Applied Nursing Research 32 (2016) 262–268

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original Article

Gender-based experiences on the survival of chronic renal failure

patients under hemodialysis for more than 20 years
Mi-Kyoung Cho, PhD, APN a, Gisoo Shin, PhD, RN b,⁎
a
Eulji University, Gyeonggido, Republic of Korea, 1315
b
Chung-Ang University, Seoul, Republic of Korea, 06974

a r t i c l e i n f o a b s t r a c t

Article history: Background: Chronic kidney disease (CKD), which causes reduction in kidney function, is a common public health
Received 11 May 2016 problem worldwide. Among patients who have received hemodialysis for 20 years, the survival rate in first 5
Revised 20 August 2016 years is merely 39.9%. Such rate is lower than that of cancer patients.
Accepted 20 August 2016 Objectives: In an effort to understand and develop helpful realistic nursing interventions, we interviewed hemo-
Available online xxxx
dialysis patients of different genders, who have survived more than 20 years, regarding what their survival expe-
riences meant for them.
Keywords:
Chronic kidney disease
Methods: While the phenomenological research method was used, the data were analyzed the by Colaizzi.
Hemodialysis Results: We found that the essential meaning of survival experiences was as follows: the stress of hemodialysis
Survival patients is similar to that of late-stage cancer patients, and the patients of each gender go through different ex-
Qualitative research periences due to the country's specific cultures. However, regardless of genders, the positive supports from
Gender identity their families and nurses were important influences in their 20 years long survival. The results imply that an
in-depth understanding of hemodialysis patients' experience is an essential element for developing effective
nursing interventions.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction
Chronic kidney disease (CKD), which damages and hinders the func-
tion of kidney, is increasingly recognized as a major health problem
worldwide. CKD has been identified as a predictor of lower quality of
life. The estimated prevalence of CKD is 8–16% worldwide, and preva-
lence rate of CKD seems to be high in both developing and developed
countries (Meuwesen, Plessis, Burger, Lubbe, & Cokeran, 2016). The
number of CKD patients in Korea was about 28,000 in early 2000s, but
it tripled to about 80,000 in 2014. Moreover, about 73% of the CKD pa-
tients are receiving hemodialysis (Korean Society of Nephrology,
2014). Among the number of hemodialysis patients in Korea, number
of CKD patients is higher than other numerous countries like Japan or
the United States. The increase rate of incidence and prevalence of he-
modialysis patients in Korea was also higher than global average
(Park, Baek, & Jung, 2016).
The application of hemodialysis in CKD patients allows a longer
lifespan, but the patients also suffer from accompanying physical and
Declaration of conflicting interests: The author(s) declared no potential conflicts of in-
terest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship,
and/or publication of this article.
⁎ Corresponding author at: Red Cross College of Nursing, Chung-Ang University, 84
Heukseok-ro, Dongjak-gu, Seoul, South of Korea, 156-756. Tel.: +82 2 820 5975;
fax: +82 2 824 7961.
E-mail address: gisoo@cau.ac.kr (G. Shin).
psychological pain. During each round of dialysis, the patients have to
endure the pain caused by vascular perforation and stay in bed without
moving for 4 hours, 2–3 times a week. Therefore, the treatment does not
cure the disease completely, but it is continued throughout the patients'
lifetime until death to extend their lifespan (Murtagh et al., 2007). Fur-
thermore, hemodialysis patients need to control their eating and drink-
ing habits, manage their medications, and should be aware of the
potential complications (Grva et al., 2013). These conditions lead to
their loss of job, poor financial stability, reduced social activity, resultant
isolation from society, and mental problems such as helplessness,
depression, anxiety, and frustration (Macaron et al., 2014). Thus, com-
pared to the patients with other chronic diseases, such as hypertension
and diabetes, hemodialysis patients complain about psychogenic symp-
toms more frequently, and many of them are unable to adjust them-
selves to hemodialysis treatment, eventually dropping out of the
treatment (Cukor et al., 2008). As hemodialysis patients fear that they
might die as soon as the treatment is stopped and witnessed the
death of other peer patients who received the same treatment, they
tend to think about death more often than cancer patients do
(Russ, Shim, & Kaufman, 2007). Although the long-term survival
rate among hemodialysis patients has increased since the past,
their survival rate in the first 5 years after the diagnosis has been
merely 39.9% for the last 20 years, lower than the survival rate of
45.9% among cancer patients. It was also noted that the first 5 years
survival rate was higher among male patients (The Korean Society
of Nephrology, 2014).

http://dx.doi.org/10.1016/j.apnr.2016.08.008
0897-1897/© 2016 Elsevier Inc. All rights reserved.
 M-K. Cho, G. Shin / Applied Nursing Research 32 (2016) 262–268
Different from male counterparts, female hemodialysis patients en-
counter additional problems related to their appearance, sex, pregnancy,
childbirth, and role in their marital life (Peng et al., 2005). Moreover, it
has been reported that they suffer from more severe mental conflicts
and show a higher rate of suicide ideation or attempt than the male pa-
tients. Especially, since child birth and parenting are emphasized for sex-
ual roles of women in Korea, having the illness is equivalent of losing their
female roles and identities as wife and mother (Chen et al., 2010).
On the other hand, male hemodialysis patients experience stress due
to sexual dysfunction induced by hemodialysis, which leads to negative
emotions in terms of their masculinity (Turk et al., 2004). Furthermore,
in Korean society, the generations from the 1960s through the 1980s
perceive gender roles that are clearly distinguished between a father
and a mother, usually considering the father as a breadwinner who
plays an economic role and assumes a strict patriarchal attitude (Lee &
Janey, 2002). For this reason, male hemodialysis patients are daunted
by their economic incapability and sexual dysfunction during the hemo-
dialysis procedure.
Most of the previous studies on hemodialysis patients were quantita-
tive researches that assessed the factors influencing nursing interventions
and quality of life for providing the optimal quality of life to the patients
after considering the chronic and incurable characteristics of the disease
(Cleary & Drennan, 2005; Kring & Crane, 2009; Tasy & Healstead, 2002).
However, quantitative research has limitations in assessing hemodialysis
patients as a whole, because it simplifies and reduces the meaning of their
experiences. In an effort to understand and develop more helpful and re-
alistic nursing interventions, we need to examine the meaning and es-
sence of subjective experiences from male and female hemodialysis
patients who have different gender roles based on social cultures.
Therefore, the following study aims to explore the survival experi-
ences of hemodialysis patients based on genders by using a phenome-
nological method among CKD patients who have survived for more
than 20 years in Korean society.
2. Design and method
2.1. Methodology
Using the phenomenological research method, this study collected
data on gender-based experiences of Korean hemodialysis patients who
had survived for more than 20 years through in-depth interviews and an-
alyzed the data by using the method proposed by Colaizzi (1978). In the
process of data collection through in-depth interviews, involvement of
the participants was voluntary, and we tried to understand their empirical
world through conversations. By holistically approaching the gender-
based survival experience phenomena for more than 20 years among he-
modialysis patients, we made efforts to find the meaning of the experi-
ences and gain an insight into their empirical world.
2.2. Participants
The participants of this study were six hemodialysis patients who
had been diagnosed with CKD and received hemodialysis for more
than 20 years in the hemodialysis room of a university hospital in
South Korea. Only the patients with normal cognitive and memory func-
tions were selected for the study. The participants were provided with
the explanations about the purposes and the method of the study and
were those who gave their consent for voluntary participation. Among
six participants, one participant died of complications during the re-
search, and the data of other five participants were analyzed in this
study. The five participants consisted of two females and three males,
ranging between 37 and 67 years old with the average age of 53. The
causes of their CKD included glomerulonephritis, polycystic kidney,
and IgA nephropathy.
263
2.3. Data gathering
Based on the previous studies related to the research topics and the
researchers' experiences and through researchers' discussions, this
study developed open questions that could comprehensively and thor-
oughly reveal the phenomena experienced by Korean hemodialysis pa-
tients who had survived for more than 20 years. The following questions
were asked: ‘How did you live while receiving hemodialysis?’; ‘While
receiving hemodialysis, what problems did you experience as a
woman or a man?’; and ‘How did you solve these problems and adjust
to them?’ Before conducting in-depth interviews for data collection,
we met the participants and built trust with them. The interviews
were conducted in the hemodialysis room, which was comfortable for
the participants, after hemodialysis. Each interview lasted about 30 mi-
nutes, with each participant having 3–7 interview sessions. Thus, the
total interview time was 1.5–3 hours per participant. There were two in-
terviewers in each session, one to conduct the interview and the other
to tape-record the conversations and monitor the participant's state. If
the interviewee complained of fatigue, the interview was stopped at
that point and the next interview was scheduled. All the interviews
were tape-recorded, and noteworthy contents were recorded.
This study was approved by the institutional review board of the
university. Concerning the ethical issues, we explained to the partici-
pants about the purposes and intentions of the research before each in-
terview and the fact that the interview would be tape-recorded. They
were also ensured that the recorded contents of the interview would
be transcribed anonymously and confidentially and all the records
would be discarded at the end of the research.
2.4. Data analysis
For data analysis, tape-recorded data were transcribed as they are.
The transcripts were cross-checked with the records for confirming
the reliability of data. Data collection and analysis were performed cycli-
cally as data were analyzed immediately after they were collected, and
the method proposed by Colaizzi (1978) was used for data analysis. We
read the transcribed data repeatedly and extracted meaningful phrases
or sentences directly related to the phenomena. During the course, we
focused on the context, the participants' response, and etc. in the data.
Through careful examination of the extracted meaningful statements,
redundant expressions were removed and the statements were refined
into more general and abstract forms. The reconstructed meaningful
statements were grouped by the theme based on their contents, and
for higher abstraction, those with similar themes were categorized
and the main themes were derived.
For ensuring higher reliability and validity of this study, the identi-
fied themes were described and the contents were cross-checked with
the participants' experiences through a feedback process. Through
cross-checking and discussions, we derived consistent results. More-
over, new insights, prejudices, etc. found in this study were recorded
for comparison with the interview data and relevant literatures.
3. Findings
In order to understand the essence in the experiences of Korean he-
modialysis patients who had survived for more than 20 years, this study
performed an analysis by using the Colaizzi's (1978) method and de-
rived four themes (Table 1).
1. Lifelong nasty disease beginning with ‘Surely not’
For both, male and female participants, the reasons for starting he-
modialysis were not clear, and the time of diagnosis of renal disease var-
ied from the period of elementary school to adulthood. All the
participants answered that they started dialysis by denying the reality
and thinking that ‘Surely, I will not have such disease like this.’ They
mostly started hemodialysis due to unexpected happenings, as
264 M-K. Cho, G. Shin / Applied Nursing Research 32 (2016) 262–268
Table 1
Survival experience of chronic renal failure patients.
suggested by their responses, which included ‘When I was an elementa-
ry school child, I fell down/ill in the school and was admitted to a hospi-
tal’ (Participant 1), ‘Since my whole body was swollen …’ (Participant
5), ‘Suddenly through a physical examination in the university’ (Partic-
ipant 3), ‘Since I experienced shortness of breath at the beginning of my
married life’ (Participant 2), and ‘Since my body suddenly began to
swell after childbirth’ (Participant 4). The participants stated that they
took a long time to accept their changed bodies and had to undergo
many trials and errors. During the course, they admitted and accepted
hemodialysis as their lifelong companion.
1.1. Beginning of hemodialysis and the announcement of limited life
All of the participants stated that, after knowing they had to rely on
hemodialysis throughout their lifetime, which they started unexpected-
ly, they identified hemodialysis as the announcement of limited life and
experienced unbearable despair. On seeing the odd hemodialysis ma-
chine and other patients under hemodialysis in the hemodialysis
room, they wished for nothing else but to run away.
“I could not visit the hospital because my father was a busy army of-
ficer, and my mother did not have any basic medical knowledge. I
thought that I would be all right with one or two rounds of dialysis…
I almost wriggled to death and then fell asleep due to exhaustion… It
was scary. I just wanted to run away.”
[(Participant 1)]
“I cried a lot. I could not stop crying… I felt sad… and did not want live
anymore. I asked how many times do. I have to undergo this, but the
nurse hesitated to answer… Later, when I learned that it was a lifelong
procedure, the frustration that I felt was indescribable.”
[(Participant 5)]
1.2. Changes in the body and trials and errors
With the requirement of an arterio-venous fistula for hemodialysis,
the participants experienced changes in their appearance and the com-
plications of long-term hemodialysis such as hypotension, anemia, and
itching. Due to the various physical problems induced by hemodialysis,
they were easily deceived by false advertisements and sometimes tried
traditional methods such as taking Chinese medicines and herbs, mak-
ing a retreat to a prayer house, or calling shaman.
“I called a shaman. It was when my mother was alive. She said that I
needed an exorcism… I just wished that it would work. I was willing
to do whatever might be helpful.”
[(Participant 2)]
“I tried something like a bloodletting therapy or natural therapy…
and a lot of different kinds of herbs and Chinese medicines. Only
when I was brought to the emergency room, I realized that all of
them were useless.”
[(Participant 3)]
Female participant 4 expressed that she had difficulty in adjusting to
a more radically changed body than male patients after several arterio-
venous fistula surgeries. Female participant 5 stated that she gave up on
her marriage due to her abnormal menstrual cycle.
“I underwent vascular surgery five times in one and a half years. The
blood vessels became very sensitive. I have to sleep on only one
side… I hate to show my arms. Too many things trouble me.”
[(Participant 4)]
“I was embarrassed because I did not get my period after starting di-
alysis. At first, I mistook it for pregnancy, but on hearing that I might
not be able to have a baby, I thought that my life as a woman was
over. I do not know how long I cried. There is no hope for my mar-
riage in the near or distant future.”
[(Participant 5)]
1.3. Living with the nasty disease
All of the patients agreed that the worst troubles were restrictions
on their available time and daily activities due to the regular schedule
of hemodialysis. Since these restrictions would continue throughout
their lifetime, they called their illness ‘a nasty disease’ or ‘a curse of
heaven’. Nevertheless, they had to accept it as a companion throughout
their lifetime.
“When I was a university student, I occasionally drank alcohol along
with my friends and ate whatever was in front of me. I could not tol-
erate the restrictions binding me. What a nasty disease! I have un-
dergone hemodialysis for almost 20 years; however, I accepted it.
This is now a part of my body. I have to carry it in my body.”
[(Participant 1)]
“They said that I should undergo hemodialysis for 5 hours and 2–3
times every week. How can I do that throughout my entire life? I felt
that I was condemned by God. At the beginning, I tried to adjust my
work hours to meet the hemodialysis schedule, but finally, I had to
quit the job. When I resigned, I rather admitted that dialysis was a
part of my life that would continue forever and ever.”
[(Participant 3)]
2. Searching for myself on the boundary of life and death
Living with the hemodialysis machine and under the shadow of
death, all the participants experienced powerlessness and anxiety, but
at the same time, they were ready to face death that might come at
any time. On the other hand, they were able to turn their attention
from death to themselves and learned the meaning of life.
2.1. Peace treaty with death
Every participant had eagerness for life, but like the two sides of a
coin, they also experienced psychological pain due to the fear of death.
What they feared the most regarding death was separation from the
family, and the death of a peer patient who had received hemodialysis
along with them, leading them to think that ‘Now I need to be prepared
for my own death.’
“I really want to live longer…. To put it bluntly, I do not know when I
will die of this disease. It is scary…. terrifying…. From time to time
when I was troubled by the complications of dialysis, I asked myself,
 M-K. Cho, G. Shin / Applied Nursing Research 32 (2016) 262–268
‘Am I now dying in this way?’ I always tell myself that I should get
ready for death.”
[(Participant 1)]
“To be frank, it is extremely dreadful for me to die. The thought of
death wakes me up at midnight. It is frustrating and unfair that I
have to die. I cannot help shedding tears as I have to leave this world
before my parents. Sometimes I look around calmly to see what I
should do before I leave this world.”
[(Participant 5)]
2.2. Living this moment better before death
The participants who had endured the pain of hemodialysis for more
than 20 years expressed that, ‘I should live this moment, the present
better.’ They said that when the present moment was found to be tiring
and difficult, they drew out ‘death’ and used it as a guide for their
daily living.
“Recalling my past, I would have been arrogant in the absence of the
illness. I might have chased girls and lived a disorderly life….. Having
to undergo dialysis for almost 30 years and to think of death that
might come at any time has made me humble. Every day is precious
for me, and I try to be positive even for a small thing.”
[(Participant 3)]
“I do not think of my distant future, about how long I will live. What
is important to me is living the present better. Death tells me how to
live today. It shows the meaning of my life.”
[(Participant 4)]
3. Fixed ideas regarding gender differences corrected by the power
of the family
In particular, the male participants had fixed ideas about men's tra-
ditional gender roles and experienced frustration caused by the ideas.
However, during more than 20 years' of their life while undergoing he-
modialysis, the support of their families changed their ideas about gen-
der differences and roles. Within the boundary of their family, the
female participants also reestablished their roles, which were different
from the traditional belief that a woman should support her husband
at home.
3.1. Mental pain induced by traditional gender roles
The male participants confessed that, due to their inability to play
their social and economic gender roles in supporting their families,
their self-esteem deteriorated so low that they suffered from ‘hypo-
chondria.’ They also expressed that they felt themselves to be ‘worse
than a puppy’ when they became sexually dysfunctional due to
hemodialysis.
“As I could not continue my job…… my wife assumed many of my
roles, sometimes working for a company, doing beauty art, or selling
insurance…… Although I was a man responsible for my house, I was
of no use to the family…. Then I felt a surge of anger….”
[(Participant 2)]
“My erectile dysfunction started to develop 10 years ago, and recent-
ly it grew worse rapidly. As a man, this is quite a serious problem.
Still I could not ask the doctor to prescribe Viagra…. This is a man's
pride…. Oh my! A droopy man…. Isn't it worse than a puppy?”
[(Participant 3)]
The female participants were hurt due to their inability to play a gen-
der role as ‘a mother’ rather than physical and social gender roles as ‘a
265
woman,’ and they stated that their emotional wounds will never
be healed.
“The most frustrating thing is that I cannot travel freely with my chil-
dren even for a few days. I feel sorry for my husband as I cannot do
what I should be doing as a wife…… but it is more painful that I have
never been out with my children for a summer vacation. When I die,
I will apologize to my children for this.”
[(Participant 4)]
“It is a woman's desire to marry at the right age, give birth to chil-
dren, and become a mother…. But now it is hardly possible for me
to have a baby. Even if I have children, I will be a burden on them….
This tears my heart apart.”
[(Participant 5)]
3.2. The power of family is stronger than femininity and masculinity
The male participants said that they were comforted by their wives
and children with respect to their wounded ‘masculinity,’ and it was
the power of ‘the family’ that enabled their survival until now. In addi-
tion, they mentioned that their mothers' tearful prayers were also the
factors that have supported their lives.
“My daughter loves that I stay at home. She does not think that I, as a
father, should go out and make money but she is glad that I am at
home. When she comes home, she shouts, “Daddy is at home!”
and throws herself into my arms. I am grateful to her for growing
as a bright girl. Always……”
[(Participant 2)]
“One thing I have earned in my life is my wife who is always beside
me. She has enabled me to survive until today. I was born blessed.
My wife is the best. Even with many difficulties and troubles, she
takes care of me without showing unpleasantness. I cannot imagine
life without my wife.”
[(Participant 3)]
Female participant 5, who was unmarried, stated that she found
‘ideal masculinity’ in her father taking care of herself, and female partic-
ipant 4 who was married stated that it was her caring husband who ‘had
held her up.’
“As a wife and a woman, I feel really sorry. Marrying a person like
me, he might have suffered a lot of pain in his heart. I have not been
of any use. I am only receiving from him….. I have hurt him many
times. I was always first in everything. I have been able to en-
dure…… thanks to my husband.”
[(Participant 4)]
“It takes more than an hour from my home to the hospital, and my
father always gave me a ride. At night, early in the morning, when
visiting the emergency room … A few years ago, he fell down/ill
and was hospitalized, and even at that time, he had a brief outing
with me to my hospital. If I fall in love with someone, I would like
to meet a man who is like my father.”
[(Participant 5)]
4. Living from survival to hope
The participants explained that they were highly attached to the
hemodialysis room, in which they had spent a long time during more
than 20 years' survival, and their relationship with the nurses was
even stronger than that with their families. When asked about their
future life, they kept their hopes for the future of their children, and
not for themselves.
266 M-K. Cho, G. Shin / Applied Nursing Research 32 (2016) 262–268
4.1. Hemodialysis room as the lamp of hope
For the participants who were as helpless as a young child, the he-
modialysis room was considered to be ‘the space of care’ and even ‘a
place where the lamp of hope continues to burn’ until the time of death.
“For me, the hemodialysis room is like a religion. When renal trans-
plantation failed, I was nothing but a helpless young child before the
dialysis machine. Without the hemodialysis room that takes care of
me from top to toe, I would not have survived until now.”
[(Participant 3)]
“About 3–4 years ago, I threw up awfully. I thought I was dying, but
when I woke up I was in the hemodialysis room. I was surrounded
by the dialysis machine, and the scene and noise in the hemodialysis
room resembled a movie scene…….with the thought that my lamp
of hope has not yet extinguished.”
[(Participant 4)]
4.2. Community of hope with nurses
Spending the longest time together during more than 20 years in the
past, all of the male and female participants initially used to hide their
private matters from their families or nurses. However, through
experiencing heart attacks or withdrawals in their social relationships,
they found ‘comfort, relaxation, refuge, and shelter’ in the nurses. For
them, the nurses were ‘props’ who had been supportive in the past
and would be dependable in the future as well.
“When a new nurse comes in, she usually scolds the patients for their
slowness. However, sometimes, the patients teach the new nurses
how to perform priming. Then, we become one family…… sharing
difficult times and good times together. They are different from the
nurses in other wards. The patients sometimes cry or become fretful
in the presence of the nurses. How could we survive without them?”
[(Participant 2)]
“Because I cannot associate well with friends at school, I lost them
one by one, and naturally I became timid. But the nurses know me
better than I know myself….. As a result of sharing our joys and sor-
rows for a long period of time, they became my friends and sis-
ters…… my props who I can rely on as long as I live.”
[(Participant 5)]
4.3. Earnest hopes for the children, not for me
All the participants had ‘earnest hopes’ to be with their children in
their future, not for themselves, and stated that the earnestness was
the reason and hope for their survival.
“I have been sick since I was 25, and at that time, I talked to myself, ‘Just
live 25 years more until 50’…… But now I pray desperately that I should
remain alive until my daughter's wedding. I want to walk my daughter
down the aisle. What if she is mistreated for being a fatherless child……?”
[(Participant 3)]
“Luckily, I have survived till now. It would be even better if I could
see my child's wedding. I would like to prepare this and that for
her. This is the reason and hope of my life.”
[(Participant 4)]
4. Discussion
Using a phenomenological qualitative research method, this study
performed a gender-based analysis on the meaning of survival
experiences in Korean hemodialysis patients who have survived for
more than 20 years. From the analysis, the following four main themes
were derived with respect to the long-term survival experiences of he-
modialysis patients: lifelong nasty disease beginning with ‘Surely not’;
searching for myself on the boundary of life and death; fixed ideas regard-
ing gender differences corrected by the power of the family; and living
from survival to hope. Here, we present the results of this study according
to the main theme and discuss the essence of the participants' experi-
ences beyond the gender and according to the gender and Korean culture.
Terminal renal failure, which is one of the chronic diseases, is charac-
terized by irreversible loss of the renal function for discharging wastes
in the body and regulating the electrolyte and fluid balance. It is incur-
able by conservative treatment, and the patients' life can be extended
only through renal transplantation or renal replacement therapy (Paul
et al., 2005). While the most common causes of a terminal renal failure
in Korea are diabetes mellitus, hypertension, and glomerulonephritis
(Park et al., 2016). However, the participants of this study did not
have any knowledge about their chronic renal failure and hemodialysis
until they were diagnosed for the treatment. Consequently, they started
hemodialysis with denying and doubting the disease. They also
expressed that having to receive hemodialysis throughout their lifetime
was equivalent to the announcement for the start of their limited life.
And after a period of denying the reality and relying on religion or su-
perstitious beliefs, they accepted hemodialysis as a part of their life
through trials and errors. Such behaviors might result from the psycho-
logical stress of CKD patients receiving hemodialysis, which is similar to
that of late-stage cancer patients. The widespread prescriptions of gin-
seng and other natural herb medicines in Korea and the strong faith in
traditional medical treatments among Korean middle-age adults and el-
ders may also account for their reliance on superstitious beliefs (Choi &
Park, 2011).
In Korea, the number of hemodialysis patients has been increasing
over the last 10 years, and the country is ranked at the 10th place in
terms of the prevalence and incidence of the disease. More importantly,
CKD patients who had been receiving hemodialysis for 20 years showed
a 5-year survival rate that was lower than the survival rate in cancer pa-
tients, which supported the finding in the report that frustration expe-
rienced by hemodialysis patients was extremely severe and raised
their rate of suicide attempt (The Korean Society of Nephrology,
2014). The life span of hemodialysis patients is extended through the
procedure, but they experience various types of pain and difficulties.
During their lifetime, they have to endure restrictions on their diet
and activities and regularly receive hemodialysis for 4–6 hours and
2–3 times a week, which deprives them of their freedom, job, and social
relationships, etc. and leads them to isolated life (Cleary & Drennan,
2005). More importantly, most of the hemodialysis patients have phys-
ical symptoms including fatigue, sleep disorder, hypotension, nausea,
vomiting, itching, and pain. Furthermore, they are known to suffer
from a high level of depression and anxiety, as well as fear and terror
of death (Sharona, 2015). The participants of both genders in this
study also had a fear of death, but they tried to accept death and prepare
themselves for it, thinking that they might die in any time. They ex-
plained that their attitude toward the present life was changed as they
were grateful and faithful. According to the previous study (McClain,
Rosenfeld, & Breitbart, 2003) on the attitude of terminal cancer patients
toward death, when these patients who were facing death accepted it as
a part of their life process, they considered their remaining time more
valuable than any other moment in the past and developed an active at-
titude toward their life. The participants of this study also responded
that accepting death was fearful and painful, but at the same time,
they were trying to determine the valuable meaning of their experi-
ences as a part of their life. These findings support the notion that chron-
ic disease patients need a self-management process for maintaining
their health (Novak, Costantini, Schneider, & Beanlands, 2013).
However, the relationships with their families experienced by the
participants were different due to their differently perceived gender
 M-K. Cho, G. Shin / Applied Nursing Research 32 (2016) 262–268
roles. Particularly, due to the influence of the Confucian beliefs in Korea,
it is traditionally assumed that men should support their families eco-
nomically and display sexual masculinity. According to the study
which compared Korean and Western men suffering from depression,
social and environmental factors played bigger role than biological fac-
tors in the depression among Korean men. Because men in Korean soci-
ety live in a pressuring culture where the need of masculinity is strongly
emphasized, they tend to link weak physical conditions to failing their
roles as man and father (Lee & Choi, 2013). Such difference can also be
explained by the influence of Korean culture, which strongly focuses
on others' perceptions about oneself. Thus, from this study, we could
see the close link between the survival experiences of Korean hemodial-
ysis patients and their heavy responsibilities as man and father.
In case of Korean women, the fixed idea about women's gender roles
is that they, as a mother, should take care of children and be responsible
for child-rearing. The participants of this study also had these fixed ideas
about traditional gender roles and said that their hearts were wounded
by their inability to play the roles. Especially, because the image of a
great mother with the motto “Women may be weak, but mothers are
strong” has been emphasized and passed down in the society, it was
often thought that femininity was same as maternity (Park, Kim, &
Son, 2015). The female participants in this study also focused more on
their maternity than femininity while sharing the stories of experiences.
Despite such environment, what helped them to overcome their
frustration with respect to gender roles was the power of the family. Ac-
cording to Thomas-Hawkins and Zazworsky (2005), a supportive rela-
tionship with the family was most important for the maintenance of
CKD patients' health. They reported that the family's supportive rela-
tionship provided them with a positive belief, which induced behavioral
changes and consequently improved their quality of life. In the study by
Richa (2014), the family's emotional support was the most crucial re-
quirement for CKD patients to maintain the normality of their roles
and functions in daily living. Most importantly, we need to develop
nursing interventions for changing the perception of gender roles
among hemodialysis patients and strategies for promoting continuous
family support systems.
The last main theme derived from this study was ‘living from surviv-
al to hope.’ The participants of this study, who were hemodialysis pa-
tients for more than 20 years, thought that they were living an
unusual life and experienced difficulty in developing interpersonal rela-
tionships. In addition, they recovered from their old physical and mental
wound after being comforted in the space of the hemodialysis room and
developing relationships with their nurses. The past study (Belasco &
Sesso, 2002) also similarly suggests that hemodialysis patients who
led an isolated passive life due to their abnormal condition became
timid and were easily hurt during the course of interacting with people
around them. Several previous studies suggest that the relationship
with the medical team is one of the most influential factors for the pa-
tients to overcome these negative emotions (Cleary & Drennan, 2005;
Gillanders, Wild, Deighan, & Gillanders, 2008; Kontos et al., 2007;
Tanyi, Werner, Gentry Recine, & Sperstad, 2006).
More importantly, regardless of differences in genders, the reason
why all the participants continued their life was their hope to be with
their children in the future. When the attitude of Korean parents toward
their children was analyzed from the perspective of indigenous psychol-
ogy, their sense of achievement in the future was characterized by
achievement through parent–child relationship and child-centered
value orientation. In terms of Korean children's perception, they consid-
ered their parents to be the most important source of support for their
future achievements (Lee, Jun, & Kang, 2009). These findings suggest
that the future-oriented hopes of our participants reflect their desire
to share the future with their children.
Based on the findings of this study, while developing nursing inter-
ventions for hemodialysis patients, we need to recognize the differences
in individuals' behaviors and psychological meaning of their experiences
and consider important characteristics resulting from such differences.
267
5. Conclusion
In conclusion, the essential meaning of survival experiences that the
chronic renal failure patients had for more than 20 years while receiving
hemodialysis in Korea was as follows: the stress from the CKD patients
starting to receive hemodialysis is similar to that of late-stage cancer pa-
tients, and the patients of each gender go through different experiences
due to the country's specific cultures. However, regardless of genders,
the positive supports from their families and nurses were important in-
fluences in their 20 years long survival, and their children were hope for
their future survival. The results imply that an in-depth understanding
of hemodialysis patients' experience is an essential element for devel-
oping effective nursing interventions.
6. Limitations
Only five participants were analyzed due to the difficulty in
recruiting CKD patients who had survived for more than 20 years,
which limited the generalizability of the findings in this study.
Nevertheless, the results of this study, which used a phenomenological
method, provide natures of CKD patients' experiences during their long-
term survival of more than 20 years based on the genders and beyond
gender differences.
7. Implications for practice
The findings of this study are expected to contribute in developing
evidence-based nursing interventions for hemodialysis patients with
incurable diseases whose survival rate is lower than that of cancer.
Above all, interventions for promoting psychological support from a
patient's family and nurses should be applied in order to raise the sur-
vival rate among hemodialysis patients and to help them overcome var-
ious difficult situations expected during the process of hemodialysis.
Furthermore, as there are differences in patients' behavioral and psy-
chological characteristics, differentiated nursing interventions should
be developed for individual participants.
Acknowledgments
First of all, we would like to thank patients who have participated in
this study. We would also like to thank hemodialysis nurses who took
strong responsibility and were excellent in taking care of the patients.
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