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INTRODUCTION

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INTRODUCTION:
According to National Kidney Foundation, it has been noticed that 10% of the population worldwide is influenced by chronic kidney disease. As the number of patients with Chronic Kidney Disease increases, their global burden will also grow as premature mortality and morbidity in addition to the poor quality of their life (Schoolwerth, 2006) due to which the dependency of kidney dialysis patients is high on their caregivers. Caregivers can be recognized as the individual(s) who during the course treatment are most closely associated in caring for the patient and helping the patient cope with and manage their chronic illness; also, they create an impact on their perception of physical health, and an impaired quality of life (Mukadder Mollaog?lu and Mansur Kayatas, 2013). According to a research patients and their families who understands the importance of resilience, are able to reduce the stress and frustration associated with chronic disease (Li-Ching Ma, Hong-Jer Chang,  HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Liu%20YM%5BAuthor%5D&cauthor=true&cauthor_uid=23589703” Yueh-Min Liu, 2013). Furthermore, the other factor; which is increasingly understood to be more than an evolutionary adaption or method of social exchange is Gratitude (Emmons, McCullough & Tsang, 2004). Gratitude may change the nature or progress of other factors such as a person’s environment or a depressive episode, it may also be key in terms of perceived social support such that, when it is expressed to a benefactor then they are more likely to provide support in the future (Bartlett ; DE Steno, 2005). Therefore, it can be concluded that gratitude and resilience is related with the quality of life or primary caregivers of hemodialysis patients. In order to explore this conclusion, current study aims to see the impact of resilience and gratitude on the quality of life (QOL) of the ‘caregivers’ of patients undergoing dialysis.
Caregiver is a person, who faces the challenges of taking care of their beloved ones; express their feelings depend on their social support networks to assist them understand with their life situations (Garcia-Dia, 2013). Care giving is not restricted to a single support type; on the contrary it involves emotional, physical and financial support (Toseland, 2001). Issues such as routine health care (drug intake, medication, follow-up), personal care (bathing, feeding, toilet, and dressing), transportation, shopping, petty housework, money management, are all included in care giving (Toseland, 2001).
Partners, adults and other family members are alike at risk of caregiving fatigue whether they are providing caregiving from a distance or twenty-four hours a day. Most of the challenges have to face by the sandwich generation because they have to provide care to their parents who are getting older while juggling the demands of families and their own fulltime career careers (Laura Downs, 2013)
Family caregivers are at risk of physical and emotional problems of their own while they are giving care to their loved one. Fatigue contributes to an increased vulnerability to disease and it is frequent in nearly all caregivers yet ignore by most. The results of caregiving fatigue gradually increase in overtime and it steals the energy and focus of a caregiver. They often become so indulged in their role as they forget their own health and personal lives. By the time many care providers realize they have become caregivers; they are already suffering from the symptoms of caregiver fatigue and are leading towards the burnout Living with kidney disease is not something from which only patient is suffering. No doubt that family dynamics also change when one member has a chronic illness. The person who is more close to the patient are often emotionally affected (Kristine Dwyer, 2017).

The pain and distress of patients who are undergoing hemodialysis impact every aspect of their lives (Kutner NG, 2004).Their illness does not just interfere with the life that is undergoing dialysis but it also affects the lives of their primary caregivers. Caregivers of hemodialysis patients plays vital role in the life of patients because they have a heavy burden on their shoulders. These caregivers often spend most of their time in taking care of their patients and undergone considerable fatigue and caregiver burden (Matsuu K, Washio M, Arai Y, Higashi H, Saku Y, Tokunaga S ; Ide S, 2001).

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Most of the caregivers reported social isolation, physical and mental health problems, and brief or short time for their own self-care. Factors those weakening caregiver’s burdens included faith in God, participating in religious practices and venting of feelings (Alnazly EK and Samara NA, 2012). Caregivers of hemodialysis patients are facing significant burden and more than one third caregivers are suffering from moderate to severely depressed (Dayana Shakya, Jyoti Tuladhar and SabitraPoudel, 2017). Caregivers have faced psychological and physical distress for example increased workload, limitations to personal and social activities, and financial problems. They may feel tired, anger, depression, helplessness, guilt, isolation, loss of freedom, fear, vulnerable, and neglect their own health. They face difficulties with dating and marriage and problems with their job (Grapsa Eirini and Gerogianni Georgia, 2018). Research is required to counter the problems of caregivers as their situations are more severe than other like intellectual or physical disability because of death anxiety and others.
Extending beyond stress and burden, positive aspects of family care giving contribute to an empowering paradigm of care provision. An emphasis on care giving resilience, instead of care giving burden, it provides greater opportunity for them to cope better with the stresses of life (V Lou, 2015). Psychological resilience may be a more common reaction to severe stress and loss than psychopathology (Bananno, 2004).Caregivers who had been identified as being ‘resilient’, had discovered methods of dealing successfully with the demands of care giving (Lynn Ross LMSW, Diane Holliman &Danny R. Dixon, 2003). Other variable of interest in the present study that may be related to resilience is gratitude. Gratitude is also play the beneficial role in coping with care giving distress (B. Lau, 2017).

George Bonanno (2004) defines resilience to loss and trauma as the ability in adults in otherwise normal circumstance who are exposed to an isolated and potentially highly disruptive event such as the death of a close relation or a violent life or life-threatening situation, to maintain relatively stable, health levels of psychological and physical functioning. Resilience is defined as a class of phenomena characterized by patterns of positive adaptation in the context of significant adversity or risk. Resilient individuals possess and exhibit protective factors, such as personality features or characteristic coping patterns. This is not to say that resilient individuals do not have difficulties in the face of traumatic stress, but it is typically of a shorter duration and less intense overall (Masten & Reed, 2002)
The thrive model of resilience developed by Dr. Mollie Marti (2002), the concept of “thriving” introduce to a person’s ability to go beyond his or her original level of functioning and to grow and function despite happened again and again exposure to stressful experiences. People will respond to thriving in three different ways when confronted by a challenge: First they may survive the incident; second they recover from the incident, and third thrive as a result of hardships they gone through (Nishikawa, 2006). As a result, survivor continue to work although it may be a weaken state. Recovery shows that return to baseline where individuals return their previous level of functioning. However, as consequences thriving is transformation which includes a cognitive shift in response to a challenge. The person may re-focus priorities and have a stronger sense of self. Usually thriving results from a profound event or crisis where a person’s sense of purpose, meaning, or identity is called into question. Additional transformations include the reconstruction of meaning; the renewal of faith, trust, hope, and connection; and redefinition of self, self in relation, and sense of community. After the crisis or trauma, adaptation occurs stemming from our attempts to survive and heal in the midst of suffering ( HYPERLINK “http://journals.sagepub.com/doi/full/10.1177/2158244014545464” Saakvitne, 1998).

Researchers have shown that, there is a negative relationship between resilience and caregiver burden that enhancing a caregiver’s resilience shows promise in reducing caregiver burden (Cathy B Scott, 2010). Psychological resilience may be a more common reaction to severe stress and loss than psychopathology (Bananno, 2004).Resilience may have a prophylactic role in preserving physical and emotional well-being in family caregivers; however, resilience and burden may have a more nuanced relationship (Keith A. Anderson, Noelle L. Fields, 2013).

Along with resilience, gratitude is also the key factor to reduce the distress in caregivers. Gratitude play beneficial role on coping with care giving distress (Bobo Hi Po Lau and Cecilia Cheng, 2017). Other than resilience, gratitude can also be beneficial for the caregivers as gratitude reminds us of the good that exists in the world and it also provides a sense of security and resilience (Dr. Robert Brooks, 2015).

Gratitude is the feeling experienced by the people when they receive a gift or benefit from other person. It can be an attitude of appreciating life as a gift. People with grateful disposition tend to experience it more frequently, more intensely, toward people, and for more things in their life at any given moment (McCullough, Emmons ; Tsang, 2002). Gratitude is considered a moral affect because it results from and stimulates behavior that is motivated by a concern for other people’s wellbeing (McCullough, Kilpatrick, Emmons & Larson, 2001).

Utilization of Gratitude in life resulted in higher reported levels of alertness, enthusiasm, determination, optimism and energy. In addition, it has been showed that the group of gratitude experienced less depression and stress, was more likely to help others, they exercised more regularly and made more progress toward personal goals. According to the findings, people who are grateful are also more likely to feel loved. McCollough and Emmons also noted that gratitude encouraged a positive cycle of reciprocal kindness among people since one act of gratitude encourages another (Connie Miller, 2010).

The findings indicated gratitude was a significant predictor for positive mental health and there was a positive correlation between satisfaction of life and positive aspects of caregiving. (Cristy DeGregory, 2014). Gratitude is related to higher levels of psychological resources as well as emotion-focused coping. In turn, psychological resources and emotion-focused coping mediated the relationship of gratitude with lessening psychological distress (Bobo Hi-Po Lau & Cecilia Cheng, 2015).
According to an article, Gratitude shifts our focus from what our lives lack to the richness that we already have. People who give thanks are happier and resilient, it also strengthens interpersonal relationships, and it improves mental and physical health and reduces stress. Practicing gratitude is intentional. This intentional approach to being thankful can cause more happiness and heighten the quality of lives one day at a time. Once people become oriented toward looking for things to be grateful for, they will find that they begin to appreciate simple pleasures and things that they previously took for granted. Gratitude should not be just a reaction to getting what they want, but an all-the-time gratitude, the kind where they notice the little things and where they constantly look for the good even in unpleasant situations (Lafourche Gazette, November 23, 2016). Therefore, from above mentioned researches, it is concluded that resilience and gratitude would be beneficial for the quality of life.
Quality of life is defined as, the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events. The term itself is inherently ambiguous, as it can refer to both, the experience an individual has of his or her own life and to the living conditions in which individuals find themselves. Hence, quality of life is highly subjective. One person may define quality of life according to wealth or satisfaction with life, another person may define it in terms of capabilities like having the ability to live a better life with reference of emotional and physical well-being. Within the arena of health care, quality of life is viewed as multidimensional, encompassing emotional, physical, material, and social well-being (Crispin Jenkinson, n.d.).

Caring an individual with a chronic disease may cause stress for the caregivers, who also makes efforts to struggle against difficult situations imposed by the chronic illness of the patient they are looking after. Increased responsibility is an additional source of stress for the caregivers, and this ideation decreases the quality of life and causes feeling of depression (Rutkowski & Rychlik, 2011). Caregivers of hemodialysis patients are suffering from significant burden and from them more than one third are suffering from moderate to severe depression.
An intervention to provide appropriate social support services and improve psychological conditions of caregivers is of urgent and paramount importance (Dayana Shakya, Jyoti Tuladhar and Sabitra Poude, 2017). Therefore, it is very important for the caregivers to have a good quality of life, which can be increased with an increased practice of gratitude and resilience.

Many researches provide us insight into the caregiver’s issues, however, there are limited researches examining the combined effect of quality of life, resilience and gratitude among caregivers of individuals who are undergoing kidney dialysis. Moreover, a combination these three variables (Quality of life, resilience and gratitude) together and how it has an impact on the caregivers has not been attempted. Thus current study is undertaken to explore these aspects.
Significance of Study
Sometimes, things go bad to worse and it can be difficult to balance the life or regain stability. In such scenarios resilience is the fundamental key to protect against the experiences which could be overwhelming (Maria Konnikova, 2016). Another key to getting out of the stressful situation is Gratitude. Gratitude is a selfless act which increases quality of life, better physical and mental health and strengthens interpersonal relationships (What is Gratitude, 2017).

According to statistics of Pakistan, there are 25 million people who suffer from kidney dialysis (25m kidney patients in Pakistan, 2017). Many researchers have shown that quality of life becomes poor of both, the patients of hemodialysis and caregivers. Patients get frustrated due to their disease and caregivers suffer from psychological, physical and financial crises. Caregivers of patients experience a significant burden and adverse effects on their quality of life (Seyedeh Azam Sajadi, Abbas Ebadi ; Seyed Tayeb Moradian, 2017).

Resilience and gratitude increase happiness and helps to improve the quality of life. People can use gratitude to form new relations or to make better current one and resilience, increased involvement in community or family activities and increased physical health. Therefore, the significance of our study is to find out the primary caregivers of dialysis patients who are resilient and use gratitude, have a better quality of life. Furthermore, in the future, through our research, people will get an idea of how to improve quality of life in difficult situations.
Rationale:
Primary caregivers are contemplating as hidden patients who are experiencing physical and mental issues due to continuous health care of patients. This affects not only their quality of life, but, also the patients to whom they are providing the healthcare. So the rationale behind to take this population is to see that primary caregivers who practice gratitude and resilience in their life, has better quality of life.
A decade’s worth of research on resilience shows that people who are resilient believe that they can control their lives and they are not the victims of what happened to them rather they focus on what they can do. They seat on driver’s seat, not on the passenger’s seat. Also a growing body of groundbreaking research suggests that gratitude has the power to heal, energize, and transform lives by enhancing people psychologically, spiritually, physically, and cognitively. So here we found that gratitude and resilience both increase the quality of life, one impact the other.
In current research, survey method will be used to collect the data from our respondents. The reason behind why we choose survey method is that, surveys focus on factual information about individuals and its aim to obtain the information of the individual’s opinions, characteristics and behaviors. It provides accurate data and the most importantly, surveys are very helpful to collect data from a larger population. No other method can provide such a broad capability, which makes sure a more valid sample to gather targeted results in which to obtain conclusions and make important decisions.
Research Objectives:
There are a lot of studies have been conducted on gratitude and resilience and their results suggested that they both produces multiple positive outcomes. Resilience is the ability to use positive mental skills to remain psychologically steady and focused when faced with challenges and giving thanks makes people happier and more resilient, it strengthens relationships, it improves health, and it reduces stress (Kwok ST, Wong WN ; Lee TY, 2014). Gratitude and resilience heightens the quality of life in people who consciously practice feeling thankful for the blessings in their lives and remain resilient during difficult moments of life. Resilience and gratitude positively predict the quality of life. Resilience and gratitude would increase the quality of life among the primary caregivers of hemodialysis patients.
The prevalence of severe and moderate depression among the caregivers of patient undergoing dialysis is 35% (Khurram Danial, Asifa Khurram, Kamal Ahmed and Zain Ali, 2016). Aim of the current research is to study the impact of resilience and gratitude on quality of life of primary caregivers of hemodialysis patients. There are many researches have been done on the resilience and gratitude and quality of life separately and on different populations but in our research we want to study the combination of resilience and gratitude and their impact on quality of life of primary caregivers of hemodialysis patients which haven’t studied before.
Research Questions:
Will the impact of resilience increase the quality of life of primary caregivers of hemodialysis patients?
Will the impact of gratitude increase the quality of life of primary caregivers of hemodialysis patients?
Hypothesis:
In the light of above mentioned review and rationale, it will be hypothesized that:
Resilience will increase the quality of life of primary caregivers of hemodialysis patients.
Gratitude will increase the quality of life of primary caregivers of hemodialysis patients.

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