Effects of a Self-Management SkillsAcquisition Program on Pre-Dialysis
Patients with Diabetic Nephropathy

Continuing Nursing
Education

Kana Kazawa
Michiko Moriyaman Japan, diabetic nephropathy isfound in 35.1% of total patients on
dialysis as an underlying disease, aproportion that is expected to increase in the future, considering theincrease in the number of patients with
type 2 diabetes ( Japanese Society ofNephrology, 2009). Similarly, thenumber of patients with diabetic
nephropathy is dramatically increasing globally (National Kidney Foundation [NKF], 2007; Zimmet, Alberti,& Shaw, 2001). To improve the quality of life (QOL) of these patients andreduce their medical expenditures, it
is important to prevent the progression of the disease and to delay the
introduction of dialysis or avoid it
altogether. Therefore, strict management of blood glucose and bloodpressure, whether by the patientsthemselves or their healthcare professionals, is required for controlling the
progression of diabetic nephropathy(NKF, 2007). Self-management education with content and structure

I

Kana Kazawa, MSN, PHN, RN, is a
Registered Nurse, Harada Hospital, Hiroshima,
Japan.
Michiko Moriyama, PhD, RN, is a Professor,
Division of Nursing Science, Institute of
Biomedical & Health Sciences, Hiroshima
University, Hiroshima, Japan.
Authors’ Note: As a disclaimer, the authors statethat no risk was assumed because the program
mainly consisted of education using textbooks with
content based on clinical practice guidelines andstudy materials already on the market, the safety ofwhich has been confirmed. The project was commissioned and funded by Kure City, Hiroshima
Prefecture, Japan.
Acknowledgements: This study was funded byKure City. The authors would like to sincerely
thank all the people in the relevant institutions thatcooperated with this study.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in relation to this continuing nursing education activity.
Additional statements of disclosure and instructions for CNE evaluation can be found on page
149.

Nephrology Nursing Journal

Copyright 2013 American Nephrology Nurses’ Association
Kazawa, K., & Moriyama, M. (2013). Effects of a self-management skills-acquisition program on pre-dialysis patients with diabetic nephropathy. Nephrology Nursing Journal,
40(2), 141-148.
The study was to examine the effects of a six-month educational program aiming acquisition of self-management skills on patients with diabetic nephropathy. One-group, preand post-test design was performed. Face-to-face and telephone interviews were conducted by nurses. Thirty participants completed the program. As a result of the program, selfefficacy, self-management ability, and HbA1c improved, and renal function was maintained.
Key Words: Predialysis, diabetic nephropathy, patient education, self-management.

Goal
To provide an overview of the effects of a six-month educational program aiming acquisition of self-management skills on patients with diabetic nephropathy.
Objectives
1. Discuss the impact of diabetes on the population of Japan in comparison with global
statistics.
2. Review the application of self-management education with content and structure basedon theoretical frameworks.
3. Explain the educational techniques integrated that provided evidence to improve patient
outcomes.

based on theoretical frameworks andevidence can help improve patient outcomes (Funnell et al., 2011).
In addition, early referral to a nephrologist helps inhibit the deterioration ofrenal function and prevents associatedcomplications (Inaguma et al., 2006).
However, many patients with diabetic
nephropathy are not referred to nephrologists when they are in the earlystages of renal failure, so these patientsare not aware of the need for self-management skills. Further, no structured
self-management programs have currently been introduced into healthcare
facilities in Japanese society. Therefore, an urgent task is the development and propagation of effective
learning programs, which are structured to support early detection of diabetic nephropathy and facilitateswitches to appropriate treatment.

This offering for 1.3 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing education requirements for certification and recertification.

March-April 2013

Vol. 40, No. 2

141

Effects of a Self-Management Skills-Acquisition Program on Pre-Dialysis Patients with Diabetic Nephropathy

We reviewed the literature foreducational or support programs forpatients with type 2 diabetes and diabetic nephropathy. The reviewed
studies reported that clinical indicators were improved by comprehensive therapy that involved lifestyleinterventions, such as those dealing
with diet, exercise, and smoking cessation, in addition to drug therapy(Gaede, 2009; Joss et al., 2004;
Shikata et al., 2010). However, in theirevaluation criteria, these reports did
not include programs that were structured to motivate patients to engage
in behavior modification or any of its
process indicators, such as self-efficacy and self-management behaviors.
Therefore, in this study, we investigated the effects of an educational
intervention using a self-management
skills-acquisition program for patientswith diabetic nephropathy. The goalof this study was to use this intervention to teach patients the knowledge
and techniques concerning self-management of their disease, which could
lead to delaying the introduction of
dialysis and avoiding emergency dialysis.

Table 1The Goals and Structure of the Self-Management
Skills-Acquisition Program
Goals: Improvement of self-efficacy and quality of life (QOL); maintenance andimprovement of clinical indicators.
The content of the program:
Improvement and maintenance of self-management ability.
Content in 1st to 4th Sessions• Establish a partnership with theparticipants.
• Identify supporters (such as family)
and discuss how supporters cancontribute.
(Analyze current data and lifestyle,establish diet/exercise targets.)• Establish long-term (life purpose)and short-term (6 months) goals.
• Analyze clinical indicators (lab test
results, blood pressure) and lifestyle.
(Acquire self-monitoring methods.)• Explain how to use textbooks, daily
journal, and study materials.
• Explain self-monitoring methods(blood pressure and body weight;
blood glucose, if appropriate).

Self-Management SkillsAcquisition Program
Program Content
The structure and content of the
program were based on:• Educational themes in previous
studies that have been regarded
as effective for patients withchronic kidney disease (CKD),
including diabetic nephropathy(Gaede, 2009; Inaguma et al.,2006; Joss et al., 2004; Wu et al.,2009).
• Evidence-based clinical practiceguidelines and expert opinionsfrom diabetologists and nephrologists.
• A qualitative study (mini-ethnography) with observation and interviews from home visits.
• Discussion among advanced
practice nurses in chronic care,registered dietitians, and patientswith CKD.

142

Content Throughout the Program• Learning support: nurses, as
partners of the participants, discussand teach the content of the
textbooks.
• Set short-term targets achievable byindividual participants (diet andexercise).
• Periodically analyze daily selfmonitoring results with participants• Analyze the reported results monthly
with the participants.
佥 Positively evaluate the executionof target behaviors.
佥 Consider resetting failed targets.
• Encourage participants to express
their emotions, such as feelings ofanxiety and a sense of burden.
• Confirm participants’ emotional andphysical changes resulting from theirtarget behaviors.
• Share with participants experiencesof other patients.

Improvement of monthly frequencies of target behaviors.
Improvement of self-efficacy and occurrence of behavior modification.
Improvement of QOL, maintenance and improvement of clinical indicators.
Note: Approaches to improved self-efficacy are italicized in the table.

In addition, based on work by
Bandura (1977), the following were included in the program:• Approaches for improving selfefficacy.
• Knowledge so that the patient
could evaluate his or her condition and talk with his or her
physicians when it deteriorated.
Nurses served as advisors topatients and their primary physicians
to foster good communication between the two.

Goals and Structure
The goals and structure of the
program used in this study are shownin Table 1. Approaches to improved
self-efficacy are italicized in the table.
First, participants sought to recognize
the state of their bodies and diseases
by linking their laboratory and selfmonitoring data (weight, blood pressure, and blood glucose) to theirlifestyle. Second, participants andnurses set achievable, systematic daily
goals to improve their lifestyle, as well
as long-term (life purpose) and short-

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term (6 months) goals. When participants experienced success, nurses
gave them positive feedback. When aparticipant was unable to achieve hisor her goal, the nurse evaluatedwhether that goal was achievable anddid not blame the patient for the failure. Moreover, nurses did not evaluate only numerical values of blood
glucose, weight, and blood pressure
because this could have had a negative impact on patients’ mental states;
instead, nurses made patients moreaware of changes in their bodies andfeelings.

Methods

Duration and Operation
The duration of the program wasset at six months, a period in which
the maintenance of behavior modification most often occurs (Prochaska& Velicer, 1997). The first to fourth
sessions were face-to-face meetings
conducted by nurses for approximately one hour once every two
weeks at participants’ homes or at theoutpatient clinic. The fifth and sixth
sessions were conducted for approximately 30 minutes once a month by
the method (telephone or e-mail) chosen by the participant. Thereafter,
telephone follow ups were performed
every month. Education was provided through textbooks, a daily journal,
and study materials with themes on
diabetes, nephropathy (complications), diet therapy, exercise therapy,
stress management, foot care, anddrug therapy. Dietary and exercise
target behaviors were set during andafter the second session.

Learning Supporters (Nurses)
Five nurses with clinical experience in internal medicine conducted
the intervention according to a protocol designed by the authors. Before
the intervention, lectures by a clinicalnurse specialist in chronic care, a registered dietitian, and an expert patientwith CKD were provided, and roleplay interventions were performed
for the participating nurses. Teamconferences were held periodicallyduring the intervention to ensure its
quality. Each participant’s desired
goals for the diet and exercise therapy

Nephrology Nursing Journal

were confirmed with his or her primary physician before the intervention, and reports on education andchanges in the participants were submitted to physicians every month
during the intervention period. Whendata deviated from standard values,
nurses immediately discussed thecase with the physicians. Dietarycomposition was appropriately advised by registered dietitians, and participants received nutrition counselingfrom these dietitians when they
requested it.

ParticipantsParticipants were patients with
type 2 diabetic nephropathy whowere insured by national health insurance in Kure City, Hiroshima
Prefecture, Japan, and attending anyof the 20 hospitals or clinics in Kurecity and Hiroshima city. The inclusion criteria were an eGFR between
15 to 59 mL/min/1.73m2, a urinary
albumin/creatinine ratio of 300 mg/
gCr or higher, and being between 20
to 74 years of age. The exclusion criteria were having received renal
replacement therapy, having a cognitive impairment or mental disorder,
or being pregnant.

DesignA one group pre- and post-test
design was used.

Period of Study
This study was conducted fromMarch 24 to December 31, 2010.

Evaluation Indicators
Evaluation indicators were set as
follows based on clinical practiceguidelines and specialist opinions.
The following indicators were collected before the intervention and every
three months after, up to six months.
Psychological indicators. We
used the self-efficacy scale for healthbehaviors in patients with chronic diseases created by Kim, Shimada, andSakano (1996), and the World HealthOrganization (WHO) Quality of Life

March-April 2013

Vol. 40, No. 2(WHO-QOL26) instrument published by WHO in 1997, the Japaneseversion of which was created by
Tazaki and Nakane (2007).
Process indicators. We collected
the proportion of days in a monththat participants performed the following self-management behaviors:
engaging in the dietary and exercise
target behaviors set by each participant; self-monitoring blood pressure,body weight, and blood glucose levels; and oral intake and injection ofprescribed drugs.
Physiological indicators. We
collected the following: HbA1c ( Japan
Diabetes Society [JDS] value), serum
creatinine (Scr), eGFR, blood urea
nitrogen (BUN), hemoglobin (Hb),total protein (TP), albumin (Alb),
potassium (K), inorganic phosphate(P), serum triglycerides (TG), lowdensity lipoprotein cholesterol (LDLcho), and high density lipoproteincholesterol (HDL-cho) in blood tests;
blood pressure; and body mass index(BMI). We calculated eGFR from thefollowing predictive equations: eGFR
(mL/min/1.73 m2) = 194 × Scr-1.094 ×
age-0.287(× 0.739, for females) (issued
by the Japanese Society of Nephrology [JSN]).

Data Collection
Nurses collected data on selfmonitoring and execution rate (frequency) of target behaviors every
month by telephone or mail. Data
from the self-efficacy and QOL scales
were mailed to the researchers afterparticipants had answered the scales.
Laboratory data were collected fromthe participants or their medical
records.

Recruitment and Registration
Procedures
Kure City, as a medical insurer,
selected all insured persons whose
medical fee receipts (claim data) listed
diabetic nephropathy as their current
diagnosis, and consent of their primary physicians for participation was
obtained. Each patient was asked toparticipate in this study after permission was obtained.

143Effects of a Self-Management Skills-Acquisition Program on Pre-Dialysis Patients with Diabetic Nephropathy

Table 2
Changes in Self-Efficacy, Quality-of-Life, and Self-Management Behaviors
Comparison at Each
Evaluation Time

Sequential Comparison
N

Baseline(BL)

Post 3-Month Post 6-Month
(P3M)
(P6M)
p-Valuea

BL-P3Mb

BL-P6Mb

P3M-P6M

Self-efficacy scale score(mean ± SD point)

28

77.8 ± 9.2

80.6 ± 8.2

80.9 ± 9.0

0.008**

WHO-QOL26 score(mean ± SD point)28

3.39 ± 0.43

3.51 ± 0.49

3.41 ± 0.45

0.701

Frequency of dietary target
behaviors (mean ± SD%)30

67.5 ± 26.0

75.2 ± 24.7

0.095

Frequency of exercise target
behaviors (mean ± SD%)30

48.7 ± 39.8

65.0 ± 35.1

0.043*

Frequency of self-monitoring(mean ± SD%)30

31.3 ± 38.6

75.2 ± 28.4

73.0 ± 30.7

0.000***

0.000*** b0.000*** b

0.607

Frequency of drug intake
and injection (mean ± SD%)30

92.8 ± 19.8

99.7 ± 1.3

99.7 ± 1.8

0.001**

0.017*b0.011* b

1.000

0.012*

0.011*

0.526

Note: BL: at the time of registration; P3M: 3 months after intervention; P6M: 6 months after intervention.
aFriedman testb
Wilcoxon signed rank test
*p < 0.05**p < 0.01***p < 0.001

Method of Analysis

Ethical Considerations

Evaluation of Program Effects

Scr, eGFR, and HbA1c were compared at four separate time points: six
months before the intervention, at thetime of registration, and then threeand six months after the intervention.
The indicators except for Scr, eGFR,and HbA1c were compared at either
three times (at the time of registration,and three and six months after theintervention) or two times (three andsix months after the intervention). For
indicators being compared at threeand four time points, tests of normality were performed followed by theFriedman test, and data showing significant differences were analyzed
using multiple comparisons. Indicators comparing two time points
were analyzed using tests of normality. In addition, participants’ andphysicians’ evaluations of the program were in percentages. For the statistical analyses, SPSS v. 17.0 was used
and the significance level was set at p
< 0.05.

Approval was obtained from the
ethics committees of Hiroshima
University Hospital and the participating medical institutions. All participants received an explanation of the
purpose of the study, program content, data collection methods, confidentiality, how the results would be
published, the voluntary nature of
their participation, and that theywould be at no disadvantage even if
they refused to cooperate. Writtenconsent was obtained for all participants.

The sequential changes in each
evaluation criterion six months before
the intervention, at the time of registration, and three and six months after
the intervention, excluding missing
values, are shown in Tables 2 and 3.
For psychological indicators, sequential changes in self-efficacy showed statistical significance, and significant differences were confirmed between the time of registration, threemonths, and six months after theintervention. QOL showed a slightincrease with time but was not statistically significant.
For self-management behaviors,
the frequency of dietary target behavior increased, but the difference
between times was not statistically significant. The frequency of exercise
target behaviors increased significantly between three and six months after
the intervention, but there were large
inter-individual differences, as shownby the standard deviations. The frequency of self-monitoring increased
immediately after the intervention,

144

Results
Overview of the Participants
Of the 32 individuals who were
eligible and consented to participate,
we analyzed 30 who had completed
the program. The mean age was 67.0
± 4.3 years, 20 (66.70%) were men,and the duration of their diabetes was
15.1 ± 9.2 (2–30) years.

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Table 3
Changes in Clinical Indicators
Sequential ComparisonN

6 Months
3 Months
before theafter theAt the TimeIntervention of Registration Intervention
(Pre)
(P3M)
(BL)

6 Months
after theIntervention(P6M)

p-Valuea

25

1.67 ± 0.57

1.67 ± 0.53

1.70 ± 0.52

1.67 ± 0.57

0.367

eGFR (mean ± SD mL/min/1.73 m )25

33.2 ± 11.6

33.9 ± 13.0

33.1 ± 13.3

34.8 ± 15.0

0.401

BUN (mean ± SD mg/dL)

30

30.7 ± 13.1

32.2 ± 14.3

30.8 ± 13.2

0.619

Hb (mean ± SD mg/dL)

26

12.3 ± 2.0

12.3 ± 1.8

12.6 ± 2.1

0.559

HbA1c (mean ± SD%)26

6.8 ± 1.5

6.3 ± 0.9

6.3 ± 0.9

0.044*TP (mean ± SD g/dL)

22

7.2 ± 0.7

7.1 ± 0.7

7.2 ± 0.6

0.247

Alb (mean ± SD g/dL)

22

4.2 ± 0.3

4.2 ± 0.4

4.3 ± 0.4

0.294

K (mean ± SD mEq/L)

21

4.4 ± 1.1

4.6 ± 0.7

4.7 ± 0.6

0.132

P (mean ± SD mg/dL)

16

3.2 ± 1.1

3.4 ± 0.7

3.4 ± 0.6

0.849

TG (mean ± SD mg/dL)

16

113.2 ± 47.0

104.0 ± 48.2

105.5 ± 43.6

0.717

HDL cholesterol (mean ± SD mg/dL)

29

56.1 ± 25.7

51.7 ± 18.7

54.6 ± 22.3

0.561

LDL cholesterol (mean ± SD mg/dL)

29

97.7 ± 30.0

91.2 ± 28.7

96.4 ± 30.6

0.343

Systolic blood pressure (mean ± SD mmHg)

30134.1 ± 18.4

128.4 ± 16.7

130.0 ± 14.4

0.588

Diastolic blood pressure (mean ± SD mmHg)

3072.2 ± 11.5

69.2 ± 9.5

69.6 ± 10.0

0.442

BMI (mean ± SD)

3025.5 ± 4.3

25.1 ± 4.6

25.4 ± 4.4

0.869

Indicator
Scr (mean ± SD mg/dL)2

6.6 ± 1.1

Note: Scr = serum creatinine, eGFR = estimated glomerular filtration, BUN = blood urea nitrogen, Hb = hemoglobin, TP = total
protein, Alb = albumin, K = potassium, P = inorganic phosphate, TG = triglyceride, HDL = high density lipoprotein, LDL = low
density lipoprotein, BMI = body mass index.
aFriedman test
* p < 0.05

and there were significant differences
between the time of registration, threemonths, and six months after theintervention. The frequency of drug
intake and injection showed significant differences in the sequential
comparisons, but in the multiple comparisons, showed only an increasing
tendency between the time of registration and six months after the intervention.
Regarding changes in clinicalindicators, renal function showed nochanges according to Scr, eGFR, and
BUN levels across all four measurement times, indicating that renal function was maintained. HbA1c decreased significantly three and six months
after the intervention compared withthe time of registration. TP, Alb, K, P,
TG, LDL-cho, and HDL-cho were

Nephrology Nursing Journalmaintained within the normal range
and showed no significant changes.
Blood pressure decreased after theintervention. No sequential change
was found in BMI.

Evaluation of the Program
Participants’ evaluations of the
program are shown in Table 4; 95%of participants rated the program as“very good” or “good.” Some participants said: “It is good to participate inthis program because I tend to stayindoors when I am alone,” and “Itwas very significant because I wasable to reconfirm...my kidney function, the meaning of the numericalvalues on my test results, and thenecessity of a healthy daily life.”
Regarding the face-to-face education
sessions conducted by nurses, 95% ofMarch-April 2013

Vol. 40, No. 2

participants rated them “very good”
or “good,” and telephone education
sessions and continued contact bynurses were rated “very good” or“good” by 85% of participants. However, 15% answered “hard to say” or“not good” and described that “theface-to-face education was better” and“it was difficult to have conversations
by telephone due to hearing difficulties.” While only three participants
asked nurses to contact them by email, they all answered “very good”
or “good.” Regarding the organization ability of the nurse in charge,
90% answered “very good” or“good.” Finally, regarding the program’s duration, 70% answered “hardto say,” and 30% answered “long,”“short,” or “very short.”
In the open-answer questions,145

Effects of a Self-Management Skills-Acquisition Program on Pre-Dialysis Patients with Diabetic Nephropathy

Table 4
Participants’ Evaluations of the Program
Very Good
n (%)

Good
n (%)

Participation in the program

8 (40)

11 (55)

1

(5)

0 (0)

0 (0)

Face-to-face education sessions conducted by nurses

11 (50)8 (40)

1

(5)

0 (0)

0 (0)

Telephone education sessions and contact with nurses

6 (30)

11 (55)

2 (10)

1 (5)

0 (0)

E-mail contact with nurses (if chosen; n = 3)

2

1

The system that there were nurse in charge

14 (70)4 (20)

2 (10)

0 (0)

0 (0)

Program duration

Very long
0 (0)

Long
1 (5)

Hard to say
14 (70)Short
4 (20)

Very short
1 (5)Question items

Hard to Say No Good
n (%)
n (%)

No Good at Alln (%)

Table 5
Primary Physicians’ Evaluations of the Program
Question Items

n (%)

n (%)

n (%)

n (%)

n (%)

Very necessary
2 (16.7)

Necessary
8 (66.6)

Hard to say
2 (16.7)

Not very necessary
0 (0)Not necessary
0 (0)Very useful
2 (16.7)

Useful7 (58.3)

Hard to say
2 (16.7)

Not very useful
1 (8.3)

Not useful0(0)Yes, very much6(50.0)Yes
4 (33.4)

Hard to say
1 (8.3)No, not very much
1 (8.3)No
0 (0)Patient education by nurses
in charge

Very good
6 (50.0)Good
4 (33.4)

Hard to say
2 (16.6)

Not very good
0 (0)Not good
0 (0)Cooperation with nurses
in charge

Very good
3 (24.9)Good
4 (33.4)

Hard to say
4 (33.4)

Not very good
1 (8.3)Not good
0 (0)Necessity of the programfor patientsContributions to medical care
Benefits patients

participants described: “I was encouraged by the nurse setting the achievable goal for me together,” and “Evenif my data did not readily improve,the nurses thought patiently about
how I improved it.” These descriptions revealed that the relationships
they had established with the nurses
and the education allowed them topositively engage in self-management. Further, this suggested that
nurses and participants cooperated in
the development of the direction of
the course and the methods of selfmanagement, and such an approach
benefitted participants by making
them feel supported.
The evaluation of the programby primary physicians is shown in
Table 5. Participants in this study
were selected from 13 medical institutions that had agreed to participate
out of the total 20 institutions. A questionnaire was distributed to the 17 pri-146

mary physicians of the participants inthis study, and answers were obtained
and analyzed from 12 of them
(response rate = 70.6%).
In describing the necessity of the
program for patients, 83.3% of physicians answered “very necessary” or“necessary.” Regarding its contribution to medical care, 75% answered“very useful” or “useful.” On whether
it benefitted patients, 83.4% answered“yes, very much” or “yes,” and one
physician stated: “I think that the program was useful for blood pressure
and blood glucose control throughweight loss and salt and protein
restriction.” In assessing how education sessions were conducted by thenurses in charge, 10 physicians(83.4%) answered that the nurses’ performance was “very good” or “good.”
As for each physician’s own cooperation with the nurses in charge, seven(58.3%) answered that it was “verygood” or “good.” Similarly, in the
open-answer questions, physicians
gave high evaluations of the reports
detailing participants’ educational andself-management statuses, generalcondition during the program period,and how nurses explained detailed
test results to patients after their medical examinations. We talked withphysicians who had not answered thequestionnaire, and all had positive
opinions about the program.

Discussion
Program Effects
In this study, self-efficacy andself-management behaviors improved
due to educational intervention. Therefore, we considered our hypothesis tobe supported in that self-management
behaviors can be strengthened by
improving patients’ self-efficacy using

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this intervention. Further, the processes that brought about this behavior
modification are described as follows.
First, the intervention helped motivate participants to manage their own
treatment by linking renal function
and laboratory test results with thesubjective symptoms of decreased
renal function, so participants could
better understand what it felt like, andthus, avoid it. However, some participants were unable to manage theirtreatment at first due to other reasons,such as economic status and interpersonal stress, in addition to their lack ofknowledge about decreased renal
function. Nevertheless, even thoseparticipants were able to confront
treatment in the subsequent sessions
when these problems were identified
and solved together with nurses.
Second, the intervention helped participants achieve a smooth transition
from a diabetic diet to a renal diseasediet. The significance of protein andsalt restriction in the protection ofrenal function was explained to theparticipants, and they were thentaught methods for evaluating theseeffects and specific cooking methods.
Further, we encouraged the utilizationof peer support, such as learning how
to cook renal diet-friendly foods inmonthly cooking classes and exchanging information with other participants.

acquisition of self-management ability
and improvements in their lifestyle, 2)
the appeal to participants to reflect on
their self-monitoring in the management of their disease, and 3) nurses’
accurate feedback on the data of theparticipants to their physicians.

Changes in Clinical Indicators

In this study, participants wereselected from a limited number ofareas and medical institutions, andtheir ages were high because they
were insured under the Japanesenational health insurance scheme. In
addition, a power analysis revealed
that the number of participants in thisstudy was insufficient. The reasons forthis small sample were that only 20
medical institutions agreed to participate in “a project for preventing the
progression of diabetic nephropathy
to more severe stages” proposed byKure City; similarly, in these institutions, few patients had diabetic nephropathy, and it took time to negotiatewith physicians about the registrationof their patients. However, the positive results of this study suggest that

No changes in renal function
were observed in the participants.
The American Diabetes Association(ADA) (2003) has reported that renal
function decreases annually from 2 to
20 mL/min/1.73 m2 for those at thestage of disease of our participants. As
such, this is a limitation of our study
because the data collection period
only covered six months after registration in the program. However, theaims of this program – to improveself-management ability and lifestyle
to minimize negative influences onrenal function – were successfully
achieved. Further, HbA1c levels werereduced after the intervention. We
considered the following as the likely
causes of these effects: 1) participants’

Nephrology Nursing Journal

Evaluation of the Overall
Program
As for participants’ evaluation of
the program, 95% felt very good orgood about participating. In addition,
it appeared from the open-answer
descriptions that participants had
established partnerships with thenurses in charge. However, some hadhearing impairments or wished to receive face-to-face education sessions
rather than telephone sessions, andthus, it is necessary to investigate
more effective intervention methods
in the future. In addition, many participants did not know about theirown condition until participating inthis program, suggesting the necessityof recruiting patients early in thestages of their disease for these interventions. Further, participants’ primary physicians also felt the program
was necessary for patients and gavehigh evaluations for the cooperation
with nurses, which further indicatesthe usefulness of the program.

Limitations and Future
Research

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Vol. 40, No. 2

future research investigating theeffects of a self-management skillsacquisition program on patients withdiabetic nephropathy will yield significant results when a sufficient sample
size is used; similarly, a randomly
assigned control group must be
included in future studies.
References
American Diabetes Association (ADA).
(2003). Diabetic nephropathy. Diabetes
Care, 26(Suppl. 1), S94-S98.
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Additional Readings
Curtin, R.B., Mapes, D., Schatell, D., &Burrows-Hudson, S. (2005). Selfmanagement in patients with end
stage renal disease: Exploring domains and dimensions. Nephrology
Nursing Journal, 32, 389-395.
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the Japanese Society for Dialysis
Therapy. (2009). Current status ofchronic dialysis therapy in Japan.
Retrieved from http://www.jsdt.or.jp/
overview_confirm.html (in Japanese).
United Kingdom Prospective Diabetes
Study (UKPDS) Group. (1998).
Intensive blood-glucose control withsulphonylureas or insulin comparedwith conventional treatment and riskof complications in patients with type2 diabetes (UKPDS 33). Lancet, 352,
837-853.

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