Received: 1 December 2020 Revised: 22 June 2021 Accepted: 5 July 2021

DOI: 10.1111/ijn.12993

ORIGINAL RESEARCH PAPER

Examining the influence of health on employment and work

ability of Saudi haemodialysis patients: A mixed-methods study

Nahed Alquwez PhD, RN, Associate Professor1 |

Paula Ormandy BSc, MSc, PhD, Professor2

1
Nursing Department, College of Applied
Medical Sciences, Shaqra University, Al Abstract
Dawadmi, Saudi Arabia Aims: To explore the employment, work productivity, activity impairment, and sus-
2
School of Health and Society, University of
tainability of work of Saudi patients with chronic kidney disease (CKD) on
Salford, Salford, UK
haemodialysis (HD).
Correspondence
Background: Failure to address CKD-related challenges may cause HD patients to
Nahed Alquwez, Nursing Department, College
of Applied Medical Sciences, Shaqra lose their job, create a lack of compassion from co-workers and receive discrimina-
University, Al Dawadmi, Saudi Arabia.
tion hindering progress in their profession.
Email: [email protected]
Design: This is a cross-sectional explanatory sequential mixed-methods study.
Methods: A convenience sample of 130 CKD patients was surveyed in the quantita-
tive phase using the ‘Short-Form Health Survey’ and ‘Work Productivity and Activity
Impairment Questionnaire.’ For the qualitative phase, face-to-face, semi-structured
interviews took place with 16 CKD patients. Data were collected in 2017.
Results: The respondents reported poor physical and mental health. Both employed
and unemployed respondents reported moderate levels of work productivity. Better
physical health was related to an increased likelihood of being employed. Physical
health was negatively correlated with presenteeism, whereas mental health was neg-
atively associated with activity impairment. Five key themes emerged from the quali-
tative data: work retention, sustaining employment, suitability of work, losing the
work and unemployment.
Conclusions: Physical condition, personal distinctiveness, cultural and traditional
aspects, and employment policies and approaches affect the employment status of
CKD patients on HD.

KEYWORDS
chronic kidney disease, haemodialysis patients, health-related quality of life, occupational
health, work impairment, work productivity

Summary statement
What is already known about this topic?

• Long-term disease, such as chronic kidney disease (CKD), and haemodialysis

(HD) treatment harm the patients' work-related activity and conception of self.
• The physical and mental effects of having a chronic disease on work ability and
work sustainability are often overlooked as there is little comprehension of the sit-
uation and experiences of these patients in their workplace.

Int J Nurs Pract. 2021;e12993. wileyonlinelibrary.com/journal/ijn © 2021 John Wiley & Sons Australia, Ltd 1 of 10
https://doi.org/10.1111/ijn.12993
2 of 10 ALQUWEZ AND ORMANDY

• The evidence of sustained working experiences for CKD patients internationally is

limited, but how the disease impacts the employment and workability of HD
patients within the context and culture of Saudi Arabia has not been explored.
What this paper adds?

• Both employed and unemployed respondents reported moderate levels of work

productivity. For employed respondents, absenteeism was quite higher than
presenteeism; however, work productivity was reportedly high.
• Better physical health was related to an increased likelihood of being employed.
Physical health was negatively correlated with presenteeism, while mental health
was negatively associated with activity impairment.
• Five key themes emerged from the data: work to maintain a healthy life, sustaining
employment, suitability of workplace, fake employment, and unemployment.
The implications of this paper

• The study provides direction to policy makers in planning and implementing poli-
cies geared towards improving the working conditions, employability and ability to
work among HD patients.
• The study provides evidence on the factors affecting the sustainability of work
and retention of job among patient with CKD under HD treatment, such as
increasing motivation and inspiration and having an HD-friendly workplace must
be put into policy by the government to provide a conducive opportunity for these
patients to sustain their jobs.
• The study shed light on reforming or instituting guidelines and policies to regulate
better and implement policies geared towards increasing patients' employment
with CKD to avoid being abused by companies.

1 | I N T RO DU CT I O N HD patients had worse physical functioning, concentrating ability and

agility at work during the HD treatment than before dialysis and fol-
Chronic kidney disease (CKD) has become a worldwide health crisis lowing a kidney transplant (Van der Mei et al., 2011). Furthermore,
with its increasing prevalence. In 2017, 18 270 patients were several socio-demographic factors, such as age, sex, education and
recorded by the Ministry of Health (MOH) of Saudi Arabia to have the length of time the patient received HD treatment impact the
been receiving haemodialysis (HD) in MOH facilities around the employment and ability to work of patients suffering from CKD (Julian
country (Saudi Center for Organ Transplantation [SCOT], 2018). Mauro et al., 2012).
Numbers of Saudi patients undergoing HD treatment is increasing Unemployment among these patients is a severe consequence of
due to a rise in the number of patients with CKD in the country absenteeism and poor productivity (Shaw et al., 2013). The function-
(Cruz et al., 2017). CKD patients on HD face several challenges, such ing and well-being of these patients are commonly low, as shown by
as unstable mental and physical health, food and fluid restrictions, their poor HRQOL. Their poor HRQOL scores affect their physical,
and the presence of complicated to manage symptoms (Meremo psychological and environmental function and activities (Kamal
et al., 2017). Health-related quality of life (HRQOL) is also severed, et al., 2013). Although low HRQOL of CKD is widely reported, few
especially for those receiving HD for a more extended period studies have investigated the influence of HRQOL on employment
(Cruz et al., 2016). status and work sustainability. Research is needed to develop a
One significant problem is that 70% of all CKD patients on HD deeper understanding of the factors that may facilitate work suste-
treatment are within the working-age bracket, 18 to 65 years old nance among these patients. Moreover, barriers in retaining employ-
(SCOT, 2013). As a result, the ability to sustain work is negatively ment and work productivity, including health and work-related needs
affected (Murray et al., 2014). The percentages of employed CKD of employees suffering from CKD and those receiving HD treatment,
patients have decreased from 74% to 72%; 26% of CKD patients who must be investigated (Koolhaas et al., 2013). A previous study
were employed were on leave due to sickness at the start of dialysis. assessed the experiences of people with CKD in the workplace
ALQUWEZ AND ORMANDY 3 of 10

(Schipper et al., 2016), although predominantly, these do not involve T A B L E 1 Demographic characteristics of the participants in the
patients receiving HD (de Vries et al., 2012). The present study gener- qualitative part (n = 16)

ates new evidence of work sustainability for HD patients, considering Females (n = 8) Males (n = 8)
the unique cultural and societal background of Saudi Arabia, combin-
Variable n % n %
ing and testing a variety of different methods.
Age
26–35 years 2 25.0 3 37.5

2 | METHODS 36–50 years 5 62.5 3 37.5

51–65 years 1 12.5 2 25.0
2.1 | Aim Residence area
Urban 2 25.0 1 12.5
The study was designed to explore the employment, work productiv- Rural 6 75.0 7 87.5
ity, activity impairment and sustainability of work of Saudi patients Marital status
with CKD on HD treatment. Single 4 50.0 2 25.0
Married 4 50.0 6 75.0
Employment status
2.2 | Design
Employed 3 37.5 6 75.0
Unemployed 5 62.5 2 25.0
The study used a cross-sectional explanatory sequential mixed-
methods design (Quan-qual method) (Creswell, 2013). This study has
two phases: cross-sectional quantitative research to answer the
research questions and descriptive qualitative research to explain the
findings of the first phase. The quantitative part was analysed first. recommended scores be collapsed to two domains, namely, physical
Then, the researchers developed an interview guide to explain the health composite summary (PCS) and mental health composite sum-
findings of the first phase. mary (MCS). A greater score on PCS and MCS signified improved
physical health and mental health, respectively. The Arabic version of
SF-1 was a valid and reliable instrument (Al-Shehri et al., 2008).
2.3 | Participants and settings The Work Productivity and Activity Impairment Questionnaire
(WPAI v2) assessed the participants' productivity at work and regular
Across the two dialysis centres in Riyadh and Dawadmi, Saudi Arabia, activities (Reilly et al., 1996). The measure consists of six questions
130 CKD patients participated in phase one of 183 target respon- inquiring about the patient's employment, the number of hours missed
dents. Participants were recruited if they were aged 18 to 65 years, as a result of the disease and other reasons, the actual number of
Saudi nationals, diagnosed with CKD, currently undergoing HD, working hours, hours worked, the extent of how the disease affected
received HD treatment for a minimum of 6 months and were not work productivity, and the extent of how the disease affected daily
diagnosed with any mental health or cognitive problems. Then, using activities. The questions were formatted to focus on the experience
purposive sampling, 16 CKD patients (8 males/8 females) were inter- of the patient in the last seven days. The tool produces four scores,
viewed to explore the influence of different factors such as employ- including ‘absenteeism, presenteeism, work productivity loss, and
ment status, educational attainment and age. The inclusion criteria in activity impairment’. Scores are expressed in percentage, which could
Phase 1 of the study were also used in Phase 2. The demographic range from 0 to 100. Higher scores indicate greater work impairment.
characteristics of participants in the phase 2 of the study are summa- In this study, the Arabic version was used and found to be valid and
rized in Table 1. reliable among Saudi patients (Hussain et al., 2015).
Patients identified as fit for the study were approached by one of
the researchers in the renal unit waiting room before the start of HD
2.4 | Phase 1 treatment. The study was explained, written (Arabic) information was
provided, and patients were allowed to discuss and ask questions.
The first phase utilized the quantitative questionnaire to explore the
employment, work productivity, activity impairment and sustainability
of work of Saudi patients with CKD on HD treatment. 2.5 | Phase 2
The Short-Form Health Survey (SF-12v2) with 12 questions was
used to measure the self-assessed HRQOL of patients (Ware The second phase of the study was a qualitative method using face-
et al., 2002). The SF-12v2 evaluates eight domains of HRQOL: ‘physi- to-face, semi-structured interviews intended to deepen understanding
cal functioning, role-physical, bodily pain, general health, vitality, social of the experiences of HD patients who were employed and those
functioning, role-emotional, and mental health.’ The developer who were not employed identified as having poor, moderate, and
4 of 10 ALQUWEZ AND ORMANDY

good work productivity and activity impairments. This phase provided framework. Data in the Arabic language were used for the analysis to
a deeper understanding of the patient's context, family and social situ- ensure that words and phrases retained the authentic meaning (which
ations, and the facilitators and barriers of their work sustainability as is sometimes lost if translated immediately). A second independent
they managed their long-term condition (De Souza & Oliver researcher verified each theme and key terms, phrases, clusters and
Frank, 2011; Koolhaas et al., 2013). meta-clusters to minimize bias and increase the credibility and trust-
The interviews took place on a separate day and time based on worthiness of the findings. After that, translation and transliteration
the participants' preferences. They lasted for a maximum of 45 min methods were applied through forward–back-translation technique.
and were conducted in Arabic and often before a scheduled HD treat- In the final stage of the analyses, the research team transcribed, read
ment. The questions were built on the theoretical notions of the capa- and re-read to understand patients' perceptions and experiences.
bilities approach theory, grounded on the value that an individual has
to accomplish something (Sen, 2001). This theory looks into the differ-
ent possibilities and choices that a person could make (‘capabilities’), 2.8 | Data integration
not on what that person is doing (‘functioning’). Considering the vari-
ous factors that affect HD patients' ability to work and sustain their This study utilized the interactive level of interaction, wherein the
work, understanding their capabilities to accomplish the work given researchers integrate the qualitative and quantitative aspects in
their difficult situation is crucial to their work sustainability. Hence, reporting the study's findings (Creswell, 2013; Greene, 2007). The
the capabilities approach enables the assessment of work ability and researchers conceptually inter-twined the data from the quantitative
employment sustainability among HD patients. Anchoring on this and qualitative phases using triangulation, complementary and expan-
approach (see Data S1), the interview focused on the ability of partici- sion analytic process (Greene et al., 1989).
pants to work based on the different aspects of the WPAI. The bar- In triangulation, the data analysed on work productivity, activity
riers that participants experienced, which hindered their ability to impairments, and the physical and mental components scores were
work, and facilitators that assisted or enhanced their ability to get validated, challenged and explained in the qualitative phase. In the
back to their work or sustained their employment were explored. complementary analytic process, the data on Saudi culture's impact on
the respondents' employability were explored. The qualitative data
explain the findings that cannot be capture or identified by the quanti-
2.6 | Ethical consideration tative strands. Also, the qualitative strands were used to expand the
findings of the qualitative strands. New data were identified, such as
This study was part of the dissertation for a Doctor of Philosophy data on facilitators and barriers mentioned by HD patients that help
degree at the University of Salford. Ethical approval was obtained them sustain employment. The researcher used triangulation, comple-
from the University of Salford Health Research Ethics Committee and mentary and expansion analytic approaches to enhance or strengthen
the MOH of Saudi Arabia. Participants were provided with informa- the result of the study and developed new concepts or ideas in under-
tion regarding the study during the recruitment phase, and informed standing the work-life of CKD patients.
consent was collected before completing a survey or interview. Inter-
views were digitally recorded and took place in a quiet private room.
3 | RE SU LT S

2.7 | Data analysis 3.1 | Quantitative results

SPSS version 22.0 was used to analyse the quantitative data. Mean The demographic and HD-related characteristics of participants are
and standard deviations were calculated for the HRQOL and work reflected in Table 2. The highest proportion of patients recruited were
ability variables. Binary logistic regression was used to examine the between 51 and 65 years old (42.3%). The lowest proportion was
effects of the predictor variables (socio-demographic, treatment- between 18 and 25 years old (6.9%). The majority were males
related and HRQOL) on the employment status. Pearson product (50.8%), living in urban areas (79.2%), married (76.9%), finished high
moment correlation was performed to establish the association school or less (86.9%) and unemployed (74.6%). In terms of HD treat-
between HRQOL and work ability. p values below 0.05 were consid- ment, most participants received HD treatment for 5 years or more
ered significant. (57.7%) and had HD for four h per session (76.2%). Nearly half of
Qualitative data were manually coded and organized. The seven- them (44.6%) took 15–30 min to reach the HD centre.
step method for thematic analysis was used to guide the approach
(Chesler, 1987): underline key terms; restate key phrases in the mar-
gin of the text; reduce the phrases and create clusters; compare, 3.2 | HRQOL and work ability
reduce, and group generated clusters to form meta-clusters; general-
ize statements in all generated clusters, theory generation and prose The average score in the PCS and MCS was 37.66 (SD = 11.01) and
explanations; and integrate mini-theories into an explanatory 49.90 (SD = 10.74), respectively. The respondents recorded a mean
ALQUWEZ AND ORMANDY 5 of 10

TABLE 2 Demographic and employment-related variables score of 57.00 (SD = 34.59) on work impairment from a possible
(n = 130) score of 0 to 100. These findings indicate that the respondents expe-
Demographic n % rienced moderate levels of work impairment. For the respondents

Age who were employed, the mean scores on absenteeism, presenteeism,

and work productivity were 62.21 (SD = 27.70), 42.73 (SD = 32.91),
18–25 years 9 6.9
and 74.30 (SD = 26.18) from a possible overall score of 0 to
26–35 years 18 13.8
100, respectively (Table 3).
36–50 years 48 36.9
51–65 years 55 42.3
Gender
3.3 | Impact of respondents' health on their
Male 66 50.8
employment
Female 64 49.2
Residence area A logistic regression model was significant (χ 2[16] = 79.82, p < .001),
Urban 103 79.2 explaining approximately 67.7% (Nagelkerke R2) variance in employ-
Rural 27 20.8 ment and accurately categorized 87.7% of cases. The regression rev-
Marital status ealed a higher level of physical health, aged 26 to 50 years, being
Single 30 23.1 male, and living farther from the HD centre significantly predicted

Married 100 76.9 employment among HD patients. Specifically, an increased score in

the physical component was related to an increased likelihood of
Education
being employed. This indicates that HD patients with higher levels
High school or less 113 86.9
of physical health had higher chances to be employed than those with
Undergraduate level 17 13.1
lower physical health status. Patients 26 to 35 years old and 36 to
Start of haemodialysis treatment
50 years old were 12.67 times (95% confidence interval [CI] [1.84,
Less than a year 19 14.6
87.21]) and 13.33 times (95% CI [2.23, 79.77]) more likely to be
1 to 2 years 19 14.6
employed than patients who were 51 to 65 years old. Male patients
3 to 4 years 17 13.1 were 89.52 (95% CI [8.81, 909.09]) times more likely to be employed
5 years and more 75 57.7 than female patients. These findings mean that older patients (ages
Duration of haemodialysis 51 to 65 years) and female patients had lesser chances to be
Three hours 31 23.8 employed than younger (ages 26 to 50 years) and male HD patients,
Four hours 99 76.2 respectively. Patients that took less than 15 min to reach the HD cen-
Distance of haemodialysis centre from home tre were 0.04 times (95% CI [0.00, 0.41]) less likely to be employed

Less than 15 min 26 20.0 than patients who needed more than 30 min to reach the centre,
implying that the farther the patient's home from the HD centre the
15 to 30 min 58 44.6
more chances that the patient is employed (Table 4).
More than 30 min 46 35.4
Pearson product-moment correlation was performed to investi-
Employment status
gate the association between employed HD patients' health and work
Employed 33 25.4
ability (n = 33). Table 5 shows that the physical component of the
Unemployed 97 74.6
HRQOL and the variable presenteeism had a moderate negative

TABLE 3 Health-related quality of life and work ability

Variable Mean SD Range Unemployed mean (SD) Employed mean (SD) t p

Health-related quality of life (n = 130)
Physical component 37.66 11.01 9.88 61.58 35.47 (10.97) 44.09 (8.42) 4.68 <0.001***
Mental component 49.90 10.74 21.55 71.58 50.26 (10.91) 48.87 (10.30) 0.64 0.524
Activity impairment (n = 130) 57.00 34.59 0 100 61.65 (33.90) 43.33 (33.42) 2.68 0.008**
Absenteeism (n = 33) 62.21 27.70 0 100
Presenteeism (n = 33) 42.73 32.91 0 100
Work productivity loss (n = 33) 74.30 26.18 0 100

**Significant at 0.01 level.

***Significant at 0.001 level.
6 of 10 ALQUWEZ AND ORMANDY

TABLE 4 Results of logistic regression of the respondents' employment (n = 130)

95% CI

Independent variables B SE Wald df p OR Lower Upper

Physical component 0.10 0.05 3.97 1 0.046* 1.10 1.00 1.22
Mental component 0.00 0.04 0.01 1 0.909 1.00 0.93 1.08
Activity impairment 0.00 0.01 0.02 1 0.876 1.00 0.98 1.03
Age
18–25 0.98 1.45 0.46 1 0.497 2.67 0.16 45.89
26–35 2.54 0.98 6.66 1 0.010* 12.67 1.84 87.21
36–50 2.59 0.91 8.04 1 0.005** 13.33 2.23 79.77
Gender 4.49 1.18 14.44 1 <0.001*** 89.52 8.81 909.09
Residence area 1.13 0.99 1.31 1 0.253 0.32 0.05 2.25
Marital status 1.13 0.96 1.40 1 0.237 3.11 0.47 20.43
Education 1.66 0.95 3.06 1 0.080 0.19 0.03 1.22
Start of haemodialysis treatment
Less than a year 0.01 1.03 0.00 1 0.996 0.99 0.13 7.56
1 to 2 years 0.44 0.96 0.21 1 0.650 1.55 0.23 10.21
3 to 4 years 1.56 0.94 2.76 1 0.097 4.74 0.75 29.76
Duration of haemodialysis 0.13 0.91 0.02 1 0.885 0.88 0.15 5.19
Distance of haemodialysis centre from home
Less than 15 min 3.22 1.19 7.32 1 0.007** 0.04 0.00 0.41
15 to 30 min 0.59 0.78 0.57 1 0.451 0.56 0.12 2.55

Abbreviations: CI, confidence interval; OR, odds ratio.

*Significant at 0.05 level.
**Significant at 0.01 level.
***Significant at 0.001 level.

T A B L E 5 Relationship between the respondents' health and work 3.5 | Work to maintain a healthy life
ability (n = 33)

Physical component Mental component Most CKD patients retained their employment because they were
Variable
motivated by other patients who were successful in their field. They
r p r p
drew inspiration from them to enjoy ordinary life and to become
Absenteeism 0.03 0.857 0.21 0.241
active in society. Being optimistic was their driving force to maintain a
Presenteeism 0.35 0.044* 0.33 0.060
productive and healthy life.
Work productivity 0.12 0.504 0.31 0.082
Activity impairment 0.34 0.056 0.49 0.004**
I saw CKD patients who were able to live a normal life
*Significant at 0.05 level. I mean their life did not end after they became CKD
**Significant at 0.01 level. patients as I imagined. Before, I thought that CKD will
end my life and will makes me a hopeless person but
after I saw some patients live normally, my life became
correlation (r = 0.35, p = 0.044). The mental component had a mod- more easily to live. (RH_F_1)
erate negative correlation with activity impairment (r = 0.49,
p = 0.004). The support and flexibility of the government payment scheme,
employer and workmates enabled them to maintain employment.
These findings are evident in the government sector, wherein the
3.4 | Qualitative results health benefits of HD patients include sick leaves during the period of
HD treatment with pay and 3 days off.
Five key themes emerged from the data: work to maintain a healthy
life, sustaining employment, suitability of workplace, fake employ- I am happy with this decision [paid day-off during HD
ment, and unemployment. treatment]; it helped me to keep my job. (DH_M_2)
ALQUWEZ AND ORMANDY 7 of 10

The hiring of HD patients in the Kingdom is within the framework unsupportive, I could have left my job and stayed
of legality and equality as mandated by the Islamic Shari'ah law. The home. (DH_M_2)
law states that prejudice and discrimination to work should be elimi-
nated. The disability law states that disabled persons, including those
on HD, have the right to be employed. To ensure, support and 3.8 | Fake employment
encourage the employment of disabled persons, some legislations
and measures were established. The ‘Tawafuq program’ supports and Health-related issues that affect CKD patients physically and their
empowers job seekers in private sectors, and ‘Mowaamah’ creates capability and ability to perform their job were primary factors why
frameworks of the work environment that has the best standards and some HD patients have fake employment. Fake employment is the
practice suitable for disabled persons (GOV.SA, 2020). Participants' scheme used by private institutions, wherein HD patients were hired
remarked: but not allowed to work. However, the participants perceived that this
practice affects their future employment because they cannot avail
I have many options… I can work in hospitals or health scholarships to further their studies to be qualified in a higher position.
services departments or in a primary health center
where I am working now. (RH_F_1) I worked under the Saudization scheme and they were
giving me 500 SAR for doing nothing, I didn't even
know where the location of the company is. Then my
3.6 | Sustaining employment social security benefits stopped as they considered me
employed and I didn't know that this will happen, oth-
Sustaining employment is the participant's perception of his/her erwise, I will not accept 500 SAR as I was receiving
workplace as safe and with good working conditions. Participants 1000 SAR from the social security department. Then I
perceived that their work promotes physical and psychological went to search for the company in the department of
well-being. In addition, their employer's acceptance of their health labor and I found that the company hired me for a sal-
condition makes them happy and healthy as they perform their job. ary of 3500 SAR (in the register), so I felt very disap-
pointed and then I realized that they were not helping
Regular absent from work makes me bored and will me they were benefiting from my status as a disabled
have negative impacts on my psychological condition person. (RH_M_34)
and will let me think negatively—if I stayed home or
without work, therefore, I love to go to work even
when I have HD session on the same day, simply 3.9 | Unemployment
because I do not want to be isolated. (RH_F_1)
This theme presents the factors that contributed to the unemploy-
[My manager and co-workers] are very supportive ment of HD patients. First was discrimination, wherein HD patients
especially after they knew about my health condition. were viewed as incapable of performing the required jobs. The second
(DH_M_2) was personal situations, such as the lack of education, which hinders
patients from having another job that required less physical work. The
third was Saudi culture, where women are not allowed to work and
3.7 | Suitability of workplace drive around the city. Last was environmental and societal issues such
as the lack of parking spaces, ramps in the building and toilets for
The suitability of a job is another critical factor that influences the patients with disabilities.
employment of HD patients. The participants expressed that their
workplace was HD patient-friendly due to the following key charac- The disease does not have an impact on my ability to
teristics: (1) reduced tasks, (2) they can avail a regular absence when work but it does influence the decision of the
needed and allowed to rest at work and (3) reduction of heavy physi- employers when I applied for a job. My application for
cal work that may damage the vascular access. a job in a private healthcare centre have been rejected
after they knew that I am a CKD patient and undergo-
They [colleagues and managers] treat me in a great ing HD. (RH_F_15)
way, and I feel that they become more supportive with
me, and I think this is because of my health condition.
(DH_F_13) 4 | DI SCU SSION

I did [request to be transferred for another depart- Sustaining employment is a serious issue for a CKD patient undergo-
ment], and they were very supportive… If they were ing HD treatment, but the positive psychosocial impact of continuing
8 of 10 ALQUWEZ AND ORMANDY

to work cannot be overlooked. The deteriorating physical status of Furthermore, government and social security benefits were
HD patients, often managing multi-morbidity, was considered by the identified as factors affecting respondents' employment. Similarly,
participants as the predictor of job loss, affecting their function and most HD patients in Spain receive financial support from social secu-
working capacity, and productivity. The study reinforces current evi- rity, which causes a decrease in the employment rate (Julian Mauro
dence suggesting that the improved physical dimension of patients et al., 2012). Having CKD and being on HD treatment are regarded
leads to employment (Al-Jumaih et al., 2011). Physical symptoms such as a disability, and these patients are receiving financial support from
as feelings of fatigue, decreased strength and energy are strong pre- the government and social security. These social security benefits are
dictors of retaining employment among HD patients who were among the reasons why some of the respondents, especially those
employed (Tsutsui et al., 2017). who are single and have fewer responsibilities, choose to stay
Of note, employer's and colleagues' support, understanding, flexi- jobless. On the other hand, respondents expected to provide for their
bility and knowledge about the health status of the HD patient were family had to sustain better employment means with higher salaries
the primary factors of employment sustainability. These elements of even if it meant termination of social security benefits. Hence, it is
employment sustainability are present in public sectors where HD deemed essential to evaluate the capability and capacity of patients
patients have a flexible work schedule and paid sick leave during their to sustain work and allocate funding for patients who are not capable
HD treatment. However, the considerable flexibility in the govern- of finding a suitable job or for patients whose medical conditions
ment sector has a negative effect, including misuse of paid sick leave limit their ability to work.
by HD patients. At a closer look, the misuse of paid sick leave by HD The quantitative findings had also uncovered some factors socio-
patients is due to the lack of guidelines or rules on how and when to demographic factors that influenced the HD patients' employment,
avail of this health benefit. This finding suggests proper policy and including age, gender and distance of HD centre from home. The find-
guidelines regarding paid sick leave of HD patients to avoid abuse of ings suggest that being younger, being male and living away from HD
this benefit. centres predicted employment among HD patients. These associa-
HD patients working in the private sector reported a lack of sup- tions of employment to gender and age had been supported in previ-
port, understanding and flexibility in their workplace, forcing them to ous studies (i.e., Gilmour et al., 2008; Koolhaas et al., 2013). Some of
resign from work or accept fake employment. HD patients resigned the factors that favour employment among men include environmen-
from their work due to the inability to provide quality work and their tal, social and cultural norms. These were supported by the qualitative
absenteeism due to their HD treatment. Some participants opted to findings that indicate Saudi women face employment and movement
accept fake employment to sustain their basic needs. Fake employ- restrictions due to the country's strict social and cultural norms. The
ment of HD patients is described as being paid regularly as an influence of age on the employment of HD patients could be associ-
employee but not required to work, which is favourable. Fake employ- ated with the working-age where individuals ages between 51 and
ment is rampant in private sectors due to the mandate of the govern- 65 years are already in the retirement phase. The impact of the dis-
ment to employ disabled individuals, including HD patients. This tance of the patient's home to the HD centre on their employment
mandate further states that the employment of one disabled person in may be related to the country's availability of transportation and envi-
the workplace is equivalent to four working visas for foreign workers. ronmental condition. However, this finding needs further exploration
However, this policy is often being abused. Companies recruit disabled to understand this relationship better.
individuals for fake employment to employ foreign workers because Another important finding of the study is the negative association
they can offer a low salary compared with Saudi nationals. between these patients' mental health and activity impairment.
Furthermore, the study's findings revealed the lack of social Mental health problems, such as depression, anxiety and stress, have
responsibility in some private sector companies as some HD shown negative impacts on the work-related variables of HD patients
patients employed in private companies mentioned that they are (AlShahrani et al., 2018). Employees' mental health problems affect
unhappy with the workplace and worried about possible retrench- their work productivity due to absenteeism and poor performance
ment. One HD patient narrated that he was forced to resign from (Goetzel et al., 2018).
work due to his health condition and requested a decrease in hours Meanwhile, mental health status, including the appropriate coping
during his HD treatment. Therefore, the absence of understanding, mechanism of some HD patients, helped them sustain employment
support, knowledge on disabled policy and employer's accountability and productivity. The most common coping mechanism used is accep-
towards society reduces employment sustainability among HD tance, wherein employed HD patients acknowledged their situation
patients. and lived as healthy individuals. Likewise, patients avoided self-pity to
Discrimination of HD patients when looking for a suitable job also become prolific in their jobs. Furthermore, the inspiration they
contributes to the reduced employment sustainability and unemploy- received from other successful CKD patients undergoing HD treat-
ment as HD patients mentioned that their health condition is one of ment motivated them to keep going.
the reasons for the rejection of their application despite being quali- Another factor for the employment sustainability of the respon-
fied. This finding is consistent with Murray, Dobbels, Lonsdale, and dents was the positive work environment and managerial support.
Harden (2014), who reported that employers prefer not to hire Some employers had changed the job descriptions of patients as nec-
patients with chronic diseases. essary and had moved them to other departments where they fit.
ALQUWEZ AND ORMANDY 9 of 10

Finally, family support was one of the factors for the work sus- implement the Saudization scheme to avoid being abused by
tainability of HD patients (Townsend, 2008). This was apparent to companies. Finally, private institutions should be encouraged to
women who relied on family members for transportation services. provide equal opportunities for employment for HD patients and pro-
This outcome then implies that solid family ties posit numerous opti- vide a working environment and condition conducive for these
mistic implications for the respondents' well-being and employment patients.
status.
CONFLIC T OF INT ER E ST
No conflict of interest.
4.1 | Study limitations
AUT HOR SHIP S TAT EME NT
Some limitations are acknowledged in this study, which should be N. A. and P. O. made substantial contributions to conception and
considered when interpreting and utilizing the findings. The study design. Acquisition of data and analysis and interpretation of data was
included fewer employed respondents than unemployed respondents performed by N. A. N. A. and P. O. were involved in drafting the man-
due to the unavailability of such a sample in the present findings. uscript. Revising the manuscript critically for important intellectual
Thus, the associations or differences between study variables content was performed by N. A. and P. O. N. A. and P. O gave final
(i.e., HRQOL, absenteeism, presenteeism, work productivity and work approval of the version to be published and agreed to be accountable
impairment) and the demographic characteristics of the employed HD for all aspects of the work in ensuring that questions related to the
patients were not examined. Future studies should include more HD accuracy or integrity of any part of the work are appropriately investi-
centres to ensure a larger sample size of employed HD patients and gated and resolved.
to ensure deeper explorations of these patients' study variables. Also,
the association between the efficacy of dialysis and the physical fit- DATA AVAILABILITY STAT EMEN T
ness of employed patients was not explored in this study; this could Data available on request from the authors.
be the focus of future studies on this topic.

OR CID

5 | C O N CL U S I O N Nahed Alquwez https://orcid.org/0000-0002-8954-9061

Physical condition, personal distinctiveness, cultural and traditional RE FE RE NCE S

aspects, and employment policies and approaches affect the employ- Al-Jumaih, A., Al-Onazi, K., Binsalih, S., Hejaili, F., & Al-Sayyari, A. (2011). A
study of quality of life and its determinants among hemodialysis
ment status of HD patients, especially for women. Mental health also
patients using the KDQOL-SF instrument in one center in Saudi
impacts the productivity of HD patients at work. Improving the Arabia. Arab Journal of Nephrology and Transplantation, 4(3), 125–130.
HRQOL, working conditions, employment policies, approaches and https://doi.org/10.4314/ajnt.v4i3.71024
government support may improve these patients' work ability and AlShahrani, M. A., Alayed, A. S. M., AlShehri, A. H., Solaiman, O.,
Awadalla, N. J., & Alhomrany, M. (2018). Depression and impaired
employability.
work productivity among hemodialysis patients in south region of
Saudi Arabia. Saudi Journal of Kidney Diseases and Transplantation, 29
(5), 1133–1138. https://doi.org/10.4103/1319-2442.243970
5.1 | Implications for practice Al-Shehri, A., Taha, A., Bahnassy, A., & Salah, M. (2008). Health-related
quality of life in type 2 diabetic patients. Annals of Saudi Medicine, 28
(5), 352–360. https://doi.org/10.5144/0256-4947.2008.352
The study extends the evidence base of employment issues for HD Chesler, M. (1987). Professionals' views of the'dangers' of self-help groups.
patients. Health professionals can use the findings to plan specific Ann Arbor: Center for Research on Social Organization Working Paper
interventions for the identified predictors of employment and work Series. University of Michigan.
Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed
ability of HD patients. Nursing care and interventions should aim at
methods approaches. Sage publications.
improving the physical functioning and mental health of these patients Cruz, J. P., Colet, P. C., Alquwez, N., Inocian, E. P., Al-Otaibi, R. S., &
as they were found to affect their employment and work impairment, Islam, S. M. S. (2017). Influence of religiosity and spiritual coping on
respectively. The findings may also provide direction to policy makers health-related quality of life in Saudi haemodialysis patients. Hemodial-
ysis International, 21(1), 125–132. https://doi.org/10.1111/hdi.12441
in planning and implementing policies geared towards improving the
Cruz, J. P., Colet, P. C., Qubeilat, H., Al-Otaibi, J., Coronel, E. I., &
working conditions, employability, and ability to work of HD patients.
Suminta, R. C. (2016). Religiosity and health-related quality of life: A
The factors affecting the sustainability of work and job retention were cross-sectional study on filipino christian hemodialysis patients. Jour-
identified in the present study. For example, increasing motivation nal of Religion and Health, 55(3), 895–908. https://doi.org/10.1007/
and inspiration and having an HD-friendly workplace must be put into s10943-015-0103-9
De Souza, L., & Oliver Frank, A. (2011). Patients' experiences of the impact
policy by the government to provide a conducive opportunity for HD
of chronic back pain on family life and work. Disability and Rehabilita-
patients to sustain their jobs. Furthermore, the findings shed light on tion, 33(4), 310–318. https://doi.org/10.3109/09638288.2010.
reforming or instituting guidelines and policies to better regulate and 490865
10 of 10 ALQUWEZ AND ORMANDY

de Vries, H. J., Reneman, M. F., Groothoff, J. W., Geertzen, J. H., & employment in young adults: A mixed methods study. Journal of Ado-
Brouwer, S. (2012). Factors promoting staying at work in people with lescent Health, 55(4), 505–512. https://doi.org/10.1016/j.jadohealth.
chronic nonspecific musculoskeletal pain: A systematic review. 2014.03.017
Disability and Rehabilitation, 34(6), 443–458. https://doi.org/10.3109/ Reilly, M. C., Tanner, A., & Meltzer, E. O. (1996). Work, classroom and
09638288.2011.607551 activity impairment instruments. Clinical Drug Investigation, 11(5),
Gilmour, J. A., Huntington, A., & Wilson, H. V. (2008). The impact of endo- 278–288. https://doi.org/10.2165/00044011-199611050-00004
metriosis on work and social participation. International Journal of Saudi Center for Organ Transplantation. (2018). Dialysis in the Kingdom of
Nursing Practice, 14(6), 443–448. https://doi.org/10.1111/j.1440- Saudi Arabia. Saudi Journal of Kidney Diseases and Transplantation, 29
172x.2008.00718.x (4), 1012–1020.
Goetzel, R. Z., Roemer, E. C., Holingue, C., Fallin, M. D., McCleary, K., Schipper, K., Van der Borg, W. E., de Jong-Camerik, J., & Abma, T. A.
Eaton, W., Agnew, J., Azocar, F., Ballard, D., Bartlett, J., Braga, M., (2016). Living with moderate to severe renal failure from the perspec-
Conway, H., Crighton, K. A., Frank, R., Jinnett, K., Keller-Greene, D., tive of patients. BMC Nephrology, 17(1), 48. https://doi.org/10.1186/
Rauch, S. M., Safeer, R., Saporito, D., … Mattingly, C. R. (2018). Mental s12882-016-0263-1
health in the workplace: A call to action proceedings from the mental Sen, A. (2001). Development as freedom. NY, USA: Anchor Books.
health in the workplace: Public health summit. Journal of Occupational SCOT. (2013). Saudi Center for Organ Transplantation (SCOT): Annual
and Environmental Medicine, 60(4), 322–330. https://doi.org/10.1097/ report. Retrieved from http://www.scot.org.sa/en/
JOM.0000000000001271 Shaw, W. S., Tveito, T. H., & Boot, C. R. (2013). Introduction to the special
GOV.SA. Rights of people with disabilities. (2020, May 3). GOV.SA. section: Sustainability of work with chronic health conditions. Journal
Retrieved from https://www.my.gov.sa/wps/portal/snp/aboutksa/ of Occupational Rehabilitation, 23(2), 157–161. https://doi.org/10.
RightsOfPeopleWithDisabilities/!ut/p/z0/04_Sj9CPykssy0xPLMnMz0 1007/s10926-013-9448-7
vMAfIjo8zivQN9DDycTAz9LZxCHQ0CA91MQyzMgo0NDEz1g1Pz9 Townsend, G. (2008). Supporting people with multiple sclerosis in employ-
AuyHRUB3hwS1Q!!/ ment: A United Kingdom survey of current practice and experience.
Greene, J. C. (2007). Mixed methods in social inquiry. San Francisco, CA: The British Journal of Occupational Therapy, 71(3), 103–111. https://
John Wiley & Sons. doi.org/10.1177/030802260807100306
Greene, J. C., Caracelli, V. J., & Graham, W. F. (1989). Toward a conceptual Tsutsui, H., Nomura, K., Ishiguro, A., Tsuruta, Y., Kato, S., Yasuda, Y.,
framework for mixed-method evaluation designs. Educational Evalua- Uchida, S., & Oshida, Y. (2017). Factors associated with employment in
tion and Policy Analysis, 11(3), 255–274. https://doi.org/10.3102/ patients undergoing hemodialysis: A mixed methods study. Renal
01623737011003255 Replacement Therapy, 3(1), 23. https://doi.org/10.1186/s41100-017-
Hussain, W., Janoudi, N., Noorwali, A., Omran, N., Baamer, M., 0105-z
Assiry, E. H., Alrayes, H., Alosaimi, H., Ibrahim, A., Gohary, S., Van der Mei, S. F., Kuiper, D., Groothoff, J. W., van den Heuvel, W. J., van
Minguet, J., & Almoallim, H. (2015). Effect of Adalimumab on work Son, W. J., & Brouwer, S. (2011). Long-term health and work
ability assessed in rheumatoid arthritis disease patients in Saudi Arabia outcomes of renal transplantation and patterns of work status
(AWARDS). The Open Rheumatology Journal, 9(1), 46–50. https://doi. during the end-stage renal disease trajectory. Journal of Occupational
org/10.2174/1874312901409010046 Rehabilitation, 21(3), 325–334. https://doi.org/10.1007/s10926-011-
Julian Mauro, J. C., Molinuevo Tobalina, J. A., & Sánchez González, J. C. 9317-1
(2012). Employment in the patient with chronic kidney disease related Ware, J., Kosinski, M., Turner-Bowker, D. M., & Gandek, B. (2002). User's
to renal replacement therapy. Nefrologia, 32(4), 439–445. manual for the SF-12v2 health survey. Lincoln, RI: QualityMetric
Kamal, N. N., Kamel, E. G., Eldessouki, K. H., & Ahmed, M. G. (2013). Incorporated.
Health-related quality of life among hemodialysis patients at El-Minia
University hospital, Egypt. Journal of Public Health, 21(2), 193–200.
Koolhaas, W., van der Klink, J. J., Vervoort, J. P., de Boer, M. R., SUPPORTING INF ORMATION
Brouwer, S., & Groothoff, J. W. (2013). In-depth study of the workers' Additional supporting information may be found online in the
perspectives to enhance sustainable working life: Comparison
Supporting Information section at the end of this article.
between workers with and without a chronic health condition. Journal
of Occupational Rehabilitation, 23(2), 170–179. https://doi.org/10.
1007/s10926-013-9449-6
Meremo, A. J., Ngilangwa, D. P., Mwashambwa, M. Y., Masalu, M. B., How to cite this article: Alquwez, N., & Ormandy, P. (2021).
Kapinga, J., Tagalile, R., & Sabi, I. (2017). Challenges and outcomes of Examining the influence of health on employment and work
haemodialysis among patients presenting with kidney diseases in ability of Saudi haemodialysis patients: A mixed-methods
Dodoma, Tanzania. BMC Nephrology, 18(1), 212. https://doi.org/10.
study. International Journal of Nursing Practice, e12993.
1186/s12882-017-0634-2
Murray, P. D., Dobbels, F., Lonsdale, D. C., & Harden, P. N. (2014). Impact https://doi.org/10.1111/ijn.12993
of end-stage kidney disease on academic achievement and