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IDENTIFICATION OF THE NEEDS OF HAEMODIALYSIS PATIENTS USING

THE CONCEPT OF MASLOWS HIERARCHY OF NEEDS
Magda Bayoumi, PhD
College of Health Science, King Khalid University in the Medical & Surgical Departments, Mohail-Asser, Saudi Arabia

Bayoumi M. (2012). Identification of the needs of haemodialysis patients using the concept of Maslows hierarchy of
needs. Journal of Renal Care 38(1), 43-49.

SUMMARY
Along with basic survival and other clinical outcomes, patients quality of life is an important indicator to reflect the needs of
these patients. Human needs are classified in Maslows hierarchy, where the most essential basic physiological need provides
the base, and self actualisation is at the top of pyramid.
Aim: The aim of this study is to identify the patients needs who are on maintenance haemodialysis using concept of Maslows
hierarchy.
Method: The descriptive study was conducted in the dialysis unit of Suez Canal University Hospitals. The study included 50
patients attending the dialysis unit.
Results: The findings showed that the patients highest need was for self-esteem (92.0%), whereas the lowest was for love
and belonging (38.0%). Statistically significant relationships were revealed between the identified love and belonging needs
and patients age and the duration of dialysis (p 0.008). The total needs score was lower with the longer duration of dialysis
(59.6 7.3), compared to those with a duration less than 24 months (65.7 8.1), p 0.02.
Conclusion: Based on the main study findings it is concluded that haemodialysis patients highest need was for self-esteem,
and the lowest was for love and belonging. These needs increased with longer duration of dialysis. Nurses need to be aware of
these findings in order to be able to supply the necessary support to help the patient regain his/her self-concept.

K E Y W O R D S End Stage Renal Disease Haemodialysis Maslows Hierarchy Needs

INTRODUCTION
B I O D ATA
M a g d a B a y o u m i is currently working
as an Assistant Professor, Dean College
of Health Science, King Khalid University
in the Medical & Surgical Departments.
She has been a lecturer in the Faculty of
Nursing, King Saud University for four
years and before that working in haemo
and peritoneal dialysis for seven years. She was awarded
a PhD in 2007. Her main interests are in nursing research,
adding to new nursing knowledge for the benefit of patients,
families and communities. This encompasses all aspects of
health including promotion and prevention. She applies the
scientific approach in an effort to solve problems using
evidence-based practice to improve quality of care especially
for dialysis patients.

Patients with end-stage renal disease (ESRD) have significant

impairment in health related to the illness impact. The treatment of ESRD in any of the four forms Peritoneal dialysis,
haemodialysis, transplant or conservative therapy, although is
a life prolonging treatment, has many clinical and psychological side effects (Manns et al. 2002).

CORRESPONDENCE

The number of patients with ESRD increases, and the

number of those who experience a progressive decline in
renal function also increases, therefore the need for renal
replacement therapy (RRT) grows. There is a necessity for
renal nurses to change from disease management, through
careful assessment of the physiological effects of the
disease, to that of providing support and symptom management (Noble 2008).

Magda Bayoumi
Dean College of Health Science,
Medical & Surgical Nursing,
King Khalid University, KKU,
Mohail-Asser, Saudi Arabia
Tel.: 966535203797
Fax: 966-7-2855389
mbayeome@kku.edu.sa

Despite high mortality rates, surprisingly little research has

been done to study chronic kidney disease (CKD) patients preferences for end-of-life care, therefore the current end-of-life
the clinical practices which focus more on practical management do not always meet the needs of patients with advanced
CKD (Davison 2010).

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The patients identified theirs and their familys needs and the
problems associated with complications of the disease and its
management. Additional attention and support are required for
patients who identify themselves as more nonadherent to enable
them to live with ESRD and benefit from the treatment (Lam et al.
2010). RRT is very prescriptive and patients have to adhere to strict
fluid and dietary restrictions (Rambod et al. 2010), also RRT is
extremely time consuming with a rigid appointment schedule
which has to be complied with, all this adds to stressors and complications for managing the disease (Christensen et al. 2002).
The hypothesis of this study is that when nurses have identified
the prioritised patient needs they are better able to offer support which helps the patient regain his/her self-actualisation,
giving back the ability to solve problems and cope realistically
with life as it now has to be lived, with renal failure.
Curtin and Mapes (2001) defined self-management as clients
positive efforts to oversee and participate in their health care
to optimise health, prevent complications, control symptoms,
marshal medical resources and minimise the intrusion of the
disease into their preferred lifestyle.
In order to benefit from the RRT ESRD patients must make fundamental life style changes which include dietary and fluid restrictions, adherence to the medication regime, recognition of signs
and symptoms associated with potential complications, vascular
access care (Richard 2006) and many social and family changes.
However, this study has categorised the life style changes according to Maslows human needs which in turn are classified in a
pyramidal hierarchy, where the base is the most essential basic
physiological and biological needsurvival, and self-actualisation
which is the top of the pyramid (Maslow & Lowrey 1998).

SUBJECTS AND METHODS

RESEARCH DESIGN
A descriptive study was used to explore the specific needs of
patients receiving HD.
STUDY SETTING
The study was conducted in the dialysis unit of Suez Canal
University Hospitals.
PARTICIPANTS
A convenience sample of 50 adult patients attending the dialysis unit of Suez Canal University.

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Journal of Renal Care 2012

Needs

Questions numbers

Physiological

1,4,6,7,8,9, 10, 11, 13, 17, 18, 19, 23, 25

Safety and security

12, 14, 15, 16, 20, 21, 22,32,33

Love and belonging

2,5,31

Self-esteem

3, 26, 27, 29,30

Self-actualisation

24, 28

Table 1: Categorisation of questions.

Hospitals during the study period were recruited for this study;
date from July to September 2008.
EXCLUSION CRITERION:
1. Those without enough education to understand the project.
2. Those patients who due to mental disabilities were unable to
answer questions and were unable to determine his/her needs.
3. Unwillingness to participate.
ETHICAL APPROVAL
The researcher approached patients individually at the time of
dialysis session, explaining the purpose of the study and the
importance of identifying their needs. All participants gave
their verbal consent.
TOOLS
S t r u c t u r e d i n t e r v i e w q u e s t i o n n a i r e f o r m : Used to collect patients background data about age, sex, work status,
level of education, duration of dialysis and caregivers (the caregiver information included the relationship to the patientif
spouse, sibling, children and parents).
N e e d s a s s e s s m e n t f o r m : Used for assessment of the needs
of patients undergoing haemodialysis therapy. It is based on
Maslows principles, and includes sections for physiological,
safety and security; love and belonging needs, self-esteem and
self- actualisation.
PREPARATORY PHASE
The researcher developed the assessment forms and the questionnaire. A review of the current and past literature, which
related to various aspects of the problem was done using textbooks, scientific journals and internet. The patients needs
questionnaire was developed to measure the level of satisfaction of the five basic needs according to hierarchy of Maslows
in English and Arabic. Thirty-three questions were categorised
into five types of need as shown below (Table 1).

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Frequency

Percent

Age (years)

Frequency

Percent

Duration of dialysis (months)

<40

20

40.0

<24

15

30.0

40+

30

60.0

24+

35

70.0

Range

19.0--52.0

Range

5.060

MeanSD

40.310.7

Mean SD

035.6 17.6

Gender

Caregiver

Male

24

48.0

Parents

16.0

Female

26

52.0

Spouse

26

52.0

Siblings

6.0

Children

13

26.0

Education
Illiterate

10.0

Read/write

11

22.0

Basic

12.0

Secondary

16

32.0

University

12

24.0

Single

21

42.0

Married

29

58.0

Unemployed/housewife

29

58.0

Working

21

42.0

Urban

12

24.0

Rural

38

76.0

Marital status

Job status

Residence

Table 2: Socio-demographic characteristics of patients in the

study sample (n = 50).

Once the tools were ready, they were reviewed by experts

selected from the community medicine department, nephrology department, then pilot-tested on 10 patients who were
not included in the main study to assess clarity and feasibility
of the tools and to estimate the time required for responses.
Necessary modifications were made, such as: priorities of the
questions, modification in Arabic so the statements were
clearer and concise.
SCORING
The responses to questions were on a 4-point scale: never,
sometimes, frequently and always. These were scored from 1
to 4, respectively. Scoring was reversed for negative items. For
each category, the scores of the items were summed-up and
the total divided by the number of the items, giving a mean
score for the part, which were then converted into a percentage score. A high score indicates less need. The scores were

Table 3: Duration of dialysis and relation of caregivers to patients

in the study sample (n = 50).

categorised into minimal or absent need (60%) and present

need (60%).
FIELD-WORK
The researcher collected baseline data using interviewing
technique to get responses to the tools during each of the
three daily shifts of treatments. Three to five patients were
interviewed per day. The interview took from 30 to 40 minutes
for each patient. The fieldwork lasted from July to September
2008.

STATISTICAL DESIGN
Data entry was done using Epi-Info 6.04 computer software
package, statistical analysis was done using SPSS 12.0 statistical software packages. Data were presented using descriptive
statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. The nonparametric Mann-Whitney or Kruskal
Wallis tests were used instead. Pearson correlation analysis was
used for assessment of the inter-relationships among quantitative variables, and Spearman rank correlation for ranked variables. Statistical significance was considered at p-value 0.05.

RESULTS
The socio-demographic characteristics of patients in the study
sample are described in Table 2. Table 3 shows the duration of
dialysis and the status of the caregiver and Table 4 demonstrates patients identified needs as reported by them. The
highest need was for self-actualisation (92.0%), whereas the
lowest was for love and belonging (38.0%). Overall, 72% of
the patients declared they had some needs.

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Needs:

Frequency

Percent

No

18

36.0

Yes

32

64.0

Total needs
(mean SD)

Self-actualisation

Safety and security

No

15

30.0

Yes

35

70.0

Love and belonging

No

31

62.0

Yes

19

38.0

Physiological
No

14.0

Yes

43

86.0

Self-esteem
No

8.0

Yes

46

92.0

Total
No

14

28.0

Yes

36

72.0

Table 4: Identified needs as assessed among patients in the study

sample (n = 50).

Needs

Score (25100)
Range

Mean SD

Self-actualisation

25.0100.0

60.8 19.2

Safety and security

33.372.2

60.1 8.9

Love and belonging

33.3100.0

69.2 17.3

Physiological

44.675.0

59.2 7.3

Self-esteem

40.075.0

57.9 7.8

45.2--81.2

61.4 8.0

Total needs

Table 5: Scores of identified needs as assessed among patients in

the study sample (n = 50).

The scores of identified needs as assessed among patients in

this study are displayed in Table 5. It is evident that, again, selfactualisation had the lowest score of achievement (57.9
7.8), that is, the highest need. Conversely, love and belonging
achieved the highest score (69.2 17.3), indicating the least
need among patients. Totally, the need score ranged between
45.2 and 81.2, with a mean SD of 61.4 8.0.

MannWhitney test

p-value

1.32

0.25

0.09

0.76

1.13

0.29

1.66

0.20

1.28

0.26

H = 0.79

0.68

5.33

0.02a

1.65

0.20

Age (years)
<40

63.0 7.0

40+

60.4 8.5

Gender
Male

61.7 7.4

Female

61.2 8.6

Education
No formal education

59.6 8.0

Educated

62.3 7.9

Marital status
Single

59.5 6.0

Married

62.8 9.0

Job status
Unemployed/housewife

60.3 7.2

Working

63.0 8.9

Caregiver
Spouse

62.2 9.2

Children

59.7 7.3

Parents/siblings

61.7 5.5

Duration of dialysis (months)

<24

65.7 8.1

24+

59.6 7.3

Residence
Urban

58.6 8.8

Rural

62.3 7.6

Table 6: Relation between identified total needs as assessed

among patients in the study sample and their socio-demographic
characteristics.
a
Statistically significant at p<0.05 (H) Kruskal Wallis test.

indicates, the only relationship with statistical significance was

with the duration of dialysis, p 0.02. It is evident that the
total needs score was lower with the longer duration of dialysis (59.6 7.3), compared to those with duration less than 24
months (65.7 8.1), which indicates more needs in the former group. The relationship between the needs scores, and
patients age, education and duration of dialysis are displayed
in Table 7.

DISCUSSION
Table 6 shows the relationship between the participants identified needs and their socio-demographic details. As the table

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This national study provides a comprehensive and detailed

description of needs of Egyptian patients on haemodialysis

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Pearson correlation coefficient (r)

Variables

Need
0.60a

QOL score
Age (years)
Education (reference: illiterate)
Dialysis duration (months)

0.11
b

0.16
0.38a

Table 7: The relationship between needs scores, and patients

age, education and duration of dialysis.
a
Statistically significant at p<0.01.
b
Spearman rank correlation.

therapy using Maslows hierarchy but the findings have important implications for all nurses and physicians. Maslows base
need is the physiological and biological need to survive which
has to be met before moving to the next higher level. Each
level has specific needs, which require to be fulfilled before the
next level can be reached (see Figure 1). This continues until
the highest level of self-actualisation or self-coping strategies is
achieved (Yah & Chou 2007).
Life with dialysis requires coping and adaptation by the
patients in order to survive (the first requirement of Maslows
hierarchy). Dietary and fluid restrictions are mandatory due to
hyperkalaemia, high blood pressure and fluid retention
(Thomas et al. 2009). Thirst is one of the physiological problems, and thirst is a frequent and stressful symptom experienced by haemodialysis patients. The education of the patient
regarding fluid restrictions and diet are part of the basic
physiological needs, which have to be fulfilled. Jacob and
Locking-Cusolito (2004) have emphasised that all educational
programmes should teach patients on HD how to deal with
physiological issues to improve total Quality of Life. They give
examples for management of thirst that might help other
dialysis patients thus improving coping strategies.
Safety and security is the second stage in the Maslows hierarchy; it is divided into physical and psychological safety. The
physical safety is protecting person from potential or actual
harm. Patients need to feel safe and secure during dialysis
sessions. They need to understand why the machine alarms so
they are not frightened by the noises. Occasionally microembolic findings have been noted after the venous chamber, or
microbubbles can be seen which could pass the air trap
towards the venous line without alarming, so to achieve safety
during dialysis sessions a specifically designed ultrasound

Figure 1: Showing Maslows Hierarchy of needs (Maslow and

Lowrey 1998).

monitor is now placed after the venous air drop to measure

the presence of eventual microbubbles (Jonsson et al. 2007).
Powers (1997) suggests that the physical safety of the dialysis
unit should be evaluated. The staff need training in handling
disruptive patients and de-escalating violence. Care should be
taken to ensure all the staff have adequate practical training to
perform safe dialysis. The unit should be safe and secure for
those who work in it and all who receive care therein.
Love and comfort is Maslows next hierarchical level. In this
study, the spouse was the caregiver in more than half of the
cases whereas children caregivers constituted about a fourth of
the study sample. In other relevant studies the main carers
were wives (38%) with children at (27%), therefore social
support and psychological interventions should be considered
in dialysis units for carers in order to improve the caregivers
life and patient outcomes (Belasco & Sesso 2002).
Lingvist et al. (2000) interestingly demonstrated that the
spouses of transplant patients had better overall quality of life
than the continuous ambulatory peritoneal dialysis (CAPD) or
HD spouse groups. Emotive, evasive and fatalistic coping are
less than optimal ways to deal with problems occasioned by
the partners treatment. Dunn et al. (1994) recommended that
understanding the effects that a chronic illness has on the
spouse will assist nurses in providing better quality care for
both the patient and the spouse. Molzahn and Kikuchi (1998)
demonstrated that when children are the caregivers the

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parents renal disease and dialysis therapy impacted significantly on the childrens lives.
This study assessed the need for love and belonging, the findings
indicated that these are the least identified needs. This might be
explained by the nature of family relations, and compassion
towards chronically ill patients in Middle Eastern communities,
such as ours. However, it was found that the scores of love and
belonging needs were statistically significantly lower among
patients aged more than 40 years, demonstrating that older
patients have a greater need expressions for the feelings of love
and belonging. This is quite plausible, as aging people might
easily feel neglected and are over-sensitive to day-to-day behaviours that they could interpret as lack of love and belonging.
ESRD is marked by extreme loss of personal control and the
challenge of lifelong behavioural changes (Quinan 2007). The
change of role within the family and status both socially and
financially which chronic illness involves and is very evident in
RRT, serves to decrease self-esteem. The body image disturbances caused through fistula or Peritoneal Dialysis all decrease
self-esteem which is Maslows next level and correlates with
psychological distress (Partridge & Robertson 2010).
Jansen et al. (2010) indicate that dialysis patients beliefs about
their illness and treatment play an important role in their perceived autonomy and self esteem. Stimulating positive beliefs
and altering maladaptive practices might contribute to a
greater sense of autonomy and self-esteem, and to social reactions in general.
Stressors for patients on HD are associated with management
of the chronic illness, however coping for dialysis patients can
be adaptive or maladaptive. Adaptive coping can produce
desirable outcomes, such as employment and successful functioning within family dynamics (Quinan 2007) whereas maladaptive coping leads to nonadherence, poor treatment outcomes and family confrontations.
Pollice et al. (2010) consider the need to integrate a psychological and functional needs assessment for patients undergoing
dialysis procedures, which lead to limitations in activities and a
high level of disability. One of the often used coping strategies
is turning to religion by haemodialysis patients, the belief as
the basic and most important aspect of human life (Cinar et al.
2009). How this is manifested will very much depend on the

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local culture and beliefs but the use of this strategy can be productive or destructive. Turning to God can be an excuse but it
can also drive the patient to better coping.
The final stage of Maslows needs is self-actualisation. This is
the realisation of self and the acceptance of life as it presents
itself, illness not-withstanding, but making the most of the
opportunities which are presented and living life to the full.
The relationship between identified self-actualisation needs as
assessed among patients in this study sample showed that the
scores were slightly lower among younger educated females,
and among single unemployed or housewives, or when the
patients caregiver was a parent or a sibling, also place of residence and the duration of dialysis was statically significant.
This study has demonstrated that the length of time a patient
is receiving HD treatment alters his/her needs. In this study,
patients duration of dialysis ranged between five and 60
months, with a mean of approx. 35 months. Hsieh et al.
(2010) demonstrate that treatment outcomes, biochemical
results and quality of life decline after 16 months. The findings
from this study agree with Hsieh et al. (2010) and both
showed that duration of treatment over 16 months did impact
on patients needs. This finding cannot be generalised to units
in other countries but was demonstrated in this study.
The total needs score was lower with the longer duration of dialysis pointing to an ever-increasing level of need as the duration
of dialysis lengthens. Moreover, this is corroborated by the finding of a statistically significant negative correlation between the
needs scores and duration of dialysis, which means that as the
duration increases, the needs score decreases, that is, more
needs. The same finding was revealed regarding love and
belonging showing those who had been receiving treatment for
more than 24 months had more needs, compared to those with
less than 24-month dialysis duration. The increasing needs
which corresponded to the longer duration of dialysis might be
attributed to progress of the disease with associated more
deficits in the patients physiological and psychological functioning. It might also be explained by the effect of the long term
caring because of the increased burden, and consequently less
ability to fulfil the Egyptian patients needs.

CONCLUSION
Based on the study findings it is concluded that haemodialysis
patients highest need was for self-actualisation, and the

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lowest was for love and belonging. These needs increased with
longer duration of dialysis. Therefore to fulfil the haemodialysis patients needs the healthcare team must first identify
these needs to be able to optimise patient management.
Nurses play an important role in the care of HD patients. They
are with the patient during treatment and can identify the
patients stressors, coping methods and social support.
Through this they can assist patients to alleviate stressors and
maintain the effective coping strategies and support resources.

Further research should focus on how nurses can help support

every individual patient and by using the holistic approach provide a sense of direction and hope to patients. Using Maslows
hierarch of needs nurses have a clear well directed plan to
enable them to help the patient undergoing haemodialysis to
arrive at the final goalself-actualisation.

CONFLICT OF INTEREST
The author confirms there is no conflict of interest.

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