| Popis: |
Background: Internationally, emerging evidence of psychosocial problems in patients with end-stage renal disease has led to increasing calls for collaborative renal care models that include psychosocial services. In the UK, there is a dearth of empirical studies and clear policies to guide the implementation of these services. Methods: This thesis used a critical realist, mixed-methods approach to examine processes and outcomes of psychosocial service delivery, specifically focusing on the renal social worker role. First, an audit of the UK renal psychosocial workforce was completed. Then, a cross-sectional survey (n=869) captured and compared distress, psychosocial issues and need for services of in-centre haemodialysis patients across seven units. Focus groups (n=4) and in-depth interviews (n=6) with health professionals added a deeper understanding of processes of service delivery. In addition, diaries (n=15), questionnaires completed before and after social worker involvement (n=161), and a focus group brought insight into the renal social worker role. Results: Findings highlighted variation in psychosocial staffing patterns, with recommended benchmarks significantly exceeded. Overall, almost 50% of patients experienced distress. Multivariable logistic regression analysis showed that patients in units with better psychosocial staffing ratios [odds ratio (OR) 0.33 (95% CI 0.14-0.77); p= .01] and specifically better renal social work ratios [OR 0.15 (95% CI 0.05-0.45; p= .001) were less likely to experience distress, even after controlling for demographic variables. Nurses were found to play an important part in the process of psychosocial service delivery, yet experienced barriers in their ability to fulfil this role. Differences were found in funding arrangements and in the degree to which services were proactive and process oriented. The role of renal social worker was found to be poorly defined; and problems with their integration into renal teams and threats for the future of the role from Local Authorities were exposed. Discussion: The novel findings implicate a need for an increase in the renal psychosocial workforce. To ensure equitable access across the country, renal policy documents should make dedicated psychosocial care an unambiguous requirement and offer clear standards of practice and staffing recommendations. Renal units should explore processes, such as psychosocial education for clinical staff and distress screening, that can be put in place to ensure that a focus on psychosocial wellbeing is a standard part of renal care. To guide practice and further research, this thesis proposes a stepped-care model, putting renal social work at the heart of psychosocial service provision. |
