Hemodiyaliz Ünitesinde Takip Edilen Diyaliz Hastalarında Uyku Kalitesi, Depresyon ve Tükenmişlik Arasındaki İlişkinin İncelenmesi

İsmail Keleş; Erkan Durar; Mustafa Durmuş; Kamil Ateş

doi:10.52976/vansaglik.1315497

Araştırma Makalesi

Hemodiyaliz Ünitesinde Takip Edilen Diyaliz Hastalarında Uyku Kalitesi, Depresyon ve Tükenmişlik Arasındaki İlişkinin İncelenmesi

Yıl 2024, Cilt: 17 Sayı: 1, 6 - 14, 30.04.2024

İsmail Keleş Erkan Durar Mustafa Durmuş Kamil Ateş

https://doi.org/10.52976/vansaglik.1315497

Öz

Amaç: Bu çalışma hemodiyaliz ünitesinde takip edilen diyaliz hastalarında uyku kalitesi, depresyon ve tükenmişlik arasındaki ilişkinin incelenmesi amacıyla yapılmıştır.
Materyal ve Metod: Çalışma Türkiye’nin Doğu Anadolu bölgesinde bulunan bir araştırma hastanesinin Hemodiyaliz Ünitesinde takip edilen diyaliz hastalarıyla yürütülmüştür. Çalışma da Genel bilgi formu, Pitsburg uyku kalitesi ölçeği, Beck depresyon ölçeği ve Tükenmişlik ölçeği kısa versiyonu kullanılmıştır. Verilerin yorumlanmasında sıklık ve yüzdelik hesaplama, bağımsız gruplarda t testi ve tek yönlü anova testi kullanılmıştır. Anlamlı fark olan gruplarda farkın kaynağını belirlemek için ise Post-Hoc testleri kullanılmıştır. Ayrıca ölçek puanları arasında ilişki olup olmadığını saptamak için kolerasyon testi yapılmıştır.
Bulgular: Hemodiyaliz alan hastaların pitsburg uyku kalitesi ölçeğinden 14.291±3.09 puan, beck depresyon ölçeğinden 18.86±9.85 puan ve tükenmişlik ölçeğinden 38.48±15.67 puan aldıkları tespit edilmiştir. Hemodiyaliz hastalarının uyku kalitesi ile depresyon düzeyleri arasında pozitif yönde anlamlı bir ilişki olduğu belirlenirken (r=.227, p<0.05), uyku kalitesi ile tükenmişlik toplam puan ortalamaları arasında istatistiksel olarak pozitif yönde anlamlı bir ilişki olduğu belirlendi (r=.666, p<0.05). Ayrıca hastaların depresyon ile tükenmişlik düzeyleri arasında istatistiksel olarak pozitif yönde anlamlı bir ilişki olduğu tespit edilmiştir (r=.195, p<0.05).
Sonuç: Araştırmaya katılan hastaların kötü uyku kalitesine sahip olduğu, toplam puan ortalamalarının da orta seviyede olduğu, uyku kalitesi düştükçe depresyon ve tükenmişlik düzeylerinin arttığı tespit edildi.

Anahtar Kelimeler

Depresyon, Diyaliz, Kronik Böbrek Yetmezliği, Tükenmişlik

Destekleyen Kurum

yok

Proje Numarası

yok

Teşekkür

Dursun Odabaş Tıp Merkezi Hemodiyaliz ünitesi çalışanlarına ve araştırmaya katılan hastalarına teşekkür ederiz.

Kaynakça

Abassi MR, Safavi A, Haghverdi M, Saedi B. (2016). Sleep disorders in ESRD patients undergoing hemodialysis. Acta Medica Iranica, 176-184.
Ağargün MY, Kara H, Anlar O. (1996). Pittsburgh uyku kalitesi indeksinin geçerliği ve güvenirliği. Türk Psikiyatri Dergisi, 7(2),107-115.
Akbal A, Kızıltan G. (2019). Kronik böbrek yetmezliği olan hastalarda serum d vitamini düzeyi ile depresyon ilişkisi. Başkent Üniversitesi Sağlık Bilimleri Fakültesi Dergisi-BÜSBİD, 4(3).
Akın A. (2015). Psikolojide kullanılan güncel ölçme araçları. Baskı İstanbul, Nobel Kitabevi.
Al-Ali F, Elshirbeny M, Hamad A, Kaddourah A, Ghonimi A, Ibrahim R, Fouda T. (2021). Prevalence of depression and sleep disorders in patients on dialysis: a cross-sectional study in Qatar. International Journal of Nephrology, 2021.
Al-Jahdali HH, Khogeer HA, Al-Qadhi WA, Baharoon S, Tamim H, Al-Hejaili FF, et al. (2010). Insomnia in chronic renal patients on dialysis in Saudi Arabia. Journal of Circadian Rhythms, 8(1),1-7.
Araujo SM, de Bruin V, Daher EdF, Almeida GH, Medeiros CA, de Bruin PFC. (2012). Risk factors for depressive symptoms in a large population on chronic hemodialysis. International Urology and Nephrology, 44(4),1229-1235.
Ataş D, Arıkan H, Alışır S, Çiftçi H. (2017). Hemodiyaliz ve böbrek nakli hastalarında anksiyete, depresyon ve yaşam kalitesinin karşılaştırılması. Türk Nefroloji, Diyaliz ve Transplantasyon Dergisi, 26(2),171-176.
Avdal EU, Ayvaz İ, Uran BNÖ, Yildirim JG, Sofulu F, Pamuk G. (2020). Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study. Journal of Infection and Public Health, 13(12),1988-1992.
Bossola M, Luciani G, Tazza L. (2009). Fatigue and its correlates in chronic hemodialysis patients. Blood Purification, 28(3),245-252.
Büberci R, Karahisar Şirali S, Duranay M. (2023). The effect of vascular access type on sleep quality, anxiety, and depression in hemodialysis patients. Turkish Journal of Nephrology, 32(2),160-167.
Chang W, Han Y, Song X, Liu Y, Zhang W, Hao J, Chen J-B. (2020). Relationship between trajectory of sleep quality and short-term changes in residual renal function in stage 3–5 chronic kidney disease patients. Clinical and Experimental Nephrology, 24(6),557-564.
Cheng H-T, Ho M-C, Hung K-Y. (2018). Affective and cognitive rather than somatic symptoms of depression predict 3-year mortality in patients on chronic hemodialysis. Scientific Reports, 8(1),1-12.
Chilcot J, Davenport A, Wellsted D, Firth J, Farrington K. (2011). An association between depressive symptoms and survival in incident dialysis patients. Nephrology Dialysis Transplantation, 26(5),1628-1634.
Çelik HC, Tarık A. (2007). Kronik hemodiyaliz hastalarında depresyon ve anksiyete düzeylerinin çeşitli değişkenlere göre incelenmesi. Fırat Tıp Dergisi, 12(1),23-27.
Davey CH, Webel AR, Sehgal AR, Voss JG, Huml AM. (2019). Fatigue in individuals with end stage renal disease. Nephrology Nursing Journal, 46(5),497.
Dos Reis Santos I, Danaga AR, De Carvalho Aguiar I, Oliveira EF, Souza Dias I, Julioti Urbano J, et al. (2013). Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial. BMC Nephrology, 14(1),1-10.
Eloot S, Holvoet E, Dequidt C, Maertens S-J, Vanommeslaeghe F, Van Biesen W. (2021). The complexity of sleep disorders in dialysis patients. Clinical Kidney Journal, 14(9),2029-2036.
Ertürk M, Beyaz EK. (2020). Evaluation of gastrointestinal symptoms, quality of life, and hoodlumism in remedially patients with chronic renal failure. Baden University, 5(3), 176-189.
Flythe JE, Hilliard T, Lumby E, Castillo G, Orazi J, Abdel-Rahman EM, et al. (2019). Fostering innovation in symptom management among hemodialysis patients: paths forward for insomnia, muscle cramps, and fatigue. Clinical Journal of the American Society of Nephrology, 14(1),150-160.
Fonseca NT, Urbano JJ, Nacif SR, Silva AS, Oliveira Peixoto RA, Urbano GJ, et al. (2016). A systematic review of sleep disorders in patients with chronic kidney disease undergoing hemodialysis. Journal of Physical Therapy Science, 28(7),2164-2170.
Gao B, Song X, Hao J, Han Y, Zhang M, Sun N, et al. (2020). Association between serum uric acid and depression in patients with chronic kidney disease not requiring kidney dialysis: cross-sectional and longitudinal analyses. Medical science monitor: International Medical Journal of Experimental and Clinical Research, 26, e925386-1.
Giannaki CD, Hadjigavriel M, Lazarou A, Michael A, Damianou L, Atmatzidis E, et al. (2017). Restless legs syndrome is contributing to fatigue and low quality of life levels in hemodialysis patients. World Journal of Nephrology, 6(5),236.
Gürbüz S, Şahin F. (2018). Research Methods in Social Sciences. Seçkin Yayıncılık.
Hedayati SS, Daniel DM, Cohen S, Comstock B, Cukor D, Diaz-Linhart Y, et al. (2016). Rationale and design of a trial of sertraline vs. cognitive behavioral therapy for end-stage renal disease patients with depression (ASCEND). Contemporary Clinical Trials, 47,1-11.
Hill NR, Fatoba ST, Oke JL, Hirst J A, O’Callaghan CA, Lasserson DS, et al. (2016). Global prevalence of chronic kidney disease–a systematic review and meta-analysis. PloS One, 11(7), e0158765.
Hisli N. (1989). A reliability and validity study of Beck Depression Inventory in a university student sample). Journal of Psychology, 7,3-13.
Hoang VL, Green T, Bonner A. (2021). Examining social support, psychological status and health‐related quality of life in people receiving haemodialysis. Journal of Renal Care, 48(2), 102-111.
Horigan AE, Barroso JV. (2016). A comparison of temporal patterns of fatigue in patients on hemodialysis. Nephrology Nursing Journal, 43(2),129.
Jhamb M, Argyropoulos C, Steel JL, Plantinga L, Wu AW, Fink NE, et al. (2009). Correlates and outcomes of fatigue among incident dialysis patients. Clinical Journal of the American Society of Nephrology, 4(11),1779-1786.
Ju A, Unruh ML, Davison SN, Dapueto J, Dew MA, Fluck R, et al. (2018). Patient-reported outcome measures for fatigue in patients on hemodialysis: a systematic review. American Journal of Kidney Diseases, 71(3),327-343.
Jurado-Gamez B, Martin-Malo A, Alvarez-Lara M, Munoz L, Cosano A, Aljama P. (2007). Sleep disorders are underdiagnosed in patients on maintenance hemodialysis. Nephron Clinical Practice, 105(1), c35-c42.
Kambampati S, Wasim S, Kukkar V, Awad VM, Malik BH. (2020). Restless leg syndrome in the setting of patients with end-stage renal disease on hemodialysis: a literature review. Cureus, 12(8), e9965.
Khan A, Khan AH, Adnan AS, Sulaiman SAS, Mushtaq S. (2019). Prevalence and predictors of depression among hemodialysis patients: a prospective follow-up study. BMC Public Health, 19(1),1-13.
Kim O, Yeom EY, Jeon HO. (2020). Relationships between depression, family function, physical symptoms, and illness uncertainty in female patients with chronic kidney disease. Nursing & Health Sciences, 22(3),548-556.
Liu H. (2006). Fatigue and associated factors in hemodialysis patients in Taiwan. Research in Nursing & Health, 29(1),40-50.
Makale Ö. (2015). Kronik renal yetmezlikli ve böbrek nakilli hastalarda uyku bozukluğunun araştırılması ve bunun yaşam kalitesi üzerine etkisi. Journal of Turkish Sleep Medicine, 1,15-19.
Maruyama Y, Nakayama M, Ueda A, Miyazaki M, Yokoo T. (2021). Comparisons of fatigue between dialysis modalities: A cross-sectional study. PloS One, 16(2), e0246890.
Maung S, Sara AE, Cohen D, Chapman C, Saggi S, Cukor D. (2017). Sleep disturbance and depressive affect in patients treated with haemodialysis. Journal of Renal Care, 43(1),60-66.
Mirghaed MT, Sepehrian R, Rakhshan A, Gorji H. (2019). Sleep quality in Iranian hemodialysis patients: A systematic review and meta-analysis. Iranian Journal of Nursing and Midwifery Research, 24(6),403.
Montilla CMP, Duschek S, del Paso GAR. (2016). Health-related quality of life in chronic kidney disease: Predictive relevance of mood and somatic symptoms. Nefrología (English Edition), 36(3),275-282.
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Investigation of The Relationship Between Sleep Quality, Depression and Burnout In Dialysis Patients Followed In Hemodialysis Unit

Yıl 2024, Cilt: 17 Sayı: 1, 6 - 14, 30.04.2024

İsmail Keleş Erkan Durar Mustafa Durmuş Kamil Ateş

https://doi.org/10.52976/vansaglik.1315497

Öz

Objective: This study was conducted to examine the relationship between sleep quality, depression and burnout in dialysis patients followed in the hemodialysis unit.
Material and Method: The study was conducted with dialysis patients followed in the Hemodialysis Unit of a research hospital in the Eastern Anatolia region of Turkey. General information form, Pitsburg sleep quality scale, Beck depression scale and short version of Burnout scale were used in the study. Frequency and percentage calculations were used to interpret the data. In addition, the correlation test was performed to determine whether there was a relationship between the scale scores.
Results: It was determined that patients receiving hemodialysis scored 14,291±3.09 points from the Pitsburg sleep quality scale, 18.86±9.85 points from the Beck depression scale, and 38.48±15.67 points from the burnout scale. While it was determined that there was a positive and significant relationship between the sleep quality of hemodialysis patients and their depression levels (r=.227, p<0.05), there was a statistically significant positive correlation between sleep quality and total burnout mean score(r=.192, p<0.05). In addition, it was determined that there was a statistically significant positive correlation between the depression and burnout levels of the patients(r=.666,p<0.001).
Conclusion: It was determined that the patients participating in the study had poor sleep quality, the average total score was moderate, and the levels of depression and burnout increased as the sleep quality decreased

Anahtar Kelimeler

Burnout, Chronic Kidney Failure, Depression, Dialysis, Sleep Quality

Proje Numarası

yok

Kaynakça

Abassi MR, Safavi A, Haghverdi M, Saedi B. (2016). Sleep disorders in ESRD patients undergoing hemodialysis. Acta Medica Iranica, 176-184.
Ağargün MY, Kara H, Anlar O. (1996). Pittsburgh uyku kalitesi indeksinin geçerliği ve güvenirliği. Türk Psikiyatri Dergisi, 7(2),107-115.
Akbal A, Kızıltan G. (2019). Kronik böbrek yetmezliği olan hastalarda serum d vitamini düzeyi ile depresyon ilişkisi. Başkent Üniversitesi Sağlık Bilimleri Fakültesi Dergisi-BÜSBİD, 4(3).
Akın A. (2015). Psikolojide kullanılan güncel ölçme araçları. Baskı İstanbul, Nobel Kitabevi.
Al-Ali F, Elshirbeny M, Hamad A, Kaddourah A, Ghonimi A, Ibrahim R, Fouda T. (2021). Prevalence of depression and sleep disorders in patients on dialysis: a cross-sectional study in Qatar. International Journal of Nephrology, 2021.
Al-Jahdali HH, Khogeer HA, Al-Qadhi WA, Baharoon S, Tamim H, Al-Hejaili FF, et al. (2010). Insomnia in chronic renal patients on dialysis in Saudi Arabia. Journal of Circadian Rhythms, 8(1),1-7.
Araujo SM, de Bruin V, Daher EdF, Almeida GH, Medeiros CA, de Bruin PFC. (2012). Risk factors for depressive symptoms in a large population on chronic hemodialysis. International Urology and Nephrology, 44(4),1229-1235.
Ataş D, Arıkan H, Alışır S, Çiftçi H. (2017). Hemodiyaliz ve böbrek nakli hastalarında anksiyete, depresyon ve yaşam kalitesinin karşılaştırılması. Türk Nefroloji, Diyaliz ve Transplantasyon Dergisi, 26(2),171-176.
Avdal EU, Ayvaz İ, Uran BNÖ, Yildirim JG, Sofulu F, Pamuk G. (2020). Opinions of hemodialysis and peritoneum patients regarding depression and psychological problems which they experience: A qualitative study. Journal of Infection and Public Health, 13(12),1988-1992.
Bossola M, Luciani G, Tazza L. (2009). Fatigue and its correlates in chronic hemodialysis patients. Blood Purification, 28(3),245-252.
Büberci R, Karahisar Şirali S, Duranay M. (2023). The effect of vascular access type on sleep quality, anxiety, and depression in hemodialysis patients. Turkish Journal of Nephrology, 32(2),160-167.
Chang W, Han Y, Song X, Liu Y, Zhang W, Hao J, Chen J-B. (2020). Relationship between trajectory of sleep quality and short-term changes in residual renal function in stage 3–5 chronic kidney disease patients. Clinical and Experimental Nephrology, 24(6),557-564.
Cheng H-T, Ho M-C, Hung K-Y. (2018). Affective and cognitive rather than somatic symptoms of depression predict 3-year mortality in patients on chronic hemodialysis. Scientific Reports, 8(1),1-12.
Chilcot J, Davenport A, Wellsted D, Firth J, Farrington K. (2011). An association between depressive symptoms and survival in incident dialysis patients. Nephrology Dialysis Transplantation, 26(5),1628-1634.
Çelik HC, Tarık A. (2007). Kronik hemodiyaliz hastalarında depresyon ve anksiyete düzeylerinin çeşitli değişkenlere göre incelenmesi. Fırat Tıp Dergisi, 12(1),23-27.
Davey CH, Webel AR, Sehgal AR, Voss JG, Huml AM. (2019). Fatigue in individuals with end stage renal disease. Nephrology Nursing Journal, 46(5),497.
Dos Reis Santos I, Danaga AR, De Carvalho Aguiar I, Oliveira EF, Souza Dias I, Julioti Urbano J, et al. (2013). Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial. BMC Nephrology, 14(1),1-10.
Eloot S, Holvoet E, Dequidt C, Maertens S-J, Vanommeslaeghe F, Van Biesen W. (2021). The complexity of sleep disorders in dialysis patients. Clinical Kidney Journal, 14(9),2029-2036.
Ertürk M, Beyaz EK. (2020). Evaluation of gastrointestinal symptoms, quality of life, and hoodlumism in remedially patients with chronic renal failure. Baden University, 5(3), 176-189.
Flythe JE, Hilliard T, Lumby E, Castillo G, Orazi J, Abdel-Rahman EM, et al. (2019). Fostering innovation in symptom management among hemodialysis patients: paths forward for insomnia, muscle cramps, and fatigue. Clinical Journal of the American Society of Nephrology, 14(1),150-160.
Fonseca NT, Urbano JJ, Nacif SR, Silva AS, Oliveira Peixoto RA, Urbano GJ, et al. (2016). A systematic review of sleep disorders in patients with chronic kidney disease undergoing hemodialysis. Journal of Physical Therapy Science, 28(7),2164-2170.
Gao B, Song X, Hao J, Han Y, Zhang M, Sun N, et al. (2020). Association between serum uric acid and depression in patients with chronic kidney disease not requiring kidney dialysis: cross-sectional and longitudinal analyses. Medical science monitor: International Medical Journal of Experimental and Clinical Research, 26, e925386-1.
Giannaki CD, Hadjigavriel M, Lazarou A, Michael A, Damianou L, Atmatzidis E, et al. (2017). Restless legs syndrome is contributing to fatigue and low quality of life levels in hemodialysis patients. World Journal of Nephrology, 6(5),236.
Gürbüz S, Şahin F. (2018). Research Methods in Social Sciences. Seçkin Yayıncılık.
Hedayati SS, Daniel DM, Cohen S, Comstock B, Cukor D, Diaz-Linhart Y, et al. (2016). Rationale and design of a trial of sertraline vs. cognitive behavioral therapy for end-stage renal disease patients with depression (ASCEND). Contemporary Clinical Trials, 47,1-11.
Hill NR, Fatoba ST, Oke JL, Hirst J A, O’Callaghan CA, Lasserson DS, et al. (2016). Global prevalence of chronic kidney disease–a systematic review and meta-analysis. PloS One, 11(7), e0158765.
Hisli N. (1989). A reliability and validity study of Beck Depression Inventory in a university student sample). Journal of Psychology, 7,3-13.
Hoang VL, Green T, Bonner A. (2021). Examining social support, psychological status and health‐related quality of life in people receiving haemodialysis. Journal of Renal Care, 48(2), 102-111.
Horigan AE, Barroso JV. (2016). A comparison of temporal patterns of fatigue in patients on hemodialysis. Nephrology Nursing Journal, 43(2),129.
Jhamb M, Argyropoulos C, Steel JL, Plantinga L, Wu AW, Fink NE, et al. (2009). Correlates and outcomes of fatigue among incident dialysis patients. Clinical Journal of the American Society of Nephrology, 4(11),1779-1786.
Ju A, Unruh ML, Davison SN, Dapueto J, Dew MA, Fluck R, et al. (2018). Patient-reported outcome measures for fatigue in patients on hemodialysis: a systematic review. American Journal of Kidney Diseases, 71(3),327-343.
Jurado-Gamez B, Martin-Malo A, Alvarez-Lara M, Munoz L, Cosano A, Aljama P. (2007). Sleep disorders are underdiagnosed in patients on maintenance hemodialysis. Nephron Clinical Practice, 105(1), c35-c42.
Kambampati S, Wasim S, Kukkar V, Awad VM, Malik BH. (2020). Restless leg syndrome in the setting of patients with end-stage renal disease on hemodialysis: a literature review. Cureus, 12(8), e9965.
Khan A, Khan AH, Adnan AS, Sulaiman SAS, Mushtaq S. (2019). Prevalence and predictors of depression among hemodialysis patients: a prospective follow-up study. BMC Public Health, 19(1),1-13.
Kim O, Yeom EY, Jeon HO. (2020). Relationships between depression, family function, physical symptoms, and illness uncertainty in female patients with chronic kidney disease. Nursing & Health Sciences, 22(3),548-556.
Liu H. (2006). Fatigue and associated factors in hemodialysis patients in Taiwan. Research in Nursing & Health, 29(1),40-50.
Makale Ö. (2015). Kronik renal yetmezlikli ve böbrek nakilli hastalarda uyku bozukluğunun araştırılması ve bunun yaşam kalitesi üzerine etkisi. Journal of Turkish Sleep Medicine, 1,15-19.
Maruyama Y, Nakayama M, Ueda A, Miyazaki M, Yokoo T. (2021). Comparisons of fatigue between dialysis modalities: A cross-sectional study. PloS One, 16(2), e0246890.
Maung S, Sara AE, Cohen D, Chapman C, Saggi S, Cukor D. (2017). Sleep disturbance and depressive affect in patients treated with haemodialysis. Journal of Renal Care, 43(1),60-66.
Mirghaed MT, Sepehrian R, Rakhshan A, Gorji H. (2019). Sleep quality in Iranian hemodialysis patients: A systematic review and meta-analysis. Iranian Journal of Nursing and Midwifery Research, 24(6),403.
Montilla CMP, Duschek S, del Paso GAR. (2016). Health-related quality of life in chronic kidney disease: Predictive relevance of mood and somatic symptoms. Nefrología (English Edition), 36(3),275-282.
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Toplam 60 adet kaynakça vardır.

Ayrıntılar

Birincil Dil	Türkçe
Konular	İç Hastalıkları, Psikiyatri
Bölüm	Orijinal Araştırma Makaleleri
Yazarlar	İsmail Keleş 0000-0002-6575-8029 Erkan Durar 0000-0003-1793-0522 Mustafa Durmuş 0000-0002-7559-4187 Kamil Ateş 0000-0002-3196-9741
Proje Numarası	yok
Yayımlanma Tarihi	30 Nisan 2024
Gönderilme Tarihi	16 Haziran 2023
Yayımlandığı Sayı	Yıl 2024 Cilt: 17 Sayı: 1

Kaynak Göster

APA	Keleş, İ., Durar, E., Durmuş, M., Ateş, K. (2024). Hemodiyaliz Ünitesinde Takip Edilen Diyaliz Hastalarında Uyku Kalitesi, Depresyon ve Tükenmişlik Arasındaki İlişkinin İncelenmesi. Van Sağlık Bilimleri Dergisi, 17(1), 6-14. https://doi.org/10.52976/vansaglik.1315497