (Rogers, 2004). Tubulointerstitial versions of kidney disease are related to reflux nephropathy, polycystic kidney disease, and drug and toxin-induced versions of chronic tubulointerstitial nephritis (Rogers, 2004). The last category, obstructive, involves diseases that are related to the prostate, as well as more common ailments such as kidney stones (Rogers, 2004).

As for treating chronic renal failure, the goal there is to either slow down or preferably halt the progression of the disease, which is often seen to be very relentless in what it does, the way it progresses, and the problems that it causes for the patient (Rogers, 2004). It is hoped that, by treating it aggressively and diagnosing it as soon as possible, it can be slowed down to the point that the patient with chronic renal failure will not progress to end-stage renal disease, which will involve dialysis (Vernon & Pfeifer, 2003). The health of the individual that is on dialysis is often not as good as someone that does not have to have this treatment, and although dialysis generally works well, it is not as good as keeping toxins out of the blood as the normal working of the kidneys (Vernon & Pfeifer, 2003).

The reason for this is that the kidneys filter the blood constantly, and they are always removing toxins from it. In dialysis, the person only goes and has these toxins removed from their blood at certain times – two or three times per week, for example. Dialysis is usually a complicated and long process, taking several hours to filter all of the blood in the body sufficiently, and in between treatments the toxins and chemicals that would normally be filtered out of the blood simply build up until the next dialysis treatment, which obviously is not healthy and can have long-term consequences for the patient (Vernon & Pfeifer, 2003).

It is important, in the treatment of chronic renal failure, to control the patient’s blood pressure as much as possible, and also to treat whatever original and underlying disease the patient has that caused the chronic renal failure in the first place. The strong control of the patient’s blood pressure and the underlying disease, therefore, can help to slow the progression of the chronic renal failure to the point where the patient will not end up in end-stage renal disease and on dialysis to survive. There are medications that can be given to those that have chronic renal failure in order to slow the progression of the disease. These medications include angiotensin II receptor antagonists (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) (Vernon & Pfeifer, 2003). These medications have been found, in studies and clinical trials, to slow the progression of end-stage renal disease.

In addition to these medications, vitamin D3 and erythropoietin, which are two hormones that are usually processed by the kidneys, are often given to the patient as a replacement for those that are lost when the kidneys cease to function properly (Vernon & Pfeifer, 2003). Another replacement that is generally needed is calcium. While all of these replacements are important, phosphate binders are also used in that they are needed to control the levels of serum phosphate in a patient that is dealing with chronic renal failure (Vernon & Pfeifer, 2003). During chronic renal failure, the serum phosphate levels generally rise, which can lead to other problems, and therefore the phosphate binders are necessary to keep these serum phosphate levels within normal limits (Vernon & Pfeifer, 2003).

For the patient that has chronic renal failure, however, the chances of progression to end-stage renal disease at some point are relatively high. Once this occurs, the only options are dialysis or a kidney transplant (Vernon & Pfeifer, 2003). Many patients that want and need transplants find that they are on a long waiting list, and they must remain on dialysis while they wait for their transplant, as there are only so many kidneys to go around and the blood type must match or the patient will reject the kidney, so there are many issues that must be addressed when a patient is waiting for a transplant.

In summary, it can be seen that chronic renal failure is a dangerous, serious, and ultimately progressive disease that can stop a patient from enjoying a high quality of life. While there are treatments available for it, it should be caught as early as possible, and this often does not happen because it has no symptoms in the early stages. If allowed to progress too far, there are many other problems that can result from it, and dialysis or a transplant may be required to avoid death from the toxins that will build up in the blood when the kidneys fail to filter it properly.

Definition and Types of Renal Failure

According to the Organ Procurement and Transplantation Network (2005), renal failure is “the inability of the kidneys to remove wastes and maintain electrolyte balance.” There are two types of renal failure: chronic and acute. Chronic renal failure is a gradual and progressive loss of the ability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes (Medline Plus, 2005). Chronic renal failure is not reversible, unlike acute renal failure. Acute renal failure is a sudden loss of renal function, usually attributable to an underlying cause which is treatable (Medline Plus, 2005). There is no cure for chronic renal failure, which may progress to end-stage renal disease.

Chronic Kidney Disease

The worldwide increase is the number of patients with chronic kidney disease and subsequent end-stage renal failure is threatening to reach epidemic proportions over the next decade (El Nahas & Bello, 2005). In most developed countries the annual rate of chronic kidney disease is expected to rise approximately five to eight percent annually (El Nahas & Bello, 2005). The increase in chronic kidney disease is primarily due to the global epidemic of type two diabetes mellitus, which is estimated to affect about 154 million people worldwide, and this number is expected to double within the next 20 years.

According to the Third National Health and Nutrition Examination Survey, it is implied with an aging population and untreated hypertension, up to 11% of the United States population could have some form of chronic kidney disease (Coresh, Astor, & Greene, 2003). Currently, treatment costs for end-stage renal disease in the United States exceeds $14 billion annually, which comprises 6.4% of the Medicare budget (Nolan, 2005).

Treatment Options

According to the National Institute of Diabetes and Digestive and Kidney Diseases (n.d.), when chronic renal disease progresses to end stage renal disease, there are only two choice of treatment: dialysis and transplantation. Dialysis involves a machine which is used to filter blood through a special filter and dialysate solution. The waste products and extra fluid are removed by diffusion and convection. Renal transplantation involves an operation in which a person receives a new kidney from a living or deceased donor (National Kidney Foundation, 2005).

Dialysis vs. Transplantation

Renal transplantation is the preferred treatment modality of renal replacement therapy for patients with end stage renal disease in terms of health care cost, quality of life, and patient survival (Schaubel, et al., 2002). Dialysis is not the first treatment of choice for renal replacement therapy due to numerous complications associated with this type of treatment which include: anemia, bone diseases, fluid overload, and malnutrition. The mortality rate from cardiovascular disease for patients with end-stage renal disease receiving dialysis is 10 to 30 times higher than the general population (Nolan, 2005). Many patients receiving hemodialysis are in a state of chronic inflammation induced by dialysis treatments which is associated with long-term complications (Cristol, 2005).

Literature Review Related to Renal Transplantation

Graft Survival

The survival of the graft is the most significant issue when it comes to renal transplantation. The survival of the graft means that the kidney transplant was successful and the kidney had normal function (Helgeson, Snyder, & Seltman, 2004). If the transplant does not work well or there are complications with it, the kidney will not function correctly. Sometimes the kidney will not work at all, or will lose functionality over time. The goal is not only to show that the graft is working correctly but to have continued graft survival so that the kidney keeps a high level of functioning for the recipient (Helgeson, Snyder, & Seltman, 2004).

Quality of Life

The quality of life that a renal transplant recipient has depends on many factors. For example, how well someone takes care of themselves after transplant surgery will have a strong effect on the quality of life that they enjoy for their future (Helgeson, Snyder, & Seltman, 2004). They are educated about how to properly care for themselves and what kinds of problems to look out for, but many individuals get careless about this if they have not been educated properly or if they do not take what they must do seriously enough (Helgeson, Snyder, & Seltman, 2004).

If a transplant recipient takes good care of himself or herself, however, the quality of life that is enjoyed can be quite good (Helgeson, Snyder, & Seltman, 2004). Most of the medications that transplant recipients must take have only minimal side effects for most people, and diet and exercise requirements are realistic. The testing procedures that are necessary in order to ensure that the kidney is working properly on a daily basis can get tiresome but they really do not take that long, and they are very important to ensure that there are no problems (Helgeson, Snyder, & Seltman, 2004). If problems are developing, they are found quickly and can usually be dealt with relatively easily and with a minimum of hassle. Quality of life, therefore, is similar to a ‘normal’ quality of life, with some exceptions for care.

Organ Rejection

The most serious issue for individuals that have gone through a kidney transplant is organ rejection. This can put them back on dialysis, and it can be deadly in some cases (Helgeson, Snyder, & Seltman, 2004). Most organs that are matched correctly are not rejected, but anti-rejection drugs must be taken for the rest of the individual’s life. There are also risks and side-effects of the anti-rejection drugs (Helgeson, Snyder, & Seltman, 2004). However, these are less severe than the problems that come into play when someone is required to be on dialysis, especially if this is for a prolonged period of time (Helgeson, Snyder, & Seltman, 2004). By being careful and taking self-care and monitoring seriously, however, organ rejection can generally be avoided.

Economic Outcomes

The economic outcomes of renal transplantation can vary widely (Helgeson, Snyder, & Seltman, 2004). Some people recover very quickly and have little trouble learning their new regimen for self-care. Others struggle for months before they begin to feel ‘right’ again (Helgeson, Snyder, & Seltman, 2004). Either way, however, most people are able to go back to work at some point after their surgery. Despite this, though, the cost of the transplant is very expensive and the aftercare also costs money (Helgeson, Snyder, & Seltman, 2004). There is the hospital stay, the time that the individual may have spent on dialysis before the surgery, and other issues. It is important that individuals understand the costs of this procedure, but saving lives is obviously more important (Helgeson, Snyder, & Seltman, 2004).

There is another economic cost to this issue as well, as dialysis and transplantation costs a great deal for Medicare every year (Helgeson, Snyder, & Seltman, 2004). Most of the individuals that have kidney transplants are older people, and they have Medicare insurance. The Medicare system is already stretched thin and struggling (Helgeson, Snyder, & Seltman, 2004). While it will not turn away individuals that are eligible and need services, Medicare also knows that the system is running out of money (Helgeson, Snyder, & Seltman, 2004). More and more people are ending up with renal failure and in need of transplants late in life, and much of this comes from individuals that struggle with weight problems and diabetes, as well as high blood pressure and other factors (Helgeson, Snyder, & Seltman, 2004).

Literature Review Related to Transplant Teaching in Post-Op Patients

Individual Teaching in Renal Postoperative Patients

When a person experiences individual teaching, he or she is made to feel as though the information being imparted is significant (DiMatteo, 2004). It also seems as though individuals that are taught in this way feel that they matter more because they were individually addressed by the nurse giving them their instructions. It makes them feel as though they are a person instead of just a patient (DiMatteo, 2004).

Group Teaching in Renal Postoperative Patients

Group teaching is much faster and takes less manpower (DiMatteo, 2004). One nurse can teach a group of patients what they need to know rather quickly. It takes much longer with individual teaching (DiMatteo, 2004). When individuals are taught in a group they can also help others in the group understand the instructions if they get confused. However, these people can be left to feel as though they are not that important because they are nothing but a small part of a large group.

In other words, they do not feel as though they are being singled out and taught to do things properly because they are cared about by others (DiMatteo, 2004). This can be problematic for individuals that have just gone through an operation and are scared because they are uncertain about what happens next and how they are going to take care of themselves properly and safely (DiMatteo, 2004).

Literature Review Related to Emotional Acceptance of Chronic Illness

Chronic illness does not ask anything from the patient, it simply demands it. Sometimes, the demands that an illness can make are not that great, but the concern is always that the illness will demand so much that the entire life of the chronically ill person and the lives of his or her family will be taken up by it. The physical demands of the chronic illness are often great, and therefore the emotional and behavioral demands that should also be dealt with are often avoided or compromised in some way (Anderson, 2002; Goldring, et al., 2002; Helgeson, et al., 2004).

Where these emotional and behavioral issues are concerned, physicians have been overlooking ways to help patients deal with problems on these levels. This is something that many believe should be changed because it is detrimental to the overall healing and well-being of the chronically ill patient (Susman, 2001). The interaction between the mind and the body is very significant for those that are chronically ill and when the body is being treated but the mind is not the healing process is slowed or interrupted because the patient is not getting what he or she needs (Susman, 2001).

This is also true of the families of these patients, as they often do not get what they need emotionally or behaviorally in the way of support due to the fact that they are not the ones that are ill and the physician is only focusing on the physical aspects of the patient alone. Balancing the coping skills that families and chronically ill patients have is one way to help with the issues that they are facing (Suls & Rothman, 2004). These coping skills involve balancing what the illness requires with what the patient and the family are still able to do together. It effectively puts the illness ‘in its place’ and does not allow it to rule the lives of the family or the life of the individual that is suffering with it. This may, however, be easier said than done, and this is one of the reasons why it is believed that the services of a mental health professional can be very important and significant in the lives of those with chronic illnesses.

Mental health professionals can help individuals learn about this kind of coping model, where the disease or illness and the individuals that are affected by it have a reciprocal relationship. In other words, they do not simply allow themselves to be affected by the illness, but instead they influence the illness just as the illness influences them (Symister & Friend, 2003). This allows them to feel that they have some measure of control over the illness, and this control is important to keeping a positive attitude (Keefe & Blumenthal, 2004; Turk & Okifuji, 2002).

It is no surprise that children and adults that are suffering from chronic illnesses have a higher chance of having mental health problems. These individuals must struggle with problems that the rest of society can only imagine and would largely prefer not to think about (Keefe & Blumenthal, 2004). While much of society sympathizes with these individuals and their plight, the understanding of what it is really like to deal with a chronic illness escapes the majority of people and therefore getting empathy and honest understanding from many people is difficult. This can make the person with the illness feel depressed and isolated (Johnson & Millstein, 2003). When this takes place, the person does not fight the illness as well, because depression has been shown to lower immunity to disease (Nicassio, et al., 2004).

It is also suggested that treating these individuals on a mental health level as well as a physical health level may be more cost effective (Tovian, 2004). This is related to the fact that those that feel better fight infection and other problems more easily, and therefore they may require less physical treatment and fewer trips to the doctor or the emergency room. This is important on several levels. Not only is it significant for the bills that these individuals may have to pay, but also for the well-being that they have. When the chronically ill individual feels better, he or she makes less trips to the doctor, and when he or she makes less trips to the doctor, he or she feels better. There is a cycle to this that is significant for many people that are ill and for their families as well, and not allowing the illness to become the central focus of their lives is very important (Roberts, et al., 2002).

Adjusting to illness on a psychological level, however, is still very difficult (Rogers, 2004). There are several things that people can do in order to try to adjust more easily. One of these is exercise. Exercise has long been proven to be good not only for physical health, but for mental and emotional well-being as well (Emery, et al., 2003). Because of this, studies have shown that there are benefits to exercise when it comes to chronic illness, and those with chronic illnesses should exercise at whatever level they can for as long as they are able to do so.

Part of this idea regarding exercise has to do with the idea that the perceptions of illness and health are in the heads of each individual. In other words, how sick someone thinks they are can have something to do with how sick they really are. This does not mean that someone can think themselves healthy, but they can be affected to a certain extent by what they think of themselves and the perceptions that they have of their own health. The support that they have from others also plays a strong role. This support can help to encourage them when they are not feeling well, and can also help to boost their confidence when they do feel well. Both of these issues are very important for the way that the person dealing with the illness feels and how well they are able to keep their illness in check or recover from any setbacks that they might face.

With a chronic illness, there are almost always going to be ups and downs. There will be very good days where the person really does not feel sick at all, and there will be setback days where the person will feel (and possibly be) very sick. This is significant for the individuals that are dealing with chronic illnesses and also significant for the people that are taking care of them during their illness.

The main statement of the Callista Roy Nursing Adaptation Model centers around serious illnesses and caregivers, and how the caregivers adapt to dealing with the illness of the patient. There are several different areas in which caregivers can adapt to the illness, and adapting in one area does not necessarily mean that they will adapt in another area.

There are several assumptions made by the model. These can be divided into two groups: scientific and philosophical. Rather than create a lengthy discussion about these assumptions, it will be easier to simply reproduce them in list form here (Boston, 2003).


Systems of matter and energy progress to higher levels of complex self-organization.

Consciousness and meaning are constitutive of person and environment integration.

Awareness of self and environment is rooted in thinking and feeling.

Humans by their decisions are accountable for the integration of creative processes.

Thinking and feeling mediate human action.

System relationships include acceptance, protection, and fostering of interdependence.

Persons and the earth have common patterns and integral relationships.

Persons and environment transformations are crated in human consciousness.

Integration of human and environment meanings results in adaptation.


Persons have mutual relationships with the world and God.

Human meaning is rooted in an omega point convergence of the universe.

God is intimately revealed in the diversity of creation and is the common destiny of creation.

Persons use human creative abilities of awareness, enlightenment, and faith.

Persons are accountable for the processes of deriving, sustaining, and transforming the universe.

The interest in the creation of the Roy adaptation model began in 1964. It was in this year that Sister Callista Roy entered the master’s program at the University of California in Los Angeles. She was encouraged throughout her graduate work to create a conceptual model for nursing and adaptation. She worked on it extensively throughout her schooling, and her work on it continued when she received her degree (Boston, 2003).

Seventeen years of work with the faculty at Mount St. Mary’s College in Los Angeles was also involved in the creation of the model. It was first used in 1970, the same year that the first article on it was published. By 1987, at least 100,000 different nurses had been educated on this particular adaptation model (Boston, 2003).

During the 1990s, Roy believed that the model should be somewhat redefined to fit the 21st century. She delved more deeply into the relationship between science and spirituality, and explained these differences in a 1997 article and in the new version of the theorist book which came out in 1999 (Boston, 2003).

There are non-nursing related assumptions that come with Roy’s model. Many of these assumptions deal with the environment. There is only so much control that a caregiver has over the surroundings, and the environment is always changing. The person who is ill also changes over time, and while most of us is noticed and dealt with by the caregiver, sometimes it can be startling and drastic which will put it into a category that the caregiver had not expected. It then becomes a non-nursing issue.

The four nursing metaparadigm concepts all come together to make the model work. The four concepts are as follows. (1) Person: The individual is a biopsychosocial adaptive system and is in constant interaction with a changing environment. (2) Environment: All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups constitute the environment. Having both internal and external components, the environment is constantly changing.

3) Health: “Health and illness are one inevitable dimension of a person’s life” Health is a process of being and becoming an integrated and whole person. Conversely, illness is a lack of integration. (4) Nursing: An external regulatory force, nursing acts to modify stimuli affecting adaptation by increasing, decreasing, or maintaining stimuli. The goal of nursing is to promote the person’s adaptation in the four adaptive modes, thus contributing to health, the quality of life, and dying with dignity (Arszyla & Gastelum, 2001).

One concept that is not a metaparadigm concept is that of coping. Coping is a mechanism that individuals use to adapt to changes. It is related to the environmental metaparadigm concept in that coping is often used to adapt to changes in the environment, but it is not the same thing. There are also four adaptive modes that Roy points out in her model. These are physiologic, self-concept, role function, and interdependence, and they are related to being able to cope with serious illness and other health issues.

Theoretical Framework: Dorothea Orem’s Theory of Self-Care

Recipients of kidney transplants have many psychosocial and physical needs that are sometimes complex. This makes proper care of these patients a challenge for nurses. These nurses must teach the patients what they need to know for the rest of their lives when it comes to taking care of themselves. For this study, the theoretical framework used will be Dorothea Orem’s Theory of Self-Care. This theory is based upon the fact that individuals can learn to care for themselves if they are taught the proper way to do this. By instilling this information into people they can have a better and higher quality of life for many years to come.

While the job of a nurse is to take care of patients, this can be accomplished in several ways. One of those ways to take care of patients is to show them how to take care of themselves. Orem’s Theory of Self-Care works on this principal in that it is designed to show the different levels of care that a patient goes through. These begin with the level in which nurses have to do all of the patient care, and end with the level in which the patient does all of the self-care and the nurses does not have to do anything for the patient. Getting to this level can take some time, but it is important that patients work toward this goal for themselves.


As can be seen from the review of the literature, there are many issues that surround an individual that has had a kidney transplant. Both physical and mental self-care and well-being must be addressed thoroughly in order for the patient to return to a good quality of life, similar to what was seen before the kidney failure became an issue. While there is no guarantee that the individual will be able to have the same quality of life, most transplant patients are able to attain a quality of life that is relatively strong and healthy, provided they take care of themselves. This means learning all they can from the nurse that teaches them post-op and also keeping up with both their physical and mental health as much as they are able to. If they cannot do these things for themselves they should find someone that can help them so that their quality of life can be as high as possible for as long as is reasonable.




The methodology of any study is particularly important. Without a clear understanding of how the study was conducted and what was dealt with in it, it becomes very difficult to analyze data in a way that makes any kind of sense later on. Because of this, the methodology that is carried out must be explained clearly and precisely, so that there is no confusion about what was done, and what was discovered. The methodology for this particular study will be discussed in this chapter.

This section of the methodology deals specifically with how the research was designed and what approach was utilized. The approach to this particular study is considered to be really a relatively simple one, but it is also a very important one, and it makes the most sense for the information that is available and the answers that the researcher seeks to find in this particular study. Instead of re-examining everything that has been done in the past when it comes to the literature review and drawing conclusions from it, which would be very time consuming and difficult, the information for the analysis will come from what was gathered by the researcher from the surveys that were conducted regarding chronic renal failure and the problems that are often caused by it.

The collected data of others will be utilized, however, in order to determine what kind of information has been seen in the past and whether the current study indicates the same types of concerns. This is important, since there may be different, and new, information that is presented from the data that the researcher has collected. This type of analysis can allow for a better understanding of what has gone on in the past, what the current study shows, and where future trends are heading when it comes to this very important issue.

While many studies interview subjects or conduct surveys, analyzing and reviewing the work of others is still quite a common method for many researchers to use when conducting a study of this nature, which is why it will be done for help in understanding what has gone before where research into renal failure and kidney transplantation is concerned. Surveying those that have actually been through this is vital, however, to an understanding of what is really happening with these individuals and how it can be changed through the use of better understandings of both renal failure and the problems that many individuals with this condition face, even after they have been through a kidney transplant and have learned self-care techniques.

This is especially true for a subject such as this where there is so much information available in articles and studies, and when that information goes back so far, since helping to find ways to help these individuals, and helping to understand what their problems really are and where they come from is something that the literature review is especially good for. This issue has been studied for many years, and this provides a wealth of information that deals with the issue and those smaller issues that surround it. Were it not for this information, it would be necessary to conduct a costly and time consuming method of study that would provide enough data for the current research, in addition to the surveys that were conducted by the researcher for this purpose. Since there is so much relevant information already available when it comes to renal failure and kidney transplantation, however, this will not be necessary.

An approach such as this one showcases the information that was collected by others in the literature review and also allows the researcher’s collected information to be examined and studied in a way that might be different from the ways that other researchers would utilize it or from the ways that similar information has already been presented in articles and other studies, thus broadening the issue and the understanding of the information provided.

It is for this reason that the researcher has chosen to use this particular method when it comes to the study of kidney transplantation and whether individual or group teaching is better. Much of this is done by using the survey information that was collected by the researcher and relates specifically to kidney transplantation. This not only showcases the information that is already available, but also indicates the importance of the survey work done by the researcher and presents it all in such a way as to bring new consideration to what is being examined.

Not all approaches work well for all studies, and care must be taken to ensure that the proper approach is utilized so that the study will be the best that it can be and make the most sense for all involved who read it. It is also important that the study impart the information that it is designed for, so that it will answer the question that was really asked. While there is no reason to assume that this is the only approach that will work, it is reasonable to assume that it is one of few approaches that will work, and that trying to utilize too many approaches or working with one that would be unfamiliar to the researcher would be difficult and would result in problems with the rest of the study.


The setting for this study will be a postoperative kidney transplant unit. A large patient gathering area will be used for the teaching of the group sessions, and individual patient rooms will be used for the teaching sessions that are conducted on an individual level.

Selection of Participants

Participants will be selected randomly from the individuals that have received kidney transplants and are scheduled to be taught post-op care. The requirements discussed earlier will be used to ensure that all individuals meet selection criteria.


The instrument that will be used for this study will be the Evaluation of Transplant Teaching Test. This will evaluate the subjects’ cognitive learning ability. The instrument was developed by Ellen M. Mastrangelo, RN, MSN, CS, to make a determination based on recipients of kidney transplants and whether they comprehend and are able to retain what they are taught by nurses regarding their post-op self-care. The test is 24 items, 18 of which are open-ended questions. This helps to show whether the transplant recipients can take the information that they are given by nurses and synthesize it, or whether they can only handle multiple-choice or yes/no types of questions where the information that they were given is basically given back to them in various ways. This would not indicate actual understanding and retention of the information that they were given.

Data Collection Procedure

Because of the approach to this particular study, the method that will be used to gather the data will consist of an analysis of the information that was presented in the literature review regarding kidney transplantation and information collected from the researcher’s surveys into the current state of the surveyed individuals where that issue is concerned. All of the information found in the literature review articles could not possibly be incorporated into the literature review, but a great deal of it is in there. Other information that was read and understood but was not able to fit into the literature review will also be used in determining the answers that will be incorporated into the data analysis that will take place, although enough new information will not be introduced to confuse or upset the reader in any way.

The survey data will also be incorporated into the findings, as it is vital to a complete understanding of the information that is presented about renal failure, kidney transplantation, group vs. individual teaching, and what should be the best plan of action so individuals realize how important and significant renal failure is, as well as how debilitating and harmful it can be if it is left untreated. The same is true with a lack of desire or understanding when it comes to taking care of oneself correctly, especially in the early post-op period.

When collecting the data, however, the articles that were used for the literature review will be carefully examined so that any pertinent information is not only included in the literature review but also compiled for use in the chapter on data analysis.

While this may seem like a simple way to gather data, the sheer volume of information that must be sifted through and considered makes the process somewhat time consuming. Not as time consuming, however, as utilizing only surveys or other ways of gaining information, which can take much longer while the researcher compiles them, makes sure they are appropriate and will provide the necessary information, and then attempts to have them answered. If this technique was employed for renal failure in general, instead of just for the specific group of surveyed individuals, the whole process would soon become much too large of an undertaking.

By using data that has been previously collected elsewhere and compiling it for the purpose and intent of the renal failure information in this study, the researcher carefully avoids all of the problems that can come from surveys that do not ask the right questions and from individuals who are unwilling to participate and return the surveys that have been sent to them.

The time is shorter when the data from the literature review is used, and the amount of information is much larger than what could have been collected by any other realistic means.

The literature review is also wonderful for gathering data from because the studies that are used provide so much information and are so repetitious in what they have to say. In other words, many of them confirm what others say and so it makes sense to look at these studies as an important collection of what has been said about this subject and what will likely continue to be said well into the future. It will be of interest to see whether the current study’s surveys find that same sort of repetition when compared to renal failure studies and transplant studies that have been conducted in the past.

Data Analysis

The data analysis will use information that has already been collected by others that have written articles about the subject at hand, or about parts of the subject that work to make up the whole of the issue, as well as information that has been collected by the researcher. The information from the literature will generally consist of a great deal of information from articles, but information from other sources will also be used to provide some of the data that is so important to the study. This is done for several reasons, but the two most significant ones are time and cost.

This does not mean that the literature that was reviewed will be the main focus of the data analysis conducted in Chapter Four. The main focus will always be on the information that was collected by the researcher. However, some information from the literature and studies of others can be mentioned and incorporated in the analysis of the data to back up claims made by the researcher or to tie information together more clearly.

One advantage to doing this is that the database for the study is quite large. This is due to the fact that there are so many Web sites and articles published about this issue. Not all of them are studies, but they still contain a great deal of information, and that information can then be used by the researcher, coupled with the surveys that the researcher has done, to create a study that examines the issue of kidney transplantation and which type of learning strategy works best for patients.

Studies must have something new to present, and if the data that they use is not original, they must present something new and important in some other way, such as the way that the information is examined. Studies often end by being uncertain as to whether the problem statement is valid or whether the question asked has truly been answered. This study is likely no exception to this rule, but every effort has been made to see that the study is as clear as possible and that it validates or invalidates the problem statement as much as it is able to with the information collected. As for the hypothesis that individual testing causes more retention than group testing, a paired t-test will be used for this determination.


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