Effect of Educational Program on Energy Conservation during Daily Activities Living among Renal Failure Patients Undergoing Hemodialysis

Background: Kidney failure is a serious health issue in the developing countries. Fatigue is a common and disabling symptom among hemodialysis patients, and it has a negative impact on quality of life and clinical results . Aim: To evaluate the effect of educational program on energy conservation during daily activities living on renal failure patients undergoing hemodialysis. Design: A quasi-experimental. Setting: Tanta University Hospitals hemodialysis centers. Subject: It consisted of 100 patients; they were randomly allocated to 50 patients in each group. Tools: The following two tools were used to gather data: First tool: patient evaluation. Tool (1): was composed of two sections: Part B contained the patients' demographic information; Part A was Modified Barthel Index . Tool (II) Fatigue Symptom Inventory. Results: It was revealed that more than half (54%) of the study group have moderate fatigue before implementation energy conservation educational program while majority (100%) of the study group have mild fatigue after implementation energy conservation educational program. Furthermore, a significant difference was observed between the study group and the control group in relation to fatigue levels, with a p-value of 0.0001. Conclusion: Application of energy conservation educational program had a positive impact on their clinical findings. Recommendations: The implementation of an energy conservation teaching program should be conducted as a regular component of treatment for patients undergoing hemodialysis.


Introduction
Renal failure is a common, morbid illness that affect patients' quality of life and it is a significant health issue in developing countries.Worldwide, the prevalence of End-stage renal disease (ESKD) varies extremely; being 1500 per million population in the United States.End stage renal disease is a prominent health concern in Egypt.(3)(4) .Because chronic kidney disease causes gradual, permanent destruction to both kidneys' nephrons, which collects toxins and fluids and leads in fluid and electrolyte imbalances, renal replacement therapy is required to treat the condition.Hemodialysis is well recognized and often used as a primary modality for renal replacement treatment.The effective management of ESKD necessitates the implementation of renal replacement treatment, which may be achieved by either dialysis or transplantation.Hemodialysis is a medical technique in which a dialysis machine and an artificial kidney, also known as a dialyzer, are used to purify the blood.In the course of hemodialysis, the patient's blood is cycled through a dialyzer including two distinct fluid Vol. 31.No. 4 (Suppl 1) ,November 2023 compartments.The compartments are constructed in two different configurations: one consists of bundles of hollow fiber capillary tubes, while the other consists of parallel sheets composed of semipermeable membranes that are bonded together.(6)(7) .
Individuals diagnosed with ESKD who undergo hemodialysis (HD) have a significant prevalence of symptoms both during and after dialysis sessions, resulting in a negative impact on their overall quality of life . (8)ultiple symptoms occur for patients with ESRD receiving hemodialysis, fatigue is one of these most symptoms and it is debilitating and difficult to manage.All hemodialysis patients often complain of fatigue, which is regarded as a serious health issue that might lower their quality of life (7,8) There are three main components to fatigue: psychological, emotional, and physical.(3) The exact timing of exhaustion in relation to HD therapy may provide some insights into processes and possible therapies.Nevertheless, the pathophysiology of fatigue in individuals with renal disease is probably multifaceted but is yet poorly understood.11)(12)(13) Personal care tasks are included in activities of Daily Living (ADLs).These consist of walking, using the bathroom, eating, dressing, getting in and out of bed or a chair, and bathing or showering.A person is considered to have a restriction in an activity if, due to health issues, they are unable to execute it alone or with special equipment, or if they are unable to undertake it at all.The restriction might be long-term or transient. (14)emodialysis patients who are fatigued need greater effort to accomplish physical and cognitive activities of daily life than they did before to the onset of tiredness.To lessen tiredness, a variety of therapeutic techniques including exercise, psychological support, stress management, a healthy diet, sleep regulation, and restorative therapy must be used (15)(16)(17) .In order to give pharmacologic and nonpharmacologic intervention for patients undergoing hemodialysis, it is essential to determine the underlying reasons of their weariness.To prevent weariness, a variety of pharmaceutical and nonpharmacological interventions are used; While non-pharmacological treatments include integrated therapies including exercise, relaxation, yoga, acupressure, hypnosis, reflexology, aromatherapy, and massage, pharmaceutical treatments often entail giving medicine for anemia and depression (18,19) .Energy conservation and continued autonomy are among the many benefits of educational programs that include energy discussion tactics for patients suffering from tiredness, joint tension, or pain.In conjunction, energy conservation education rehabilitative program is essential because Fatigue is a persistent state of extreme tiredness that may Vol. 31.No. 4 (Suppl 1) ,November 2023 result in diminished capacity for both physical and cognitive tasks.Moreover, fatigue is a complex phenomenon influenced by several causes.Therefore, it is crucial to consider and manage all potential confounding variables in order to provide complete treatment and achieve favorable results (20,21) .
The Nurses roles in energy management education, sometimes referred to as energy conservation or adaptive pacing, is a well-established rehabilitative methodology that instructs people in the use of ways to effectively regulate their energy usage during routine daily tasks.Energy management methods include many approaches aimed at optimizing energy use.These strategies encompass activities simplification, adoption of energyefficient postures, and organization of home and work surroundings.Previous research has shown the efficacy of energy management education in enhancing outcomes related to tiredness in various chronic illness populations, such as multiple sclerosis (MS) and heart disease.This intervention is believed to operate by diminishing exertional weariness experienced during routine activities.Considering the considerable demands associated with dialysis treatment, such as attending sessions, managing medications, and closely monitoring dietary and fluid intake, individuals undergoing dialysis may derive advantages from acquiring knowledge of energy management principles.32)(33) Significance of the study: -The treatment of fatigue has significance for healthcare professionals as it represents a very difficult symptom experienced by individuals with Renal Failure.This symptom not only impacts their overall quality of life but also elevates their susceptibility to cardiovascular events and contributes to heightened mortality rates.Studies on the topic of tiredness in patients with renal failure have shown that, in order to improve poor health outcomes and quality of life, fatigue is a significant problem that requires attention.

Aim of the study: -
To evaluate the effect of educational program on energy conservation during daily activities living on renal failure patients undergoing hemodialysis.Research Hypothesis:-1-Patients undergoing hemodialysis will exhibit improvement in their activities of daily living post implementation of program through nurses.Subjects and Methods: Design: A quasi-experimental was used to achieve the aim of this study.Setting: Tanta University Hospitals' hemodialysis facilities hosted the research.There are 25 hemodialysis machines in total.Subjects: Those who suffer renal failure who are scheduled for hemodialysis are moved here from other hospital departments, such as medicine, the emergency room, and the outpatient clinic.The sample of this study was consisted of: It consisted of One hundred patients randomly selected from the hemodialysis centers; they were randomly allocated to fifty patients in each group.Control group: (50)   (24) The procedure of assessing the functional capabilities of individuals with disabilities in doing routine physical activities.This index is a compilation of 11 distinct types of self-care.consists of 14 self-report items that are intended to evaluate the intensity, frequency, and daily routine of fatigue, in addition to the way in which it is perceived to disrupt one's quality of life.On distinct eleven-point scales (0 = not at all fatigued; 10 = as fatigued as I could be), severity is determined by evaluating prior week's most, least, and average fatigue, in addition to current fatigue.The frequency of fatigue experienced by respondents is determined by the number of days in the previous week (0-7) and the average duration of that fatigue on each day (0=none of the day; 10=the entire day).Perceived interference is assessed using distinct 11-point scales (0 = no interference; 10 = extreme interference).These scales determine the extent to which fatigue was perceived to have hindered various functions such Vol.31.No. 4 (Suppl 1) ,November 2023 as overall activity level, ability to bathe and dress, normal work activity, concentration, interpersonal relationships, life satisfaction, and mood during the previous week.The sum of these ratings for perceived interference yields the overall score.The ultimate component offers qualitative data regarding potential diurnal fluctuations in the daily occurrence of fatigue.

Scoring system
The scoring items use an 11-point Likert-type scale, spanning from one extreme connected to exhaustion to another (with lower scores indicating less severe fatigue-related issues).A comprehensive score may be derived for items 1-13 on a global scale.The purpose of Question 14 is to only gather qualitative data.Furthermore, it is possible to compute a Disruption Index score by summing the scores acquired on items 5 to 11.It is possible to score each item on the FSI separately, giving details about that particular variable.Moreover, the Disruption Index may be calculated overall by adding elements 5 through 11.Item 14 is not meant to be used as a quantitative scale; rather, it solely offers qualitative data.

Method of data collection:
Administrative process: 1-An official permission was obtained from the vice dean of postgraduate studies and researches and the dean of the nursing faculty received an official letter outlining the goal of the study.

2-Ethical consideration:
A. The purpose of the research was to provide no discomfort or injury to any individual in the sample.B. They were informed about confidentiality of data collection, their right to refuse participation and to withdraw at any time without any consequences.
C. All patients enrolled in the trial gave their written permission after being informed of the study's purpose and their freedom to discontinue participation at any time.
D. The ethics committee accepted this research under code 130-11-22.All tools of the study were developed by the researchers after reviewing relevant literature and used to collect data except tool1 part 2 and tool 2.

3-Validity of tools:
The content validity of all instruments was assessed by a panel of 9 specialists in the fields of medical-surgical nursing and mental nursing, who are affiliated with the college of Nursing.Additionally, a professor specializing in urology from the department of medicine was also included in the evaluation process.

4-Reliability of the tools
The dependability of tool (I) refers to its capacity to consistently provide accurate and precise results.In the subsequent phase of the investigation, the Alpha Crombach's factor was used to evaluate the test's reliability, resulting in a coefficient of 0.950.The instrument's dependability was evaluated using the Alpha Cronbach's coefficient, which resulted in a value of 0.820.5-A Pilot study: Prior to commencing the main investigation, 10% of the study subjects participated in a pilot study to determine the usability and clarity of the research instruments and to identify potential challenges that could arise during data collection.The researcher undertook modifications prior to the commencement of the primary investigation.The subjects in question were excluded from the actual research sample after being selected proportionally.-At the beginning of dialysis in first session, the capacity to execute routine tasks as measured by the Modified Barthel Index (MBI).It is employed to assess the physical functional capacity of disabled patients both prior to and subsequent to the conclusion of the Energy Conservation Education program.
-The Fatigue Symptom Inventory (FSI) was utilized to evaluate the patients' severity, frequency, daily pattern, and perceived interference with quality of life with fatigue.The assessment was conducted both prior to the commencement of the study and subsequent to the conclusion of the energy conservation education intervention.
During this phase, instructional session development was implemented.
The instructional approach comprised re-demonstration, group discussions, and demonstration.Furthermore, the instructional resources comprised a videotape, a PowerPoint presentation, and a colored document.The handout was specifically designed by the researcher in Arabic and distributed to the patients as a reference and guidance to help them comprehend every facet of the energy conservation education program.

3-Implementation phase: -Study group
After the patient was connected to the machine and all alarms were deactivated, the study group was provided with standard care and educational requirements, which included diet counseling, monitoring of blood pressure (BP Sessions 4: Summaries the content of the booklet & Review Face-to-face education session Participants will engage in four in-person instructional sessions as part of their normal hemodialysis therapy.The sessions are scheduled to take place during weeks 1, 3, and 5, with an additional booster session planned for week 12.Each session will have a length of 30 to 45 minutes.

Control group
The control group was provided with normal treatment from their healthcare providers, aimed at reducing symptoms.Upon completion of the trial, the control group was provided with an ECE program and accompanying manual during the 12th week.

4-Evaluation phase:
-Comparison was done after 12 weeks to evaluate the effect of on reduction fatigue for patients receiving hemodialysis by using tool 1 part two and tool 2 in pre -intervention and post in 12 weeks.Modified Barthel Index and Fatigue Symptom Inventory were evaluated at baseline and 12 weeks post-intervention.

Statistical analysis:
The data that was gathered was systematically arranged, compiled into tables, and subjected to statistical analysis using SPSS software (Statistical Package for the Social Sciences, version 26, SPSS Inc. Chicago, IL, USA).The range, mean, and standard deviation were computed for the quantitative data.Qualitative data pertains to a categorical dataset, whereby the description of each category is conveyed using measures such as frequency, percentage, or proportion.The t-test was used to compare the means of two sets of parametric data that were obtained from independent samples.The F value of the analysis of variance (ANOVA) test was computed to facilitate the comparison of means for parametric data involving more than two groups.(White, & S.E., 2019 ) (34) .The evaluation of the correlation between variables was conducted using Pearson's correlation coefficient (r).A significance level of P <0.05 was used to interpret the findings of tests of significance, whereas a higher level of significance, P <0.001, was used for the interpretation of very significant results of tests of significance.

Table (1): Illustrate distribution of studied groups undergoing hemodialysis according to their socio -demographic data patients undergoing hemodialysis.
It reveals that near half (44%) of the study group, and more than half (52%) of the control group were in age group of 30-40 years with Mean ±SD (41.100 ± 9.691, 40.160 ± 7.715) respectively.A significant proportion of participants in both the study group and the control group were male, with 60% and 72% respectively.Furthermore, with regards to educational attainment, it was found that 30% of the study group had completed secondary level schooling, while 44% of the control group had achieved a high degree of education.In regard to marital status, the majority of participants in both the study group and the control group were married, with percentages of 74% and 66% respectively.Table (2): This table shows medical data of studied groups.Concerning duration of hemodialysis.It reveals that near half (48%) of the study group, and near one of third (30%) of the control group were on hemodialysis from 3 to 5 years.Regarding number of dialysis session/week, the majority of the study group and the control group (64%, 60% respectively) undergo dialysis three times per week.Also in relation to type of vascular access, the majority of the study group Vol. 31.No. 4 (Suppl 1) ,November 2023 and the control group have Fistula.Furthermore, the majority of the study group and the control group complain from hypotension.

Table (3): Levels of functional independence for both groups according Modified Barthel Index
This table reveals that levels of functional independence for both groups according modified barthel index, it reveals more than half (58 %) of the study group have moderate functional dependence before implementation energy conservation educational program while majority (74%) of the study group have mild functional dependence after implementation energy conservation educational program.There were highly statistical significant difference in study group before and after implementation energy conservation educational program (P = 0.0001).
Also, this table reveals the mean score of functional independence for both groups according modified barthel index.The mean score was for the study group (14.92 ± 1.63, 17.32 ± 1.25 respectively) before and after implementation energy conservation educational program with highly significant difference (P = 0.0001).Also, here were highly statistical significant differences were found among studied groups regarding mean score of functional independence.

Table (4): Levels of severity of fatigue for both groups according Fatigue Symptom Inventory.
This table reveals that levels of severity of fatigue for both groups according Fatigue Symptom Inventory, it reveals more than half (54 %) of the study group have moderate fatigue before implementation energy conservation educational program while majority (100%) of the study group have no fatigue after implementation energy conservation educational program.There were highly significant difference in study group before and after implementation energy conservation educational program (P = 0.0001).Also, there were highly statistical significant differences were found among studied groups regarding levels of functional independence.Also, this table reveals the mean score of fatigue for both groups according Fatigue Symptom Inventory.The mean score was for the study group (53.30 ± 15.72, 20.62 ± 3.84 respectively) before and after implementation energy conservation educational program with highly significant difference (P = 0.0001).

Discussion
The effective treatment of tiredness symptoms in this particular group is of utmost importance, as fatigue has been shown to be associated with worse quality of life and increased death rates .
(30,35) Fatigue is a very prevalent and incapacitating symptom that has a negative impact on the quality of life and clinical results of those undergoing hemodialysis therapy.In addition, an individualized multidisciplinary approach is essential to ensure comprehensive care and positive outcomes (31) .Aim of this study, to evaluate the effect of educational program on energy conservation during daily activities living on renal failure patients undergoing hemodialysis.Vol. 31.No. 4 (Suppl 1) ,November 2023 The results of the research revealed that near half of the study group, and more than half of the control group were in age group of 30-40 years and a minimum of both groups belong to age group 50-60 years.This result was in agreement with Ismail et.al (2020) (36) and Çeçen et.al (2021) (37) , who found that the more than half of the control group were in age group of 30-40 years.As regard to gender, the majority of the study group and the control group were males.This finding was similar with Ismael et.al (2020 )(36), Hamza et al (2022 )(38) and Li et al (2023) (39) who reported that most of the case and control were males.This finding of the research contradicted with Solivaa et.al (2022), (40) who found that majority of the study group and the control group were females.In relation to medical history, the majority of the study group and the control group had hypertension and diabetes.This finding was similar to Wu et.al (2020) (41) and Bossola M. et al (2023) (42) who found that the most common comorbidity being had hypertension and diabetes.This finding is contradicted with Salehi F et al (2023) (43) , who reported that the majority of the studied patients have not histories of any other disease.Concerning years of hemodialysis, The findings indicate that about 50% of the participants in the study group and approximately 33% of the participants in the control group had been undergoing hemodialysis for a duration ranging from 3 to 5 years.This finding was in line with Garwai et.al (2020 ) (44) and Dsouza B et al (2023 ) (45), who reported half of the studied patients were on hemodialysis for more than five years.Regarding the number of dialysis sessions/week, the research indicated that more than three fifths of study group underwent dialysis 3 times per week.This finding agreed with Mukakarangwa et.al (2018) (46) which mentioned that more than three fifths of study group underwent dialysis 3 times per week.Furthermore, this finding is incongruent with Garwai et.al (2020) (44), The study found that a majority of individuals received dialysis three times per week.This conclusion contradicts the report of (Muz G et al (2021 ) (47) ) which stated that the patients under study underwent four sessions each week.
In relation to type of vascular access, the majority of the study group and the control group use fistula.This result is supported by Dinis et.al (2023) (48) , who found that majority of the study group and the control group utilized arteriovenous fistula.Concerning levels of functional independence, the study revealed that, more than half of the study group has moderate functional dependence before implementation energy conservation educational program while majority of the study group has mild functional dependence after implementation energy conservation educational program.
In addition, there were highly statistical significant difference in study group before and after implementation energy conservation educational program (P = 0.0001).This finding matched with the result of sankari et.al (2019) (49) , who found that, majority of experimental group were fully dependent and minority was moderately dependent in the pretest, whereas in the post test, near to half were fully independent, and moderately dependent and only tenth were fully dependent.
In relation to levels of severity of fatigue, the present study showed that, more than half of the study group has moderate fatigue before implementation energy conservation educational program while majority of the study group has mild fatigue after implementation energy conservation educational program.This result was in line with sankari et.al (2019) (49), which Vol. 31.No. 4 (Suppl 1) ,November 2023 showed that, all experimental group had fatigue in the pretest whereas in the post test, majority had no fatigue.Furthermore, The findings of the current research indicate that patients who participated in an energy conservation educational program, as well as receiving knowledge about food, physical exercise, and social support, exhibited reduced levels of weariness as measured by their scores.This result consistent with the findings of Sharma et al. (2022 )(27) , The individual(s) who discovered the efficacy of using self-management strategies in patients undergoing hemodialysis as a means to alleviate weariness.In the same line, Debnath et al. (2021) (50) , The study group, which adhered to the nursing management program including progressive muscle relaxation technique, patient education about diet, and lifestyle modification, demonstrated a significant decrease in fatigue severity compared to the control group.This finding was reported by an undisclosed source.Finally, from the same result, it can be proven that application of energy conservation educational program is effective in reducing fatigue.It supports the research hypothesis.Regarding correlation between functional independence and severity of fatigue, the present study demonstrated that, there was a significant negative correlation between functional independence and severity of fatigue after implementation energy conservation educational program.This means that increase in the severity of fatigue is consistent with decrease in physical function.This result was in line with Cecent et.al (2021 )(37 ), who showed a moderate negative correlation which was found to be statistically significant Correlation functional independence and severity of fatigue in relation to occupation, the present study revealed that, there was a significant positive correlation between functional independence and severity of fatigue before energy conservation educational program.This result was in disagreement with Zeini et.al (2023) (51) , who reported that the demographic variable educational status had shown statistically significant association with posttest level of fatigue among patients undergoing hemodialysis.

Conclusion
Application of energy conservation educational program had a positive impact on their clinical findings.Recommendations -Application of energy conservation educational program should carry out as a routine care for patients undergoing hemodialysis.

6 -
The actual study: The researchers were collected data over a period of 3 months started from November 2022 to February 2023.Vol. 31.No. 4 (Suppl 1) ,November 2023 Field work: 1-Assessment phase: --Each patient was individually interviewed.The average time to complete the questionnaire ranged from 10-15 minutes.

Energy conservation strategies and its application in daily activities, Plan and Maintain.
Changed the goals Plan what the patient is going to do first to avoid making extra trips.Get all of the tools and materials you need before you start the job.Plan to switch between heavy and light jobs.Plan your tasks for the week so that you don't have too many in one day.Make sure you get enough sleep every night.Take two deep breaths in through your nose and four out through your mouth.This is like taking a cake light off.Don't forget that it's okay to ask for help sometimes.Take care of your body and know what it can handle.