A total of 136 patients with CRF undergoing hemodialysis at Zibo Central Hospital from April 2021 to January 2022 were included in this study. The inclusion criteria are as follows: (1) aged $\ge$18 years; (2) diagnosed with CRF, which is defined as an estimated glomerular filtration rate (eGFR) 15 mL/min/1.73 m² [6]; (3) undergoing hemodialysis for at least 6 months, with at least three sessions per week, each lasting a minimum of 3 hours; (4) able to communicate clearly and read. Exclusion criteria are as follows: (1) transferring to another hospital during the study; (2) incomplete medical records; (3) with malignant tumors; (4) refusing to participate in the study; (5) developing acute complications during the study period. The flow chart of patient selection is shown in Fig. 1. After filtering through the pre-defined inclusion/exclusion criteria, eligible patients were selected and divided into either the control or observation group based on the type of nursing intervention received. Ethical approval for this study was obtained from the Ethics Committee of Zibo Central Hospital (Ethics No. 202104022).

Fig. 1.

Flowchart of patient selection and grouping. ESRD-AQ, End Stage Renal Disease-Adherence Questionnaire; GAD-7, Generalized Anxiety Disorder 7; WHOQOL-BREF, World Health Organization Quality of Life-BREF Scale.

The control group received routine nursing as follows:

(1) Pre-dialysis preparation: The nurses checked patients’ identity, evaluated dialysis equipment and vascular access before dialysis, and measured their blood pressure, heart rate, body temperature and other vital signs to ensure that they were healthy prior to dialysis initiation.

(2) Dialysis monitoring: The nurses continuously observed the patients’ blood pressure, electrocardiogram (ECG), dialysate parameters, and fluid balance during dialysis, and provided instant treatment for common complications such as hypotension, convulsions and spasms upon detection.

(3) Basic education and diet guidance: The nurses provided fundamental health education to patients during daily follow-up, including diet control (e.g., limiting potassium- and phosphate-rich foods), fluid intake control, standardized use of drugs, and the importance of maintaining dialysis compliance.

The control group received routine nursing throughout the study period, which was implemented during each dialysis session (3 times per week, 3–4 hours per session) and continued for 6 months.

Interdisciplinary collaborative nursing intervention refers to the establishment of a multidisciplinary team consisting of an attending physician, three nurses, a nutritionist, a clinical pharmacist, and a psychologist. The observation group received interdisciplinary collaborative nursing as follows:

(1) Comprehensive health education: An education manual—consisting of relevant content based on themes determined by the multidisciplinary team members through regular academic meetings—is created after strict revision. Each patient will receive a copy of the manual. The manual covers a broad spectrum of relevant health education-related content, such as dialysis compliance, timely medication use, diet and fluid control, and the interrelationship among dialysis-related symptoms, such as hyperkalemia and arrhythmia, to enhance patients’ understanding of the disease and strengthen their self-management ability. The nurses would explain and answer questions in stages during the interval of dialysis.

(2) Nutritional guidance: Nutritionists formulated a personalized diet plan tailored to each patient after assessing their nutritional status, taking into account the effects of dialysis on protein, potassium, phosphate, and electrolyte balance. They would also educate the patients on the recommended foods, cooking methods, and specific restrictions, and introduce adjustments to the plan throughout the follow-up.

(3) Drug intervention: Clinical pharmacists reviewed patients’ medication regimens, monitored for potential drug-drug interactions, and assessed the impact of dialysis on drug clearance. During their slots, they would introduce the key drugs commonly used by the patients, such as phosphate binders, antihypertensive agents, and erythropoietin, and demonstrate the proper usage to ensure patient safety and compliance.

(4) Psychological counseling: Through individual psychological counseling and group counseling regularly, psychologists offer feedback and words of advice to the patients to help them relieve anxiety and depression, so as to improve their adaptability to long-term dialysis treatment. When necessary, the psychologists will cooperate with other team members to make customized adjustments to patient’s nursing care and education plan.

The observation group received the interdisciplinary collaborative nursing intervention for 6 months. The comprehensive health education briefing was conducted weekly during dialysis session. Nutritional guidance, drug intervention and psychological intervention are carried out once a month, and these interventions can be adjusted according to the patient’s condition, when necessary.

Clinical and baseline information, including age, gender, education level, disease duration, body mass index (BMI), history of smoking, marital status, presence of chronic diseases (such as diabetes or hypertension), and family history of renal failure, was collected.

Originally introduced by Spitzer et al. [18] as a quick screening tool in clinical settings, the Generalized Anxiety Disorder 7 (GAD-7) scale was used to evaluate the anxiety degree of patients in the two groups [19]. The GAD-7 has been widely validated in general and clinical populations in various languages, showing good internal consistency and diagnostic performance (in terms of sensitivity and specificity) [18]. This 7-item scale uses a 0–3 scoring range per item, resulting in a total score spanning 0–21, where higher scores indicate increased anxiety. Anxiety severity was categorized as follows: 0–4 (slight or none), 5–9 (mild), 10–14 (moderate), and 15–21 (severe).

Questions 11, 12, 22, 23, 32, 33, 41, and 42 of the ESRD-AQ assess patients’ awareness of the disease. In the original questionnaire, no explicit scoring was provided for these eight questions. After translation, each of these questions was assigned with a scoring scale of 1–5 points. A higher total score obtained indicates that the patient has a better understanding of the disease.

Health-related quality of life (HRQoL) in both groups was assessed using the World Health Organization Quality of Life-BREF Scale (WHOQOL-BREF) [20], which contains a total of 26 items. WHOQOL-BREF was developed by the World Health Organization in 1998 and has been validated across many countries marked by distinct cultural features with good psychometric properties [21, 22]. Two items are independent analysis items for the measurement of the overall quality of life. The remaining content of the scale comprises four domains: physical (7 items), psychological (6 items), social (3 items), and environmental domains (8 items). Items are rated on a 1–5 point scale, with higher scores denoting better quality of life.

The data were processed and analyzed using SPSS 22.0 statistical software (IBM Corp., Armonk, NY, USA). Normality and homogeneity of variance of continuous data were evaluated. Normally distributed data are presented as mean $\pm$ standard deviation (SD), where non-normally distributed data are expressed as median and interquartile range [median (Q1, Q3)]. The Kolmogorov-Smirnov test was used to assess the normality of continuous variables. Normally distributed data underwent Levene’s test to assess their homogeneity of variance. When both assumptions were satisfied, independent samples t-tests were used for between-group comparisons, and paired samples t-tests were used for within-group comparisons. For normally distributed data with unequal variances, Welch’s t-test was utilized. Non-normally distributed data were compared using the Mann-Whitney U test. Categorical data, expressed as counts (n) and percentages (%), were analyzed using the Chi-square ($\chi$²) test and the corrected Chi-squared test. For all analyses, statistical significance was defined as p 0.05.

A total of 136 patients with CRF undergoing hemodialysis in Zibo Central Hospital from April 2021 to January 2022 were included in this study and divided into two groups according to the nursing mode applied. Among them, 65 patients in the control group received routine nursing care, and 71 patients in the observation group received interdisciplinary collaborative nursing care. No statistically significant intergroup differences were observed in sociodemographic variables (p $>$ 0.05; Table 1).

In this study, the ESRD-AQ scale was used as a tool to evaluate patients’ compliance. There was no significant difference in individual scores between the two groups before implementation of the nursing intervention (p $>$ 0.05). After nursing intervention was carried out, the observation group demonstrated significantly higher compliance scores across all individual items compared to the control group (p 0.05; Table 2).

Serum potassium, phosphate and IDW were measured before and 6 months after dialysis as clinical outcomes.

Before dialysis, the serum potassium levels and the number of patients meeting the serum potassium criteria were comparable between the two groups (p $>$ 0.05). After dialysis, the serum potassium level of the observation group was significantly lower than that of the control group, and a significantly higher proportion of subjects in the observation group satisfied the serum potassium qualification criteria compared to the control group (p 0.05; Table 3).

Before dialysis, there were no significant differences in serum phosphate levels and the number of patients meeting the serum phosphate standard between the two groups (p $>$ 0.05). After dialysis, the serum phosphate level of the observation group was significantly lower than that of the control group, and a significantly higher proportion of subjects in the observation group satisfied the serum phosphate qualification criteria compared to the control group (p 0.05). A significantly higher proportion of subjects in the observation group satisfied the IDW qualification criteria compared to the control group (p 0.001; Table 4).

Individual scores did not differ significantly between the two groups prior to the nursing intervention (p $>$ 0.05). After nursing intervention based on the interdisciplinary collaborative mode, anxiety levels were significantly reduced in the observation group relative to the control group (p 0.001; Table 5). Further analysis of anxiety severity categories revealed that the proportion of patients with severe anxiety decreased more substantially in the observation group compared to the control group, suggesting that the interdisciplinary collaborative mode not only lowers mean anxiety scores but also shifts the distribution toward milder anxiety levels. These findings indicate that the intervention has clinically meaningful benefits beyond statistical significance.

Both control and observation groups showed comparable levels in disease understanding prior to the implementation of nursing intervention (p $>$ 0.05). Post-intervention disease knowledge achieved significant improvements in both cohorts, with the observation group demonstrating superior gains over the controls (p 0.05; Table 6).

Before nursing interventions were implemented, the individual domain scores of the health-related quality of life were not significantly different between the control and observation groups (p $>$ 0.05). At 6-month follow-up, WHOQOL-BREF assessment revealed significantly higher scores across all domains (physical, psychological, social, environmental) in the observation group than in the control group (p 0.05; Table 7).