Nurse-Led Digital Intervention for Sodium Restriction in Chronic Kidney Disease: Mixed Methods Implementation Study

Digital interventions can support sodium restriction in chronic kidney disease; yet, implementation and engagement barriers remain poorly understood.

This mixed methods study evaluated a nurse-led digital program for sodium restriction, focusing on 3 key aspects: implementation, engagement, and patient experience.

This study was initially designed as a randomized controlled trial but was revised to a mixed methods implementation study due to high rates of missing primary outcome data. Quantitative measures included 24-hour urinary sodium excretion (the primary outcome of the original randomized controlled trial), knowledge tests, blood pressure measurements, and quality-of-life assessments. Concurrently, we conducted in-depth qualitative interviews with a purposive sample of participants. Quantitative and qualitative data were collected in parallel, analyzed separately, and then integrated to provide a comprehensive understanding of participants' experiences with the intervention.

Among 99 enrolled patients (46 in the enhanced digital intervention group and 53 in the minimal digital control group), the program led to a significant improvement in sodium-related knowledge as a secondary exploratory outcome (P=.005). However, the 24-hour urine collection completion rate was only 24.2% (n=24), precluding reliable conclusions regarding the primary outcome. Qualitative findings revealed a "measurement paradox," in which the gold-standard assessment itself posed a major barrier to adherence. Integrated data illustrated a patient journey marked by early enthusiasm, followed by declining engagement due to digital fatigue, family resistance, and poor fit with daily life. This misalignment created a disconnect between acquired knowledge and measurable behavior change.

A nurse-led digital intervention was associated with modest improvements in sodium knowledge in chronic kidney disease. However, success requires reducing the monitoring burden and improving real-world fit. The "measurement paradox" highlights the need for patient-centered outcome measures. We propose a "stage-matched intervention" framework to guide adaptive digital tools. Future research should prioritize multicenter pragmatic trials to bridge the knowledge-action gap.