Introduction

Chronic kidney disease (CKD) is a lifelong disease with progressive renal function damage, and it causes incurable harm to the physical and mental health of patients. Studies have shown that the global prevalence of CKD is 14.3%, and the prevalence in China has increased from 10.8% in 2012 to 13.4% in 2017 (Zhang et al., 2012; Nephrologist Branch of Chinese Medical Association, 2021). The number of patients with CKD worldwide has reached 697.5 million, of whom 97.8% of patients are at stages 1 ~ 3. The number of patients in China is as high as 132.3 million, which is equal to the number of patients with diabetes, making China the country with the largest number of CKD patients (Bikbov et al., 2020). According to the guidelines made by the internationally recognized Kidney Disease Outcomes Quality Initiative (K/DOQI), CKD is divided into stages 1 ~ 5 (National Kidney Foundation, 2002). Patients with stages 1 ~ 3 have mild symptoms and only slight discomfort, such as fatigue, lumbar acid, and increased nocturia. However, if uncontrolled in time, renal function will continue to deteriorate, leading to heart failure, hyperkalemia, central nervous system disorder and so on, and may even be life-threatening (Evans et al., 2022). Among hospitalized patients with CKD, the mortality rate is as high as 2.56%, which is higher than that of general inpatients (0.84%) and diabetes inpatients (1.48%) (Zhang et al., 2020). In addition, according to a survey in the United States, medical costs increase with the progression of CKD, creating a large financial burden for patients, and some patients even give up treatment (Saran et al., 2018). At present, delaying the development of kidney disease mainly depends on drug therapy and lifestyle self-management (Zimbudzi et al., 2019). In recent years, due to the impact of coronavirus disease 2019 (COVID-19), patients sometimes could not receive timely treatment and drug supplementation (Akbarialiabad et al., 2020). Therefore, hel** patients improve their self-management ability at an early stage and actively participate in decision-making can reduce the financial burden for patients and their families and by a key factor in delaying the progression of the disease.

Self-management is designed to help patients acquire the skills and confidence to cope with illness, be active in their own healthcare, and maintain good physical and mental health (Peng et al., 2019). The management of CKD is the study and practice of achieving the optimal state of overall comprehensive development based on multidisciplinary research in physiology, psychology, and organizational behavior, which involves a series of attitudes, behaviors and skills (van der Gaag et al., 2022). Many scholars believe that patients with early CKD need more optimized self-management to improve disease development, but some people are still in the denial stage and considering expensive treatment costs, strict dietary requirements, tedious treatment procedures and incurable results, which leaves them prone to negative emotions, such as fear, anger and anxiety, and affects self-management behavior (Lin & Hwang, 2020). Negative emotions refer to emotions caused by internal or external factors that are not conducive to work, life or normal thinking. It reflects the general emotional dimension of individual subjective stress experience and unpleasant input, including a series of aversive emotional experiences, such as guilt, shame, nervousness, irritation and so on (Volpato et al., 2021). Miles et al. (2018) found that negative emotions had a negative effect on self-management among diabetic patients. ** method (1000 bootstrapped samples); second, the case-drop** bootstrap** method (1000 bootstrapped samples) was used to evaluate the stability of the BEI, and the correlation stability coefficient (CS coefficient) was calculated to quantify the stability of the BEI. A CS coefficient larger than 0.5 indicates ideal stability, and a CS coefficient larger than 0.25 indicates acceptable stability. Finally, the bootstrap** method (1000 bootstrapped samples) was used to test the difference of node BEIs and the difference of edge weights of different node pairs (α = 0.05).

Ethical considerations

The present study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Air Force Medical University (No.202206-02) and was conducted in accordance with the Declaration of Helsinki guidelines. After written informed consent was obtained, participants completed the questionnaires anonymously, and their personal information was not disclosed. They were told they could withdraw from the survey at any time.

Results

Descriptive statistics

The mean age of the final sample was 46.33 ± 16.54 years (mean ± SD, range 18~90 years). Among these participants, 220 were male, 140 were female, 208 were urban residents, and 152 were rural residents; 196 were at stage 1, 181 were at stage 2, and 183 were at stage 3. The total self-management score of these 360 patients was 86.41 ± 20.15. Among them, 41.71% of patients had a low level of self-management. Table 1 shows the sociodemographic characteristics of the participants. Table 2 shows the statistical results of the mean score, standard deviation and BEI of each node of negative emotion and self-management.

Table 1 Sociodemographic characteristics of the patients with early CKD (N = 360)
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Table 2 Mean score, standard deviation and BEI of each node of negative emotion and self-management among patients with early CKD (N = 360)
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Network structure

The network structure of different components of negative emotion and self-management in patients with early CKD is shown in Fig. 1a. There were 15 edges across negative emotion and self-management communities (edge weights ranging from − 0.09 to 0.05), of which 7 were negative and 8 were positive. In the cross-community edges, SI “Self-integration” was positively correlated with NE2 “scared” (r = 0.01) and negatively correlated with NE6 “irritated” (r = -0.01). Among the 6 correlations with PS “problem solving”, there was a negative correlation with NE6 “irritated” (r = -0.05) and the 5 positive correlations, among which the strongest correlation was with NE5 “nervous” (r = 0.05). Among the 4 correlations with SSS “seeking social support”, two were positive and two were negative, and the strongest correlations were NE4 “ashamed” (r = 0.03) and NE6 “irritated” (r = -0.05). The 3 correlations with ARR “adherence to recommended regimen” were all negative, and the strongest correlation was with NE6 “irritation” (r = -0.09).

Fig. 1
figure 1

Network structure of negative emotion and self-management among patients with early CKD and the BEIs in the network. note: (a) The network structure of negative emotion and self-management among patients with early CKD. The blue and red edges represent positive and negative partial correlations among nodes. The thick edge and saturated color represent a strong correlation. (b) The BEIs of the nodes in the network (raw score). SI = Self-integration, PS = Problem-solving, SSS = Seeking social support, ARR = Adherence to recommended regimen, NE1 = Afraid, NE2 = Scared, NE3 = Guilty, NE4 = Ashamed, NE5 = Nervous, NE6 = Irritated, NE7 = Upset, NE8 = Fractious, NE9 = Jittery

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The correlations within the negative emotion community were all positive, among which the strongest correlation was between NE1 “afraid” and NE2 “scared” (r = 0.35). The correlations within the self-management community were all positive, among which the strongest correlation was between SI “self-integration” and PS “problem-solving” (r = 0.57). The correlation matrix of the network is displayed in Table S1 of the Supplementary Material.

As shown in Fig. 2, the 95% confidence interval of edge weights in the network was relatively narrow, indicating that the evaluation of edge weights was accurate. The result of the difference test of edge weights is shown in Fig. S1 of the Supplementary Material. The edge weight between ARR “adherence to recommended regimen” and NE6 “irritated” was significantly different from the edge weights of most other node pairs (P < 0.05).

Fig. 2
figure 2

The accuracy test of edge weights in the network

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Bridge expected influence

The node BEIs in the network are shown in Fig. 1b. The results suggested that ARR “adherence to recommended regimen” and NE6 “irritated” had the highest absolute values of BEI of the negative emotion community and self-management community (BEI=-0.13, -0.19). In addition, the BEIs of ARR “adherence to recommended regimen” and NE6 “irritated” were significantly different from those of the most other nodes (P < 0.05, see Fig. S2 of Supplementary Material).

The stability test result of BEI is shown in Fig. 3. As the sampling proportion decreased, the average correlation with the original sample decreased gently. The CS coefficient of BEI was 0.44, indicating that the stability was acceptable.

Fig. 3
figure 3

The stability result of BEI

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Discussion

The present study is the first attempt to examine the component-level relationship between negative emotion and self-management behavior in patients with early CKD from the perspective of network analysis. Our findings may contribute to providing emotional targets for intervention to improve self-management behavior.

The relationships between different components of negative emotion and self-management behavior were different. From the network structure between the two communities, it was found that there were intense and close negative correlations between “irritated” in negative emotion and “self-integration”, “problem solving”, “seeking social support” and “adherence to recommended regimen” in self-management behavior. This finding is consistent with that of Travado et al. (2019), who found that negative emotion was negatively correlated with patients’ self-management behaviors overall. Patients with more severe negative emotions have fewer healthy behaviors, such as diet management and self-medication (Zhang et al., 2017). This study found that the level of self-management behavior is greatly reduced when patients have negative emotions of irritation. The possible explanation for the result may be that patients with early CKD often have irritated negative emotions due to long treatment processes, frequent hospitalization, outcomes that cannot be cured completely, and restrained living habits (Guerra et al., 2021). When the negative emotion of irritation accumulates to a certain extent, patients are prone to feel powerless and indulge themselves, exhibiting poor self-management behavior (Trick et al., 2016). Therefore, clinical medical workers should detect and eliminate the irritation of patients with early CKD as soon as possible to improve their self-management.

The study also found that “scared”, “nervous” and “ashamed” emotions were positively associated with “self-integration”, “problem solving” and “seeking social support” in self-management, respectively, which is contrary to previous studies. A large number of previous studies have suggested that nervousness and fear can lead to poor self-management behavior (Huang, Li, & Zheng, 2021). This result may be explained by the fact that people are diagnosed with CKD at younger ages, and their education level is constantly improving (Heath et al., 2017). When patients are in a state of fear, they can find a suitable adjustment method through the knowledge they have acquired (Sarker et al., 2022). When patients feel nervous, they turn stress into motivation through the usual experience of study, work and life and take the initiative to solve problems (Pereira et al., 2021). When patients feel ashamed, they are more determined to overcome the disease out of a sense of responsibility to their families, and they do not want to be a burden (Darwish et al., 2020). They will actively seek support, learn theoretical knowledge about CKD through the internet and books or by asking others for advice to promote self-management (Khodarahimi et al., 2021). Therefore, this suggests that in the process of clinical psychological nursing, it is necessary to make patients with early CKD aware of the seriousness of the disease and how to mitigate the negative emotions of being scared, nervous and ashamed, which can improve the level of self-management behavior at an early stage.

Another important finding was that “irritated” is a key factor in the risk effect on self-management behavior. Bridge centrality represents the effect of a node on other community nodes. In the negative emotion and self-management behavior network in this study, the greater the bridge expected influence of the node in the negative emotion community, the stronger the impact on the self-management behavior community. Its positive or negative value indicates the protective or risk effect on self-management behavior. Within the negative emotion community, the absolute value of the bridge expected influence of “irritated” was the highest and the original value was negative, implying that the activation of “irritated” is most likely to have a risky effect on self-management behavior, which was consistent with the results of previous studies (Russell, Smith, & Smyth, 2016). It has been found that the appearance of irritation can seriously affect the regulation of daily life among patients with chronic disease. In clinical studies, irritation is also an imperative predictor of adverse clinical outcomes (Gramling et al., 2021). Irritation is often a combination of specific uncomfortable experiences and related perceptions that arise when events such as setbacks or dashed hopes occur (Kassinove & Sukhodolsky, 1995). When patients with early CKD learn that they are sick and cannot be cured, it is difficult for them to accept it in the moment. Patients often become uncontrollably angry, lose hope in life, and feel that illness is a punishment, and they may engage in some irrational behaviors (Eloia et al., 2021). Therefore, nurses taking the “irritated” of negative emotion as the target can play a more comprehensive and effective role in improving self-management behavior compared with other negative emotions when they intervene in self-management behavior by suppressing negative emotions. In the psychological nursing of patients, we should be good at discovering and identifying irritation in patients with early CKD. We can adopt the methods of catharsis, thought transfer, mind control and meditation to reduce irritation to help patients understand the disease correctly and build confidence in dealing with the disease (Lin et al., 2019).

There are limitations in our study. First, this study developed a network structure of negative emotion and self-management behavior in Chinese patients with early CKD at the group level, which may be different from the structure at the individual level. Second, although this study was multicenter, it was still a cross-sectional study, which limited causality statements. Further studies using longitudinal analysis need to be conducted around the disease progression of CKD to determine whether components of negative emotion affect self-management or vice versa. Third, this study includes multiple stages of CKD, and we did not examine differences in the network among different stages. Therefore, further research should be carried out to extend the current study results by comparing different stage groups, and these may find various targeted interventions for patients at different stages.

Conclusions

This study explored the association patterns between different components of negative emotion and self-management behavior with the advantage of network analysis and highlighted that an “irritated” state of mind has the most obvious risk effect and the deepest influence on self-management behavior. Therefore, targeting “irritated” for interventions will help to improve self-management behavior in patients with early CKD to a greater extent, which will be conducive to delaying the progression of kidney disease.