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Effects of interpersonal relationships and forgiveness on post-traumatic growth in hemodialysis patients: a cross-sectional study

BMC Nephrology volume 26, Article number: 212 (2025) Cite this article

Abstract

Background

Post-traumatic growth is regarded as a screening indicator for quality of life of hemodialysis patients. Interpersonal relationships and forgiveness of hemodialysis patients may play an important role in improving post-traumatic growth. Few studies reveal the relationship between interpersonal relationships, forgiveness, and post-traumatic growth. This study aimed to explore the relationships among interpersonal relationships, forgiveness, and post-traumatic growth in a sample of hemodialysis patients and analyzed the influencing factors associated with post-traumatic growth in hemodialysis patients.

Methods

In a cross-sectional study involving convenience sample from August to October 2022, 369 hemodialysis patients from nine hospitals completed the Interpersonal Relationship Comprehensive Diagnosis Scale, Heartland Forgiveness Scale, Post-traumatic Growth Inventory, and demographic characteristics and clinical information. Data were analyzed using SPSS and multiple linear regression analysis was used to identify the variables associated with the scores of post-traumatic growth.

Results

Interpersonal relationships showed a significant negative correlation with forgiveness (r = -0.251, p< 0.01) and a negative correlation with post-traumatic growth (r = -0.112, p = 0.02). A significant positive correlation was found between forgiveness and post-traumatic growth (r = 0.169, p< 0.01). In the regression analysis model, gender (β = 0.195, p< 0.01), marital status (β = 0.156, p< 0.01), number of complications (β =−0.194, p< 0.01), interpersonal relationships (β =−0.098, p= 0.03), and forgiveness (β = 0.127, p= 0.01) impacted post-traumatic growth significantly.

Conclusions

There were significant correlations among interpersonal relationships, forgiveness, and post-traumatic growth. Post-traumatic growth in hemodialysis patients was related to gender, marital status, number of complications, interpersonal relationships, and forgiveness. Number of complications, interpersonal relationships, and forgiveness should be monitored and positively managed to improve effects on post-traumatic growth in hemodialysis patients. Nurses should consider implementing interventions with an keynote on controlling complications, ameliorating interpersonal relationships, and increasing forgiveness to help hemodialysis patients improve their post-traumatic growth.

Clinical trial number

Not applicable.

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Introduction

Chronic kidney disease (CKD), which damages human health, is a public health problem worldwide that is classified into five stages. The prevalence of CKD has been reported to be 8.2% in Chinese adults and 13.4% worldwide [1, 2]. End-stage renal disease (ESRD) characterized by irreversible kidney function damage is the final stage of CKD, and its prevalence has shown an upward trend in recent years [3]. Maintenance hemodialysis (MHD) is the most commonly used therapeutic approach for nearly 90% of ESRD patients in China [4]. Until the end of 2021, over 751,000 Chinese people received hemodialysis [5].

The most commonly complications of hemodialysis patients include fatigue, pruritus, headache, nausea and vomiting, dry skin, swelling in legs, muscle cramps, and hypotension [6, 7]. Compared to other renal replacement therapies such as peritoneal dialysis and kidney transplantation, hemodialysis patients had a greater care burden and poorer quality of life [8,9,10]. ESRD and MHD could be considered a traumatic event which could easily have psychological distress, such as prompting stress, anxiety, depression, and post-traumatic stress disorder (PTSD) [11]. However, for some hemodialysis patients, the traumatic experience of ESRD and MHD could also lead to personal strength growth and self-perceived beneficial change in the form of post-traumatic growth [12]. Post-traumatic growth (PTG) is defined as the multidimensional positive psychological change that could result from struggling with challenging traumatic events [13]. Positive changes brought about by PTG that traumatic event survivors described include lower levels of anxiety and depression, greater sense of personal strength, higher psychological adaptation ability, better sleep quality, and improved quality of life [14, 15]. Therefore, it is necessary to pay attention to PTG acted as a useful screening indicator for quality of life of hemodialysis patients.

Several positive characteristics improve PTG. It is commonly associated with interpersonal relationships [16, 17]. Interpersonal relationships are the relationships established between two or more people during their contacts [18]. Interpersonal relationships involve shared knowledge, shared goals, shared values and beliefs, and mutual respect among members [19]. Good interpersonal relationships are profit for exchange of information, concepts and ideas to reduce the potential for conflict and misunderstanding and have many advantages including greater levels of trust, promotion of mutual understanding, more well-being, greater PTG, and lower rates of mortality [20,21,22]. For instance, the quality of family relationships could predict PTG in a sample of 126 parents of 67 children with type I diabetes or cancer three years after diagnosis [16]. Female survivors who had better interpersonal relationships with intimate partners reported higher PTG than females currently in violent intimate partner relationships [17]. In a study of cancer patients and their partners, patients’ PTG was positively correlated with partners’ PTG at 6 and 12 months after diagnosis, and PTG could be mutual and improved in close interpersonal relationships [22]. Poor interpersonal relationships are associated with a wide range of psychological and physical morbidities, including anxiety, depression, mood dysregulation, impulsivity, and reproductive problems [23, 24]. However, the relationship between interpersonal relationships and PTG is rarely seen in the study of hemodialysis patients.

Forgiveness is a positive characteristic and is defined as a transformation from negative motivators, like resentment, condemnation, and revenge after the misbehavior, to more positive motivators, such as compassion and benevolence [25]. Forgiveness, as both a trait and a state, has many advantages including improved anger, anxiety and depression; self-reported better mental health; perceived better physical function; and higher quality of life in some studies [26,27,28,29,30]. Based on the stress-and-coping theory of forgiveness, most studies on the relationship between forgiveness and PTG have shown a positive relationship [31–32]. For example, Hansen et al. found that the forgiveness therapy programme has effective in improved anger, hope, forgiveness, and quality of life for elderly terminally cancer patients [31]. Romero et al. reported that breast cancer patients who had more self-forgiveness reported less mood disturbance and better quality of life [32]. However, two studies have shown that forgiveness was not correlated with mental health in individuals [29] as well as PTG in survivors of state terrorism and their relatives [33]. These inconsistent results on the relationship between forgiveness and PTG are well worth clarifying in suggesting methods for effective intervention.

Hemodialysis patients were confronted with enormous pressure and risks during treatment, and PTG of hemodialysis patients is a hot topic which had increasing interest of nurses and nursing managers to identify levels of PTG and associated factors [34, 35]. Although some studies have focused on PTG of patients, there is rarely seen in the study on the PTG of hemodialysis patients in southwest China. Paying attention to the PTG of hemodialysis patients has important value and significance for understanding and protecting this groups.

This study explored the relationships among interpersonal relationships, forgiveness, and PTG in hemodialysis patients. In addition, its purpose was to provide basic data for the formation of intervention programs that could positively affect the PTG for hemodialysis patients. The aims of this study were as follows: ⑴ to identify differences in PTG according to demographic characteristics and clinical information; ⑵ to explore the relationships among interpersonal relationships, forgiveness, and PTG; ⑶ to identify factors influencing PTG in hemodialysis patients.

Methods

Research design

The study adopts a descriptive correlational design to identify the relationships among interpersonal relationships, forgiveness, and PTG in hemodialysis patients and to analyze factors influencing PTG.

Study population and sample size

This study involved a convenience sample of 369 hemodialysis patients from nine hospitals in the city of Yuxi in Yunnan Province in China from August to October 2022. 140 patients from the People’s Hospital of Yuxi City participated in this project, 30 patients from the People’s Hospital of Jiangchuan County participated in this project, 27 patients from the People’s Hospital of Tonghai County participated in this project, 32 patients from the People’s Hospital of Chengjiang County participated in this project, 29 patients from the People’s Hospital of Huaning County participated in this project, 35 patients from the People’s Hospital of Yimen County participated in this project, 27 patients from the People’s Hospital of Eshan County participated in this project, 25 patients from the People’s Hospital of Xinping County participated in this project, and 24 patients from the People’s Hospital of Yuanjiang County participated in this project. The inclusion criteria for the participants were as follows: ⑴ CKD5 stage status, ⑵ hemodialysis lasting over 3 months, ⑶ hemodialysis performed 2 ~ 3 times a week, ⑷age over 18 years, and ⑸ informed consent to participate in this study. The exclusion criteria for participants were: ⑴ the inability to read and write or communicate normally, and ⑵ having an infectious disease, including HIV, syphilis, or hepatitis B.

Sample sizes about 5 ~ 10 times the number of parameters should be obtained for multiple regression [36]. The number of parameters calculated for this study was 70; thus, the inclusion of 369 hemodialysis patients was in agreement with the above rules.

Measures

Demographic characteristics and clinical information

Demographic characteristics and clinical information included gender, age, education, religious beliefs, income status, marital status, primary kidney disease, and the number of complications. Marital status was divided into two categories, i.e., “married” and “others”. Primary kidney disease was grouped into “hypertension”, “primary glomerular disease”, “diabetes mellitus”, and “others”. The categories of the remaining indicators are shown in Table 1.

Interpersonal relationships

The Interpersonal Relationship Comprehensive Diagnosis Scale (IRCDS), which has good validity and reliability in the population of China, was developed by Zheng et al. (2005) to measure the interpersonal relationship levels of subjects [37]. The IRCDS is a 28-item self-report scale. Each item is rated using a 2-point scale, ranging from 0 (no conformity) to 1 (conformity). The IRCDS yields four subscales: interpersonal conversation, dealing with people, making friends, and interacting with the opposite sex. The IRCDS total scale scores are calculated by summing each item. The total score ranges from 0 to 28, with higher scores showing more negative interpersonal relationships problems. A score of 0–8 points means minimal interpersonal troubles; 9–14 points means some degree of interpersonal relationships problems; or 15–28 points means serious interpersonal relationships problems. In this study, the Cronbach’s alpha coefficient for this instrument was 0.881.

Forgiveness

To measure forgiveness, this study used the Heartland Forgiveness Scale (HFS), which was developed by Thompson et al. (2005) and translated into China by Zhang (2009) [38, 39]. The Chinese version of Heartland Forgiveness Scale [39], which has been verified in Chinese samples with good validity and reliability, was used in this study. The HFS is a 14-item self-report scale. Each item is rated using a 7-point Likert scale, ranging from 1 (complete nonconformity) to 7 (complete conformity). The HFS yields three subscales: forgiveness of others, forgiveness of self, and forgiveness of situations. The HFS total scale scores are calculated by summing each item. The total score ranges from 14 to 98, with higher scores showing higher forgiveness levels of subjects. Cronbach’s alpha coefficient of the HFS in the present sample was 0.872.

PTG

To measure post-traumatic growth, this study used the Post-traumatic Growth Inventory (PTGI), which was developed by Tedeschi et al. (1996) and translated into China by Wang (2011) [40, 41]. The Chinese version of Post-traumatic Growth Inventory [41], which has been examined in Chinese samples and has good validity and reliability, was used in this study. The PTGI is a 20-item self-report scale. Each item is rated using a 6-point Likert scale, ranging from 0 (complete nonconformity) to 5 (complete conformity). The PTGI yields five subscales: new possibilities, personal strength, spiritual change, appreciation of life, and relating to others. The PTGI total scale scores are calculated by summing each item. The total score ranges from 0 to 100, with higher scores showing more positive psychosocial changes following trauma. Cronbach’s alpha coefficient of the PTGI in the present sample was 0.885.

Data collection

After obtaining Committee of Medical Ethics approval, the hemodialysis patients were informed about the purpose and significance of this study. The privacy of patients would be protected, and the researchers encouraged them to be frank about their experiences of traumatic growth. An invitational quick response (QR) code of the software named Questionnaire Star to the survey was sent to participants in the hemodialysis centers of Yuxi city. Questionnaire Star is a professional software for online questionnaire surveys, data collection, and storage. When participants scanned the QR code, the tasks were displayed on their smartphone. Tasks included demographic characteristics, clinical information, and three questionnaires. The participants who agreed to take part provided agreement by clicking an “I agree to participate” button displayed before the start of the survey. In the nine hospitals in the city of Yuxi, as long as patients were willing to participate in this project, we would include them. The participants took 15 ~ 25 min to fill out the questionnaires.

Statistical analysis

The data for forgiveness, interpersonal relationships, and PTG showed normal distributions (tested throughout the computation of skewness and kurtosis with SPSS version 27.0). The mean PTG score in different categorical variables was examined by t tests or one-way ANOVA. Pearson correlation analysis was used to test the correlations of forgiveness, interpersonal relationships, and PTG. Using multiple linear regression analysis identified the influencing factors of PTG.

Results

Demographic characteristics and clinical information

The demographic characteristics and clinical information of the participants are shown in Table 1. The sample consisted of 369 patients, and the mean age of the respondents was 50.33 years (SD = 13.65; range 18–82); 63.96% of the respondents were male (n = 236), 60.70% were 45–82 years old, 70.46% did not have a high school diploma, 78.59% were married, 80.22% of the respondents’ income (per month) was less than 5000 Yuan, 89.97% had no religious affiliation, 30.90% had diabetes mellitus, and 57.18% had experienced 2 or more complications. There was a significant difference in the level of PTG by gender, marital status, and number of complications. The PTG score in the female group was significantly higher than that in the male group (p < 0.001). The score of PTG with a married status was significantly higher than that with other statuses (p < 0.001). Hemodialysis patients with 0 complication reported higher PTG scores than other groups (p < 0.001).

Table 1 Demographic characteristics and clinical information and distributions of PTG among haemodialysis patients (N = 369)
Full size table

Interpersonal relationships, forgiveness, and PTG

Interpersonal relationships, forgiveness, and PTG of the participants are shown in Table 2. The mean for interpersonal relationships was 10.24 (SD = 3.24). The mean forgiveness score was 63.47 (SD = 10.03), and the mean PTG score was 76.55 (SD = 12.57). According to the judgment criteria of Su (2020) [42], the mean scores of the PTG scales were moderate.

Table 2 Descriptive statistics for interpersonal relationships, forgiveness and PTG (N = 369)
Full size table

Correlations among forgiveness, interpersonal relationships, and PTG

Correlations of the three variables are implied in Table 3. The correlation analysis results showed that the three variables, forgiveness, interpersonal relationships, and PTG, were significantly related to each other, and the degree of correlation is all low (Table 3).

Table 3 Pearson’s bivariate correlations among interpersonal relationships, forgiveness, and PTG
Full size table

Factors influencing participants’ PTG

To identify the factors influencing PTG, a multiple linear regression analysis was carried out that included the independent variables of gender, marital status, number of complications, interpersonal relationships, and forgiveness. The results are implied in Table 4. The identification of multicollinearity of the independent variables was used to assess the basic assumptions of the regression. Tolerance was more than 0.1 (range 0.910–0.985), and VIF was found to be less than 10 (range 1.015–1.097). The correlations among the three independent variables were less than 0.50, indicating that there were no influence about multicollinearity among the independent variables.

The results showed that the linear regression model was significant (F = 11.065, P < 0.01) and the factors influencing PTG included gender (β = 0.195, p < 0.01), marital status (β = 0.156, p < 0.01), number of complications (β =−0.194, p < 0.01), interpersonal relationships (β =−0.098, p = 0.03), and forgiveness (β = 0.127, p = 0.01). Among these variables, interpersonal relationships and forgiveness were the most important factors. The multiple linear regression model in this study displayed an explanatory power of 12.0% for PTG.

Table 4 Multiple linear regression of factors influencing PTG (N = 369)
Full size table

Discussion

The results of this study showed that the three variables, forgiveness, interpersonal relationships, and PTG, were significantly related to each other. The factors influencing PTG included gender, marital status, number of complications, interpersonal relationships, and forgiveness. This findings open the window to new ways of improving PTG among hemodialysis patients by emphasizing the combined roles of interpersonal relationships and forgiveness.

Interpersonal relationships was found to be negatively associated with PTG and could significantly predicted the level of PTG in a sample of hemodialysis patients. This result is consistent with the results of earlier research. For instance, Canevello et al. (2016) found that interpersonal relationships could play an important role in promoting PTG [43]. Positive interpersonal relationship qualities include emotional support, satisfaction, approval, disclosure, and companionship, and negative interpersonal relationship qualities include exclusion, dominance, pressure, criticism and conflict [44,45,46]. Interpersonal relationships may provide a platform for hemodialysis patients to share and discuss their feeling, seek counsel and understand the essence and significance of the traumatic experience of ESRD and MHD, and ultimately facilitate the rebuilding of their lives positively. Good interpersonal relationships could increase hemodialysis patients’ tolerance of stress when dealing with their disease. A positive interpersonal relationship environment could provide not only a safe environment for hemodialysis patients but also the necessary resources such as companionship, disclosure, and emotional support for hemodialysis patients’ responses, encouraging hemodialysis patients to think positively about their disease and triggering hemodialysis patients integration of the new meaning of their disease.

Forgiveness was found to be significantly positively correlated with PTG and could significantly predict the level of PTG among hemodialysis patients. In other words, it was observed that as levels of forgiveness increase, levels of PTG also increase, and this finding is consistent with the literature [47, 48]. Hemodialysis patients experience self-perceived burdens, such as emotional, economic, and physical burdens [49, 50]. The most commonly psychological distress of hemodialysis patients include anxiety and depression [11]. Forgiveness has been closely tied to decreased sympathetic arousal, increased parasympathetic tone, improved physical health and longevity, and thus, is seen as an important psychological way to address strong negative emotions and restore hope [51,52,53]. Hemodialysis patients with forgiveness tendencies may be more easily able to self-regulate and set a goal to solve troubling problems. For instance, forgiveness could help hemodialysis patients overcome their negative emotions, such as anxiety, depression and anger [51]. In addition, they were more likely to inhibit behaviors reducing their quality of life and to give up intrapersonal and/or interpersonal strategies, such as physical violence, berating, and hitting [52]. Trait forgiveness is considered to be the main factor of motivation transformation, which is an effective way to inhibit negative instincts and enhance positive actions, such as rethinking the new meaning of their life [53, 54]. Therefore, forgiveness could facilitate dealing with negative emotions and bringing their fresh hopes for tomorrow during traumatic experience, and this process was good for PTG of hemodialysis patients.

Among the demographic characteristics and clinical information, marital status, gender, and number of complications significantly predicted PTG. Marital status was found to have a significantly positive effect on PTG, which is consistent with the findings of a previous study [54]. hemodialysis patients who were highly supported from spouses were likely to show better coping with the symptoms of post-traumatic stress disorder. In comparison, males had less PTG than females, which echoes the results of a previous study [55]. Women are more likely to use emotion-focused coping strategies, such as reflection, positive reassessment and positive self-talk, which involves reconsidering traumatic events and trying to make sense of them [56], thereby facilitating the enhancement of PTG. The number of complications was found to have a significantly negative effect on PTG, and the possible cause is that some symptoms that hemodialysis patients experience, such as depression, fatigue, itching, and restless legs syndrome, could give rise to a significant decline in physical and psychological function.

This study had several limitations. First, the study was cross-sectional and used a self-report questionnaire, which prevented the ability to make directional inferences about the relationships among forgiveness, interpersonal relationships, PTG, demographic characteristics, and clinical information. Second, the generalizability of findings is limited due to convenience sampling. Longitudinal research is important to replicate this study at different regional hospitals to confirm these results.

This study adds empirical evidence to the literature on PTG and it will be conducive to our understanding of the role of interpersonal relationships and forgiveness on post-traumatic growth in hemodialysis patients. The results of this study suggest that interpersonal relationships and forgiveness are a critical problem in hemodialysis patients. Interventions for improving PTG of hemodialysis patients should include elements for forgiveness and interpersonal relationships.

Conclusions

The three variables, forgiveness, interpersonal relationships, and PTG, were significantly related to each other. The factors influencing PTG included gender, marital status, number of complications, interpersonal relationships, and forgiveness. These findings can regard as the basis for evidence-based development of intervention strategies for ameliorating PTG among hemodialysis patients through the combined role of interpersonal relationships and forgiveness. In addition, nurses or medical staff interventions are needed so that hemodialysis patients do not face complications as a consequence of their disease treatment.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

PTG:

Post-traumatic growth

CKD:

Chronic kidney disease

ESRD:

End-stage renal disease

MHD:

Maintenance hemodialysis

PTSD:

Post-traumatic stress disorder

IRCDS:

Interpersonal Relationship Comprehensive Diagnosis Scale

HFS:

Heartland Forgiveness Scale

PTGI:

Post-traumatic Growth Inventory

QR:

Quick response

SPSS:

Statistical Package for Social Sciences

SD:

Standard deviation

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Acknowledgements

The authors are grateful to the 369 hemodialysis patients who took part in the study for assisting with data collection.

Funding

This study was supported by the Developing Yunnan Talent Support Program Project(XDYC-QNRC-2022-0631), Science and Technology Department of Yunnan Province-Kunming Medical University Applied Basic Research Joint Special General Project (202101AY070001-198) and Scientific Research Project of Chinese Nursing Association (ZHKYQ202102). The funding body has no role in design of the study and collection, sorting, analysis, and interpretation of data and in writing the manuscript.

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Author notes

  1. Yansheng Ye and Qin Xie contributed equally to this work.

Authors and Affiliations

  1. The Sixth Affiliated Hospital of Kunming Medical University, The People’s Hospital of Yuxi City, Yunnan, Yuxi, 653100, China

    Yansheng Ye, Yane Sun & Jianqing Xu

  2. School of Nursing, Chengdu University, Chengdu, Sichuan, 610106, China

    Qin Xie

  3. School of Nursing, Wenzhou Medical University, Wenzhou, Zhejiang, China

    Linan Cheng

  4. School of Public Health and Nursing, Hubei University of Science and Technology, Xianning, Hubei, China

    Linglin Kong

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Contributions

YY and Q X was involved in the design of this study, data collection, analysis and interpretation of data, and drafting and revising the manuscript. YS, JX, LC, and LK helped with the data collection, analysis and interpretation. All authors reviewed the manuscript.

Corresponding author

Correspondence to Yansheng Ye.

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Ethics approval and consent to participate

Ethical approval for this research in accordance with the Declaration of Helsinki was acquired from Sixth Affiliated Hospital of Kunming Medical University Medical Ethics Committee (Ethics number: 2021 kmykdx6f18). The nine hospitals ethics committee have given approval for the study. After providing a sufficient explanation of this study, we obtained written informed consent from all of the participants, and they willingly enrolled in this study. The participants were provided with the QR code and were ensured voluntary, anonymity, and confidentiality. The participants could freely withdraw from the survey and would not be disadvantaged for such a withdrawal.

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Not applicable.

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The authors declare no competing interests.

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Ye, Y., Xie, Q., Sun, Y. et al. Effects of interpersonal relationships and forgiveness on post-traumatic growth in hemodialysis patients: a cross-sectional study. BMC Nephrol 26, 212 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-04141-z

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BMC Nephrology

ISSN: 1471-2369

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