Treatment of depression and poor quality of life through breathing training in hemodialysis patients

Abstract

Background

The management of depression in patients undergoing hemodialysis remains challenging and affects quality of life; however, there is a possibility that breathing exercises may be effective in this context. Thus, the purpose of this study was to evaluate the effectiveness of a breathing training program on quality of life and depression among patients on hemodialysis.

Methods

A one-group pretest-posttest quasi-experimental design was used. Data were collected from hemodialysis patients at three dialysis centers. Initial baseline data were collected, and a breathing training program was implemented. The program included three types of breathing exercises. A total of 41 participants completed the study. The participants were asked to perform the breathing training program three times a day for 30 days. The impact of the intervention on patients’ quality of life and depression was measured using both the Kidney Disease Quality of Life Short Version and the Beck Depression Inventory-Second Edition.

Results

A significant decrease in the overall depression score was observed after implementing the breathing training program (BDI-II mean difference =-3.9, 95% CI:0.35–7.45, p = 0.03). The intervention has also had significant improvements on overall quality of life (KDQOL mean difference = 6.09, 95% CI: 0.48–11.70, p = 0.03) and a reduction in the symptoms and problems domain (domain mean difference = 6.71, 95% CI: 0.01–13.40, p = 0.05). There were some improvements on other quality of life domains but did not reach the statistical differences after program implementation.

Conclusions

Breathing exercises are associated with improved quality of life and reduced depression among HD patients, providing a simple and cost-effective intervention.

Background

Clinical depression affects 20- 50% of patients undergoing hemodialysis [1,2,3,4], a common treatment for chronic kidney disease (CKD) [5]. Such treatment imposes severe restrictions on the patient’s life, with up to three dialysis sessions per week, each lasting three to four hours. Strict fluid and food guidelines restrictions must be followed, and polypharmacy is necessary. All these burdens on the patient add to the need for emotional and psychological support. Hemodialysis patients often suffer from challenging psychological problems such as anxiety, stress, and depression [2, 4, 6, 7], resulting in higher hospitalization rates, poor treatment compliance, and a higher mortality rate [8, 9].

Furthermore, quality of life (QOL) in hemodialysis patients is known to be lower than the general population. Various factors, such as social isolation, physical limitations, and psychological disturbances, compromise it. Improving QOL is an important, realistic goal for hemodialysis patients.

Despite numerous attempts, improving the depression or QOL of hemodialysis patients remains challenging in this population. Treatment of such hemodialysis-induced depression with antidepressant medications is problematic given that hemodialysis patients already take multiple medications and could suffer interactions and side effects [10,11,12]. A non-pharmacological approach is thus preferable. Breathing exercises, as a component of a holistic health care strategy, are non-pharmacological interventions that show effective outcomes and improve physical and psychological functioning and quality of life [13]. These exercises are simple relaxation techniques that are easy to learn and perform with correct instructions. In previous studies and analyses, they have been shown to have beneficial effects on the human body and help with the prognoses of chronic illnesses. The exercises influence the main anatomical structures and neural pathways involved in the control of emotion, attention, perception, and problem-solving [14]. Since breathing exercises have been shown to be effective in chronically-ill patients in other disease groups, there is a possibility that similar interventional advantages might be found in patients with CKD [15,16,17]. Evidence has shown that breathing exercises improved mental health-related issues among people undergoing hemodialysis, such as fatigue and anxiety, and improve sleep quality [18,19,20].

However, studies examining the effects of breathing exercises on QOL and depression levels among hemodialysis patients are in their early stages. More rigorous studies are required to validate the efficacy of breathing exercises in improving the psychological status and overall QOL of patients undergoing hemodialysis. Nurses in dialysis centers may implement breathing exercise programs to improve patient psychological health, thus minimizing complications associated with hemodialysis therapy, while maintaining cost-effectiveness.

This quasi-experimental study evaluated the effect of a breathing-training program on quality of life (QOL) and depression levels among hemodialysis patients. Two hypotheses were tested: (1) patients undergoing hemodialysis therapy who use breathing exercise have better QOL, and (2) such patients have lower depression levels than those receiving standard care.

Theoretical framework

The Continuous Care Model (CCM) was used to guide this study. The primary application of this model was to guide research to evaluate and control the health of patients with coronary artery disease [21]. Continuous care and education are the basic aspects of CCM.

The CCM provides the following concepts: dynamic and adaptable, client/family centered, empowering and self-enabling, holistic, and collaborative [22]. The model has four stages: orientation, sensitization, control, and evaluation [22]. The nurse should apply a specific intervention for each stage of CCM. In the first stage, nurses should understand the patient’s health problems and work to increase the patient’s awareness of their problems. At this stage, nurses can also help by providing a training manual, individual counseling, and explanations about the importance of maintaining the care-therapeutic relationship. In the second stage, the sensitization stage, the nurse works to engage the patient and their family in implementing the care program. This can be achieved through group discussions, individual counseling, lectures, and question-and-answer sessions. In the third stage, the control stage, the nurse focuses on providing continued care. The evaluation stage is the final stage, in which the nurse maintains the care process, determines any difficulties, and identifies patient requirements. The effectiveness of the therapies, in meeting the needs of patients and resolving their difficulties, will also be evaluated at this stage [23].

Various studies have adopted the CCM as a framework to assess nursing interventions to improve QOL and reduce psychological burden, such as depression, among people with chronic illnesses including CKD patients [21, 22, 24]. Since this study aimed to evaluate the educational intervention program, the CCM is appropriate to guide this study, which requires the application of four stages related to the model. The conceptual framework of this study was adopted from the CCM, as indicated in Fig. 1.

Fig. 1

Conceptual framework of the current study adopted from the continuous care model (Ahmadi, 2001). Abbreviations: QOL, quality of life

Materials and methods

Study design

A quasi-experimental study design having one-group pretest-posttest was used. The pretest is the control group. Subjects were given a questionnaire and an intervention program of breathing exercises to complete.

Participants and setting

A convenience sample was used to select the participants. The study was conducted on adult patients (≥ 18 years) at hemodialysis departments and dialysis centers in the Qassim region, Kingdom of Saudi Arabia. Data were collected between March and April 2022 from three dialysis centers. The inclusion criteria for this study are that patients had been receiving hemodialysis therapy for at least 3 months and had stable mental and hemodynamic functions. Stable mental function refers to the capability to control thoughts, attitudes, and behaviors. The potential participants were identified with the assistance of the head nurses. Exclusion criteria include patients with severe cognitive or physical disabilities that could inhibit their ability to perform the intervention.

The sample size was computed using G*Power software 3.1, with α = 0.05, power of 0.8, and large effect size of f = 0.40. A minimum sample size of 34 participants was determined. To reduce the influence of other factors such as the missing data and withdrawals, added 10–20% of participants are required [25].

Ethical considerations

Ethical approval was obtained from the Research Ethics Committee of the Faculty of Nursing at King Abdulaziz University (Ref No 2 M.76). In addition, approval was obtained from the Ethical Committee of the Scientific Research Department for Kidney Centers at Ministry of Health in Al- Qassim region (IRB approval No. H-04-Q001). The informed consent to participate was obtained from all of the participants in the study.

Instruments and measures

Questionnaire

The questionnaire consisted of three parts. The first part examined the sociodemographic characteristics and clinical profiles of the participants, including age, sex, marital status, educational level, employment status, number of comorbid conditions using the Davis Comorbidity Index, history of visiting psychiatric clinics, and years on hemodialysis therapy. This study selected Davies et al.‘s (2002) comorbidity index due to its simple constructs and scoring, which is beneficial for patients who will be required to complete additional questionnaires to reduce response burden [26].

The second part was the Kidney Disease Quality of Life – Short Version (KDQOL™-36), a standardized tool used to measure QOL among people with CKD. This measure consisted of 36 items divided into two components: the general component, including 12 QOL questions based on the SF-12 (short version of the SF-36), and a specific kidney disease component with 24 questions. At the same time, each item or question was classified into five subscales or domains. The general component group included the physical health composite and the mental health composite. The disease-specific component included three subscales encompassing the following: burden of kidney disease, symptoms and problems, and effects of kidney disease on daily life. The maximum score was 100, with a high score reflecting a better quality of life. This tool is available in Arabic and has been validated. The Cronbach’s alpha of the scale was 0.7 [27].

The third part, the Beck Depression Inventory II (BDI-II), is used to assess the severity of depression in hemodialysis patients. A self-report rating inventory of 21 items assessing depression-related severity and symptoms [28], BDI-II is based on a 4-point Likert scale, where 0 indicates the absence of a problem and 3 indicates a highly depressed level. The total BDI-II score ranges between 0 and 63. The cut-off score 11 or more indicates that hemodialysis patient has a depressive episode. The BDI-II is a well-validated instrument that has been used extensively in individuals with CKD [9, 29]. The validity and reliability of the Arabic version of the BDI-II has been demonstrated [30, 31]. Additionally, a prior study conducted among Saudi Arabian hemodialysis patients has utilized this tool, demonstrating its good internal consistency [4].

Intervention program — breathing training

The breathing training program consisted of three breathing exercises: alternating nostril breathing (also known as anulom-vilom), 4-7-8 breathing exercises, and diaphragmatic breathing [32].

Alternate nostril breathing is accomplished by breathing through one nostril while slightly closing the other, switching nostrils, and repeating the procedure [32]. The 4-7-8 breathing exercise is performed by letting the lips separate first with a whooshing motion and then thoroughly exhaling from the mouth [33]. Then, the lips are sealed to take a silent breath via the nose while mentally counting to four. The whole breath is then held for seven seconds, and the air is finally released through an exhalation of eight seconds. This process repeats for five minutes [33]. The last type of breathing exercise is diaphragmatic breathing, which is performed while sitting or lying down in a comfortable position and by placing hands over the torso. The lower hand is placed over the abdomen to recognize movement. The other hand is either still or move simultaneously with the lower. A breath is inhaled for approximately four seconds through the nose, feeling the abdomen expand. The breath is held for two seconds, then exhaled slowly and steadily through the mouth for approximately six seconds with the patient’s mouth open and relaxed. This is repeated for another five minutes [32,33,34].

Each breathing exercise takes five minutes and was to be performed three times a day for 30 days (a total of 90 sessions); Several strategies were applied to ensure that the participants were able to perform and demonstrate breathing exercises appropriately. These included oral sessions, videos of the demonstration, re-demonstration, and a follow-up approach for encouragement and reminders. All these strategies assisted in facilitating performance and commitment to the interventional program [35,36,37].

Data collection

After obtaining ethical approval, the researcher approached the head nurse or in-charge nurse at each dialysis center to identify participants that met the inclusion criteria of the study. The purpose of the study and program details were explained to potential participants verbally as well as in written form. Participants were also given the right to withdraw from the study at any time without affecting their management or treatment at the centers. If the participant agreed to participate, informed consent was provided.

Based on the CCM, the first stage was the orientation stage, in which all participants received a pre-test evaluation to obtain baseline data. They were asked to fill out three questionnaires (i.e., sociodemographic characteristics and clinical profiles, KDQOL™-36 and BDI-II), which were available in both electronic and hard copy formats. Participants were given the option to choose the most suitable method for completing the questionnaires. This method was used to encourage eligible participants to enroll in the study.

Subsequently, the sensitization stage was applied. All participants received the same intervention, which was the breathing exercise program. Video, in-person teaching, and demonstrations were used to explain the program to the participants. The program consisted of three types of breathing exercises. The video form was developed by the researchers’ team and reviewed by an expert panel that included nurses, physicians, and respiratory therapists. One physician implemented and demonstrated the video after the final version of the transcript was approved. Then, the researcher demonstrated breathing exercises for individual participants and asked them to repeat. This allowed researchers to assess understanding and performance of the breathing exercises. Participants were instructed to perform 5-minute breathing exercises 3 times daily for 30 days. The current study implemented a 4-week intervention, drawing from previous studies that showed the impact of a breathing intervention on depression over a similar duration [17, 38]. The best times to perform these exercises are before bedtime, after waking up from sleep, before eating, or two hours after eating. Participants were informed to stop the exercises immediately if they felt fatigued, short of breath, or stressed.

At this stage, we considered the patients’ opinions and solicited their feedback on the application of the breathing exercise and the clarity of the video instructions. This will assist in evaluating the intervention’s feasibility and pinpointing any possible obstacles that participants might raise. As a result, four patients reported that implementing a daily 15-minute breathing training program for 30 days can be challenging, but if the program’s duration is shortened, it could potentially motivate them to exercise more assiduously. Three participants decided to withdraw from the study because they reported that there were no benefits to performing the breathing training program during the first two weeks. Two other participants reported that they felt tiredness when performing the breathing training program during the dialysis days. All participants commented on the video instructions’ clarity, and they found the video material helpful when they applied each exercise at the same time with the trainer in the video.

Following the framework model, the control stage was then applied. The researcher (N.A.) informed the participants that a regular log sheet would be created and was to be kept with the researcher (i.e. N.A), who worked to keep track of the date and time they conducted the breathing exercises. Individual follow-ups via phone text and WhatsApp messages were performed every day as reminders for breathing exercises. Furthermore, the other researcher reviewed and followed up on the collection process’s progress on a weekly basis to ensure compliance. In this study, the compliance checklist, which involved three questions about performing breathing exercises with a yes/no response, showed that participants had a high level of compliance (98.7%) toward the implementation of each breathing exercise of the program.

Data anonymity and confidentiality in research were maintained throughout the study. In the participant information sheet, we informed the participants and obtained their consent to follow-ups for study purposes, which included their phone numbers. After the study concluded, we removed all participant numbers from WhatsApp messages and shredded any identifiable information from the logbook. As a result, the analysis used anonymous data without including personal identification information.

Finally, the evaluation stage according to the CCM was ensured. After completing 30 days of the breathing exercise program, the same participants were asked to fill out the study questionnaires again as a post-test to assess the effectiveness of the program. In addition, each participant was assigned a study symbol at the beginning of the study to match the pre-test and post-test information. This symbol contained three letters, which were made by taking the first letter of the patient’s name, followed by the first letter of the fathers’ names, and finally the first letter of their grandfather’s name. This symbol was used only for the purpose of matching data and was then discarded and shredded. This procedure ensured that the data were collected anonymously and without the inclusion of personal identification information.

Validity and reliability

The video of the breathing program was developed after reviewing relevant literature to ensure face and content validity [33]. Further, content validity was ensured by an expert panel. This panel included faculty from nursing faculty, registered nurses, physicians, and respiratory therapists to assess clarity, consequence, and relevance of information to achieve accuracy of the study aim. The experts recommended some linguistic modifications in the instructions of the breathing application in the video recording to make them clearer for patients with varying educational levels.

The following four items were evaluated in the assessment of the validity of the intervention program: (1) the objective of the video is stated clearly, (2) steps and instructions are stated clearly, (3) the video is easy to understand, and (4) the video is relevant to measuring the goal of the study. The eight experts were asked to provide a rating from 1 to 4 for each item, ranging from 1 = strongly agree, 2 = agree, 3 = disagree, and 4 = strongly disagree. The minimum content validity of a scale item (S-CVI) should be at least 0.8 to assure its content validity [39]. The S-CVI was calculated and found to be 0 0.88, indicating high content validity. Supplementary material 1 presents a video transcript.

Statistical analysis

Statistical analyses were conducted using IBM Package for the Social Sciences (SPSS) version 26. Descriptive statistics facilitated the presentation of the findings. Baseline patient characteristics were calculated as percentages and frequency for categorical data and means and standard deviations for continuous variables. A paired sample t-test was performed to determine the differences in the KDQOL and BDI-II scores before and after the breathing training program. The differences in the level and severity of depression before and after the breathing training program were conducted using the Wilcoxon signed-rank test as well as the McNemar test. Pearson’s correlation was also carried out to determine the correlation between KDQOL and BDI before and after the program. A normality test was performed using the Shapiro Wilk test. In all analyses, the level of significance was set at 0.05.

Results

A total of 41 participants completed the study out of 44 who were initially invited. The mean age of the patients was 52.1 ± 15.0., 63.4% male, and 73.2% married (Table 1). 39% were university graduates. 46% of the sample had been undergoing hemodialysis for 1 to 4 years, and 7.4% for up to 10 years. Comorbidities were reported by 51.2%, and 17.1% of participants had visited a psychiatric clinic 1–3 times.

Table 1 Socio-demographic characteristics (N = 41)

The effects of breathing-training exercises on QOL and depression were examined to assess the efficacy of the program. The overall KDQOL (mean difference = 6.09, 95% CI: 0.48–11.70, p = 0.03) and symptoms and problems domain (mean difference = 6.71, 95% CI: 0.01–13.40, p = 0.05) scores increased significantly (Table 2), but no significant differences were observed in the rest of the KDQOL domains after the program.

Table 2 Descriptive statistics for KDQOL before and after breathing training program

Table 3 shows the effect of the breathing training program on the depression level. Overall BDI score decreased significantly (mean difference = -3.9, 95% CI:0.35–7.45, p = 0.03), but the prevalence of depression did not change (p = 0.27). This indicates that depression decreased by at least four thresholds after the posttest.

Table 3 Descriptive statistics for BDI-II before and after breathing training program

Relationships between KDQOL and BDI before and after the program were determined using Pearson correlation coefficients. Table 4 reveals significant correlations before and after the program between the BDI score and the physical component score (r = -0.7, r = -0.6, respectively), mental component score (r = -0.4, r = -0.5, respectively), burden of kidney disease score (r = -0.4, r = -0.6, respectively), and total KDQOL score (r = -0.5, r = -0.6, respectively). In addition, a significant correlation was observed between BDI and symptoms and problems (r = -0.4) at the end of the program.

Table 4 Correlation between KDQOL and BDI-II before and after breathing training program

Discussion

This study used a robust theoretical framework and a bundle of multiple breathing exercises to examine the impact of a breathing-training program on QOL and depression in hemodialysis patients. Regular breathing exercises had positive impacts on overall QOL and depression, with the veracity of these findings supported by similarly positive results in previous studies [17, 40, 41].

People on hemodialysis who received any type of training, either physical, breathing, or cognitive, have significantly improved QOL and psychological status compared to those who did not receive any training or exercise [42]. In common with this study, other research has shown that non-pharmacological interventions, such as breathing techniques (e.g., deep breathing and diaphragmatic breathing), used by hemodialysis patients to manage depression symptoms, play an important role in reducing those symptoms and in improving hemodialysis patients’ psychological status [42, 43]. Recent studies which aimed to evaluate the effectiveness of different breathing-training programs on depression among hemodialysis patients discovered that the level of depression was reduced, and the participants’ psychological status improved [11, 12, 20, 42].

Whereas antidepressants work on the autonomic nervous system, improving mood and reducing depression, breathing exercises may indirectly decrease depression by managing other latent symptoms, such as fatigue or sleep issues. In this study, we found significant improvement in the symptoms and problems domain score. This could potentially validate the hypothesis that alleviating other hidden symptoms indirectly improves depression. A recent study showed that daily deep breathing exercises for one month improved fatigue levels in dialysis patients [44]. The clustered nature of hemodialysis symptoms may influence the success of interventions [45]. Just how breathing exercises exert their effectiveness in relieving depression symptoms is not fully understood, and we need further studies to determine the underlying mechanisms.

Patients undergoing hemodialysis suffer from multiple comorbidities that add to the complexity of their management and increase the risk of psychological issues, such as depression. Many pharmacological agents are either prohibited or used with caution in hemodialysis patients suffering other chronic conditions [11]. In addition, the pharmacotherapeutic effects of antidepressant agents have not established their efficacy in hemodialysis patients. Therefore, nursing management of patients on hemodialysis should use safe practices to minimize adverse effects. Regular breathing training programs could provide promising interventions for this population, in combination with physical training programs. Nurses could integrate breathing exercises into psychoeducational programs in dialysis units to encourage behavior change and improve patients’ self-management skills. Nevertheless, identifying those patients with clinical depression should take first place. Interestingly, most participants in this study did not visit a psychiatric clinic (82.9%) during their hemodialysis treatment. The nephrologist bases the referral for psychiatric consultation on the evaluation of high-risk patients for depression and those exhibiting signs of depression, such as sadness and sleep disturbance. However, our study identified that 73.2% of the participants had mild depression. This may indicate that more effort is needed from nurses and other healthcare professionals to screen for depression and make early intervention using validated tools.

A breathing training program that includes different types of deep-breathing exercises is considered the first step in learning relaxation skills. A breathing training program successfully helps solve issues related to anxiety, stress, fatigue, and sleep [40, 41, 46,47,48]. Many studies have found that breathing training programs successfully reduce some depression symptoms associated with lower quality of life [17, 40]. Studies have used different types of relaxation and breathing exercises and reported their benefits for hemodialysis patients [17, 43, 49]. In the current study, the three types of breathing exercises used: alternating nostril breathing exercise, 4-7-8 breathing exercise, and diaphragmatic breathing [32, 33]. The application of some of these exercises appears to be easier than others. One could argue that using the three types may be burdensome for patients. As part of this preliminary investigation, there was a need to assess the viability of the application of this bundle of exercises in a single program. Future longitudinal studies are needed to compare the efficacy of different types of breathing exercises.

Although the participant’s overall depression score showed statistically significant improvement in this study, it remained within the same “mild” category on the Beck Depression Inventory-II (BDI-II), and the change was not substantial enough to result in a shift to a lower severity category. The participant’s baseline score was near the upper end of the mild depression range, meaning that even after improvement, the score still fell within the mild category, albeit closer to the lower end. This improvement suggests that certain aspects of the participant’s depression, such as mood, physical symptoms, and cognitive distortions, have alleviated. However, this does not imply complete remission or a sufficient change to warrant a classification in a less severe category.

Gradual improvements are particularly common in studies involving interventions such as breathing exercises, which may not lead to immediate or dramatic changes in all symptoms. These interventions can provide relief from anxiety and sleep disturbances but may not always produce a significant enough reduction in depressive symptoms to shift the individual’s classification. Furthermore, even with overall improvements, persistent symptoms, such as low energy, difficulty concentrating, or mild sadness, may prevent a participant from progressing beyond the mild depression range. For example, continued reports of low mood or fatigue could prevent a notable decrease in the depression severity score, despite some symptomatic relief. This observation underscores the gradual nature of symptom improvement in certain therapeutic interventions and highlights that achieving a “mild” depression classification does not necessarily require rapid or substantial changes across all symptoms. Additionally, it serves as a reminder that treatment effectiveness can vary based on the individual’s symptom profile, personal characteristics, and the specific nature of the intervention employed.

Despite a small sample size, this quasi-experimental study found a significant difference between the QOL of patients before and after the intervention program. The study demonstrated the positive impacts of breathing training programs on overall QOL and the symptoms and problems domain of QOL. Although other domains of QOL were not statistically different, each domain showed some improvements after implementing the breathing training intervention. However, there was a slight positive change in the burden of kidney disease score. This finding is in line with Serin et al., 2020, who evaluated the effects of breathing exercises, and found that after three months of intervention, all domains of QOL had significant improvements, except the burden of kidney disease [50]. It was recommended to include various types of exercises in the dialysis care program [13, 40, 46, 50]. Indeed, three different types of breathing exercises were used in the current study; therefore, it seems that the domain of the burden of kidney disease score is subject to different influences.

Implications for clinical practice and research

The management of depression in patients undergoing hemodialysis remains challenging. This study demonstrates effectiveness of applying breathing training program on overall depression and quality of life. The integration of breathing training program intervention in dialysis units to manage psychological issues will offer a simple, safe, easy, and inexpensive intervention. With shortages of nursing staff in all units across the world, including kidney centers, this intervention is feasible because it offers validated video educational material. This makes it easier for nurses to help patients apply the program, follow it, and demonstrate the breathing exercises correctly. Overall, our sample was in the middle age group with few comorbidities, which may aid in the easier application of the intervention. The intervention’s effectiveness among older adults with higher comorbidities is something to investigate.

There is a need for future research to explore the influence of a breathing training program on other hidden symptoms such as fatigue and sleep disturbance and their mediation effects on depression. In addition, studies are needed to compare the effectiveness of various breathing exercises in hemodialysis patients using longitudinal studies. A recent study recommended using a cut-point of ≥ 16 for BDI-II [51]. The current study’s small sample size and inclusion of individuals with severe depression at this cut point would limit the analysis to examining the intervention’s effects. Thus, future studies could assess the effect of intervention on depression using different cut points and a larger sample.

Although prior studies informed the study timeframe, it is crucial to assess the intervention’s impact after longer application periods, like six and 12 months. We also recommend measuring the patients’ commitment to the intervention and its long-term applicability to determine the sustainability of this management for depression in hemodialysis patients.

Strengths and limitations

This study used an appropriate design with a precise theoretical framework for methodological guidance. Several strategies were used when implementing the intervention, which added strength to the study. Moreover, this study adds to the global body of knowledge regarding the effectiveness of breathing exercises among patients on hemodialysis and, more specifically, to those in the Kingdom of Saudi Arabia, as it is considered the first study there.

Nevertheless, this study had some limitations that should be acknowledged. The sample size of this quasi-experimental study was small, which makes drawing strong conclusions difficult and minimizes the generalizability of the findings. Thus, further research with larger samples is necessary to validate these findings. The subjective data collected to evaluate the impact on outcomes may have led to some response bias. However, sufficient time and similar instructions were provided to the participants to reduce the possibility of latent bias.

A significant limitation of this study lies in the difficulty of verifying participants’ adherence to the prescribed intervention. Although various strategies, such as reminders, messages, and compliance checklists, were employed to encourage and monitor engagement, ensuring consistent adherence to 15 min of breathing exercises three times daily proved challenging. To enhance the reliability of future research, it is recommended that more robust adherence monitoring mechanisms, such as activity trackers, self-reported logs, or supervised sessions, be implemented to ensure both compliance and fidelity to the intervention protocol.

Another limitation of this study is the potential impact of increased social interactions on the outcomes, particularly during the continuation phase of the intervention. Interactions with nurses and the educational support provided as part of the intervention may have contributed to improved scores, as dialysis patients often experience feelings of isolation. The additional social engagement could act as a confounding factor, influencing outcomes independently of the intervention itself. To address this, future research should consider incorporating a control group that receives only increased messaging or education, without the primary intervention, to distinguish the effects of social interaction from those of the intervention. This would allow for a clearer understanding of the specific contributions of each component to the overall outcomes.

Conclusion

The breathing training program is a non-pharmacological intervention that has demonstrated its feasibility and effectiveness among patients in hemodialysis. There was an association between a reduction in depression levels and higher QOL scores with the implementation of the program. Nurses and other health professionals may benefit from integrating this safe intervention into daily clinical practice in dialysis units and tracing changes in patients’ health status. Future research need to compare the effectiveness of various breathing exercises in hemodialysis patients using longitudinal studies.