Table 4 Themes and sub-themes from patient and staff interviews

PATIENTS

 ● The emotional burden of ESRD and treatment

  ○ Life-saving but not curative treatment

  ○ Emotional toll of treatment and impact on lifestyle

  ○ Bottling up emotions

 ● Patients have complex, multi-faceted support needs

  ○ (Presence or absence of) self-support and personal coping mechanisms

  ○ Staff recognition of distress

  ○ Experience of support provided by renal unit

  ○ Experience of support provided by renal staff

  ○ Family support

  ○ Renal unit atmosphere and environment and impact on disclosing distress

RENAL STAFF

 ● Patients and distress

  ○ Identifying distress is challenging (detecting distress; patient reluctance to disclose distress)

  ○ Beliefs about distress in ESRD patients (distress at times of change; are some patients more prone to distress?)

  ○ Responding to distress is difficult (different approach from clinical care; meeting the needs of BME patients)

 ● Staff roles and skills

  ○ Role perceptions (it’s everyone’s role; it’s not my role but whose is it?)

  ○ Fears (fears related to talking about distress; the emotional load of talking with distressed patients)

  ○ Skills, confidence and training (skills; training about supportive services; scepticism over the benefits of training)

 ● Care organisation

  ○ Limited capacity to respond (perception about how much time is needed; care settings and facilities limit responsiveness; variable access to specialist services)

  ○ Differences between staff groups (doctors, nurses and other renal staff; staff groupings)

 ● Changes

  ○ What helps (staff-patient relationships; more listening, less talking; normalising distress)

  ○ What needs to change (access to immediate support; structured approach to identifying distress; reducing the stigma of distress)