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ORIGINAL ARTICLES |
From the Institute of Hospital and Health Care Administration (S.-C.J.Y.), National Yang-Ming University; Institute of Healthcare Management, College of Management, National Sun-Yat Sen University (S.-C.J.Y.), Kaohsiung, Taiwan; and the Department of Nursing, (H.-C.C.), Kaohsiung Veterans Hospital, Kaohsiung, Taiwan.
Address correspondence and reprint requests to Shu-Chuan Jennifer Yeh, Institute of Hospital and Health Care Administration, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Beitou District, Taipei, Taiwan, 112. E-mail: syehboston{at}gmail.com
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Methods: We used the Hemodialysis Stressor Scale and the Jalowiec Coping Scale to interview 2642 patients (mean age = 57 years; 53.5% female) receiving HD. The Hemodialysis Stressor Scale measures the level of stress related to stressor subscales: daily activity, physical condition, dependency on medical staff, fluid and food restriction, role ambiguity, blood vessel problems, and reproductive system functioning. The Jalowiec Coping Scale identifies the use of the following coping strategies: problem-oriented, emotion-oriented, support seeking, avoidance, and isolated thoughts. Data were analyzed using Hierarchical Linear Modeling.
Results: Daily activity subscale scores were positively associated with using emotion-oriented, avoidance, and isolated thoughts as coping styles and negatively related to support seeking from professionals. The higher the perceived stress related to physical symptoms, dependency on medical staff, and blood vessel problems, the more the patients used emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Fluid and food restriction and role ambiguity subscales were found to be positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Reproductive system functioning was positively associated with emotion-oriented, avoidance, and isolated thoughts coping strategies. Patients on HD seldom use problem-oriented strategy to ease their stresses. Support seeking was another infrequently used coping strategy.
Conclusions: The most commonly used coping strategies in our patients were emotion-oriented, avoidance, and isolated thoughts. The choice of coping strategy depended on the types of stressor.
Key Words: stressor • coping • dialysis • end-stage renal disease
Abbreviations: ESRD = end-stage renal disease; HD = hemodialysis; HSS = Hemodialysis Stressor Scale; JCS = Jalowiec Coping Scale; OLS = ordinary least square.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Many studies have examined the stressors of patients with ESRD. Stapleton (4) categorized stressors faced by patients with ESRD as being related to physiological need, psychological need, role disturbance, and daily activity. Mok and Tam (5) studied 50 patients with ESRD in Hong Kong to determine the stressors encountered and the coping methods used; they found fluid limitation to be the most frequently identified stressor, followed by food limitation, itching, fatigue, and cost. Moreover, Tsay and colleagues (6), using the Hemodialysis Stressor Scale (HSS) to assess 57 patients with ESRD in Taiwan, found the major stressors to be limitations on time and place related to employment, limitations on fluid intake, transportation difficulties, loss of bodily function, length of dialysis treatment, and limitation of physical activities. Other studies concluded that physiological stressors were more troublesome than psychosocial stressors in patients receiving hemodialysis (HD) (7,8).
Patients receiving HD use various strategies to cope with the stressors related to their disease and the treatment procedures. The kind of coping strategies they use also depends on their personal experience, social support system, individual beliefs, and availability of resources (5,9). Mok and Tam (5) reported that the most common coping methods used by patients with ESRD include "accepting the situation because very little could be done," followed by "telling oneself not to worry because everything would work out fine" and "telling oneself that the problem was really not that important." Some researchers categorized the coping strategies as problem-focused or emotion-focused (10–13). Problem-focused coping is directed toward managing or changing a stressful situation (12), or it involves addressing the problem that causes distress (10), whereas emotion-focused coping involves explaining stress as inability to control one's own circumstances (13) and its purpose is to ameliorate the negative emotions associated with the problem (10). Some researchers have found that patients with ESRD have both psychological and physiological stressors and that they use problem-focused coping strategies more often than emotion-focused coping strategies in response to those stressors (7,14,15); others have found that patients receiving HD use more evasive coping strategies (16) and emotion-focused coping strategies (17).
In addition to identifying the coping mechanisms that patients with ESRD use when facing various stressors related to HD, research should also clarify the relationship between stress and coping strategies. Literature in this regard, particularly in patients receiving HD, is still limited and inconsistent. For example, Baldree et al. (18), in a survey of 32 patients receiving HD, did not find any significant relationship between stressors and coping scores, whereas Gurklis and Menke (7), in their survey of 68 patients on HD, reported a positive relationship between total stressor scores and total coping scores. More recently, Ersoy-Kart and Guldu (17), studying 55 patients receiving HD in Turkey, found that these patients had lower coping scores and were vulnerable to stress. Therefore, it is important to understand the extent of stress experienced by patients facing various stressors related to HD and the relationship between the patients' coping strategies and the stress factors.
In summary, most of the studies examining the relationship between stress and coping strategies for patients receiving HD are limited in sample size and seem to have inconsistent results. Thus, this study uses two scales, the HSS and the Jalowiec Coping Scale (JCS), in interviewing a large sample of patients with ESRD undergoing HD to determine if there is a positive relationship between coping strategy and level of stress in this population.
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METHODS |
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15 years old who had been on dialysis for at least 3 months. Of the 333 hemodialysis centers in 2002, we randomly selected 33 (10%) and asked for permission to enroll patients in our study. Only 27 centers agreed to participate. A total of 2977 patients receiving HD from five medical centers, five regional hospitals, 10 community hospitals, and seven independent hemodialysis centers in 13 counties were interviewed. A total of 208 patients who did not want to be interviewed and 127 patients who could not answer the questions were excluded, leaving us with 2642 patients and an effective response rate of 88.84%. Our patient sample had a mean age of 57 years (SD = 14 years, range 15–95 years) (Table 1) and was composed of a few more women (53.5%) than men. About 78% were married. The patients had received HD for an average of 54 months (or 4.5 years) (range 3–249 months). The average number of comorbidities was 0.72. Most of the patients received HD three times a week.
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Measures
We used a structured questionnaire consisting of three major sections. The first section covered demographic data (age, gender, marital status, education, occupation, and religion), as well as the characteristics of dialysis treatment (length of time receiving dialysis, major reasons for the dialysis, comorbidities, transportation, meal support, and frequency of dialysis).
The second section was the HSS, a 29-item scale used for rating the incidence and severity of stressors associated with HD (18). In addition to the 29 questions, based on the suggestions from a panel of experts, we added three more questions about the operation for an arteriovenous fistula, puncture failure, and frequent dialysis staff change. The subjects rated the extent of being troubled by each of the 32 stressors using a 4-point scale (0 = not at all, 1 = slightly, 2 = moderately, and 3 = a great deal). A subtotal stressor scale score was obtained by adding the ratings for items belonging to the same construct. The higher the score, the greater the stress. The internal consistency 
coefficient from previous studies was about 0.89, indicating good internal reliability. The instrument has an established test-retest reliability coefficient of r = 0.71 (18).
The third section contained questions for assessing the coping strategies used by patients receiving HD to handle the stressors experienced. We used the JCS developed by Jalowiec and Powers (19) and translated by Mok and Tam (5). This instrument covers 40 different coping behaviors, namely, 25 affective-orientated and 15 problem-orientated. A 4-point (0–3) Likert scale is used (0 = never used, 1 = seldom used, 2 = sometimes used, and 3 = often used). Construct validity of the scale was tested by a panel from the Midwest Nursing Research Society, who were familiar with the stress and coping literature and thus yielded a high percentage of agreement (19). The reliability coefficient of the total scale is 0.86; 0.84 for the problem-orientated coping subscale, and 0.74 for the affective-orientated coping subscale from the study by Gurklis and Menke (20). The test-retest reliability of the Chinese instrument, assessed in a pilot study with four patients receiving HD over a 2-week span, was found to be 0.87 (5).
Reconstruction of Measures
The next step was to refine the measures using exploratory factor analyses. This step sought to identify items that would form reliable scales. This required retaining as many items as possible to produce good scale reliability and eliminating items loading differently in different constructs to assure the convergent and discriminant validity. The analysis used a common factor model with varimax rotation. We used latent root (or Eigen values) >1 to determine the number of factors to be extracted. We interpreted a factor as reflecting a particular stress if 3 items designed to measure the stress had loadings >0.45 on that factor and no loadings >0.4 on any other factor. Items with factor loadings of <0.40 were deleted. On the basis of these criteria, we deleted the following three items: itching, sleep disturbances, and not smooth during the HD procedures. The varimax factor analysis conducted on the final 29-item version of the HSS indicated seven subscales accounting for 64.87% of the variance. We named the seven subscales as daily activity (defined as the changes influencing daily activities, such as limited styles of clothing, or vocation limitation, etc.); physical symptoms (including nausea, vomiting, muscle cramps, joint stiffing, fatigue, and loss of bodily function); dependency on medical staff (defined as frequent hospital admissions, dependency on staff and doctors, fear of staff turnover, and fear of being alone); food and fluid restriction (defined as intake restriction); role ambiguity (defined as change in family responsibility, spouse's role, and children' roles); blood vessel problems (related to the problems of arteriovenous fistula operation such as the arteriovenous fistula cannot be punched and insufficient blood flow of arteriovenous fistula); and reproduction system functioning (defined as decreased sexual drive and infertility). Then, items were summed to get a subtotal score for each subscale. The reliability coefficient of the total scale is 0.93; 0.84 for the daily activity stress subscale; 0.77 for the physical symptoms; 0.81 for the dependency on medical staff; 0.76 for food and fluid restriction; 0.91 for role ambiguity; 0.81 for blood vessel problems; and 0.71 for the reproduction system functioning subscale. The seven factors were treated as dependent variables. Table 2 details the factor analysis of stress.
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We did the same with the JCS scale and retained 32 items. The deleted eight items included questions 3, 10, 21, 28, 30, 32, 34, and 36. These questions are listed in the notes of Table 3. The varimax factor analysis conducted on the 32-item final version of the JCS found that five factors accounted for 55.72% of the variance. We gave the five factors these names indicating the type of coping behaviors used: problem-oriented (look at the problem objectively and see all sides; find out more about the problems; or set up a plan of action); emotion-oriented (told yourself that the problem was someone else's fault; worried about the problem; or blamed yourself for getting into such as situation); support seeking (talked the problem over with a professional person; prayed or put your trust in God); avoidance-oriented (smoked more than usual; ate more than usual); and isolated thoughts (getting away from the problem or think of something else). Then, items were summed to receive a subtotal score for each factor. The internal reliabilities of the five subscales were 0.93, 0.84, 0.68, 0.61, and 0.70, respectively. The five factors were treated as independent variables. The overall internal consistency, Cronbach's , of this scale was 0.92. The factor analyses and the scope of coping strategies are listed in Table 3.
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Control Variables
We controlled for age, gender (female coded as 1), education (illiterate, elementary and junior high, high school, as well as bachelor degree and above [as reference group]), occupation (having job [as reference group], housewife, no occupation, retirement), religion (with religion coded as 1; others coded as 0), marital status (married coded as 1; others coded as 0), and comorbidity (measured by the number of comorbidities) in all analyses.
Procedure
This study was approved by Institutional Review Board of Kaohsiung Veterans General Hospital. Patient data were collected from October 2002 to January 2003. Patients were asked to answer questions in face-to-face interviews conducted by trained nursing managers. The interviewers' training program involved both a general introduction to survey interviewing and fieldwork techniques and procedures, and a review of the stress and coping strategies for which interviewers were responsible. Inter-rater reliability was high (kw = 0.859, p < .001). The interview, held during HD visits, lasted between a half hour and 1 hour. All patients in this study gave their written informed consent.
Statistical Analysis
Descriptive analysis was used to present demographic data, type and intensity of stress, and coping styles. Mean differences in coping and stress scores were examined between male and female patients receiving HD. Pearson correlation coefficients were used to examine relationships among the stressors, coping styles, and the duration of HD. Because individual patients in the same hospital are exposed to a similar context, the assumption of independent observations that underlies traditional ordinary least square (OLS) regressions may be violated. As a result, traditional OLS regressions will generate biased estimates of the standard errors and invalid test statistics. Therefore, we adopted Hierarchical Linear Modeling (21), which explicitly takes into consideration the nested nature of the data. In this study, we entered the dependent variables and independent variables at Level 1. We do not have any hospital-level predictors, so no variables were entered at Level 2. We left the random error in the Level-2 intercepts to be freely estimated in order to capture the between-hospital variance in the dependent variables (21). We did seven multilevel models to examine the dependent variables as a function of both patients and hospitals. For each analysis, the group of control variables was forced to enter simultaneously. Then, the independent variables (coping strategies) were entered all together. Demographic variables (age, gender, education, occupation, religion, and duration) served as covariates in the multilevel models. The total r2 statistic was used to measure the proportion of the variance of the dependent variable (various stresses) about its mean that is explained by the independent variables (copying strategies). In addition, we examined r2 changes associated with the proportion of control and coping variables. Cases having missing values for any variable are excluded from all computations. All reported p values are two-tailed.
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RESULTS |
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The seven multilevel models did not show consistent results (Table 6–8). Patients receiving HD tended to use emotion-oriented (
= 0.314, p < .001), avoidance ( = 0.388, p < .001), or isolated thoughts ( = 0.228, p = <.001) coping strategies in response to daily activity-related stressors. However, patients receiving HD were less likely to cope by seeking support from professionals ( = –0.091, p = .022). The r2 changed were 0.091 and 0.211 for control variables and coping strategies, respectively.
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= 0.119–0.167, p < .001) or that involved support seeking ( = 0.084–0.138, p < .001), avoidance (ß = 0.114–0.359, p < .001), or isolated thoughts ( = 0.086–0.131, p < .001). The r2 changed in the multilevel model of physical symptoms were 0.087 and 0.169 for control and coping variables, respectively. For the model of dependency, the r2 changed were 0.059 and 0.252 for control variables and coping strategies, respectively. The r2 changed were 0.068 and 0.123 for control variables and coping strategies for the model of blood vessel problems, respectively. Fluid and food restriction-related and role ambiguity-related stressors were positively associated with coping strategies that were emotion-oriented ( = 0.137–0.187, p < .001), involved avoidance ( = 0.177 and 0.333; p < .001, respectively), or isolated thoughts ( = 0.201 and 0.058; p = < .001 and 0.039, respectively), while they were negatively related to the duration of HD ( = –0.002 and –0.001; p = .05 and 0.035, respectively). The r2 changed were 0.067 and 0.229 for control variables and coping strategies for the model of flood and fluid restriction, respectively. In the model of role ambiguity, the r2 changed were 0.068 and 0.131 for control variables and coping strategies, respectively. Patients with stress related to reproductive system functioning were positively associated with coping strategies that were emotion-oriented ( = 0.093, p < .001) or involved avoidance ( = .204, p = .001). The r2 changed were 0.098 and 0.111 for control variables and coping strategies, respectively. |
DISCUSSION |
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Besides negative emotion, Folkman and Moskowitz (11,22) also mentioned that positive emotion (such as the feeling of happiness, relaxation, direct action, problem-focused coping, or positive reappraisal) can occur with high frequency, even in the most stressful context, and can occur during periods when depression and distress are significantly increased. Positive emotion is helpful for coping. The construct of isolated thoughts from our study is more close to the meanings of acceptance and positive reinterpretation (23), which are kinds of positive emotion and help growth under stress situations.
The patients faced with stress related to physical symptoms, dependency on medical staff, blood vessel problems, and reproductive system functioning were more likely to seek support from professionals. Only patients facing the stress of daily activity were found to be less likely to use support seeking as a coping strategy. Major changes can be too burdensome for patients receiving HD. Patients with ESRD faced stress related to daily activity after HD treatments. This usually frightened most patients receiving HD. However, knowledge helps patients regain a sense of control over their experiences and environment and helps reduce feelings of vulnerability. Therefore, encouraging patients to seek professional support from medical staff can be one way for them to obtain knowledge and may be a key element to ease their distress. If not from health professionals, some type of counseling or therapy or support from support groups may also be helpful to patients receiving HD and their families.
The length of time that a patient received dialysis was often a crucial determinant in perceived stress and coping strategies. We found that the longer one has been on HD, the lower the role of ambiguity-related and fluid and food restriction-related stress. According to Maslow and Lowery, physiological needs must be met before moving to the next higher level, which includes safety, belongingness, love, esteem, or self-actualization (24). Long-term restriction of food and fluid is a difficult challenge for patients receiving HD at first, but they gradually learn to get along with these restrictions. Role ambiguity is also a source of stress in the beginning. With HD occurring an average of three times a week, the roles of parent, child, and spouse, particularly with regard to who is receiving the care, need to be adjusted over time.
In this study, women reported greater stress related to physical symptoms and blood vessel problems than men, and men reported greater stress related to reproductive system functioning than women. With the exclusion of stress related to reproductive system functioning, these results agreed with those of Lindqvist et al. in their study in which men regarded themselves as better able to cope with the physical aspects of their illness (16). Like another study (17), we found men more likely to use problem-oriented coping strategies than women. However, the men in our study were more likely to use coping strategies that involved avoidance than the women. This avoidance behavior included smoking or heavy smoking, irregular overeating, and getting drunk more often than before HD treatment. The behavior commonly has gender stigma on men than women in Asian countries. Such results may be culturally oriented. Several studies that examined the culture difference in using coping strategies also found that various ethnic groups applied different coping strategies. For example, Njoku and colleagues (25) found African Americans and Latinos, in comparison to European Americans, would be more likely to use religious coping, behavioral disengagement, and denial. In stress-related studies, one cross-cultural comparison of family resiliency in patients receiving HD also discovered that South Korean patients receiving HD and their caregivers perceived the stressors imposed by their illness to be significantly greater than Anglo Americans and Mexican Americans (26). Future research regarding cultural factors affecting stress and coping is encouraged.
In summary, the association between coping strategies and stress can be positive, negative, or neither. Regardless of the type of stress, the patients receiving HD in our study tended to use coping strategies that were emotion-oriented or those that involved avoidance or isolated thoughts. Because of the small coefficients for stressors related to role ambiguity, blood vessels, and reproduction, we are more cautious in our conclusion that isolating thoughts is a commonly used coping strategy. One of the main tasks in coping with severe stress was to integrate the occurrence of the stressors with one's beliefs about the world and the self (27). The coping strategies a patient used changed daily depending on the type of stressor he or she was facing. The duration of HD, provision of support groups, and offering information about HD care are factors that can greatly influence how much stress these patients feel and how they cope with it.
Because detailed information is needed to specify the relationship between stress and coping strategies, we strongly encourage the classification of coping strategies into more than just two groups, problem-oriented and emotion-oriented classification. Although we believe that there is mounting evidence that patients receiving HD face a lot of stress and use different kinds of coping strategies, not all studies share the similar view regarding the relationship between stress and coping strategies. It is clear that such relationship is complex and not consistent across patients receiving HD. There are also many potential moderators of a relationship between stress and coping strategies, including major causes of ESRD, the nature of stressor, environmental context, and the patients' biological, social, and psychological characteristics. These factors need further investigation.
We thank Drs. Mok and Tam for permission to use the Chinese version of the Hemodialysis Stressor Scale and Jalowiec Coping Scale. We would also like to thank the 27 hemodialysis centers and the 2646 patients who participated in this study. We appreciate the reviewers' comments and suggestions. We thank Dr. Sing-Kai Lo and Mr. Chia-Hsiung Huang for their consultation on multilevel methodology.
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NOTES |
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This study was supported by Grant NSC93-2416-H-110-043 (S.-C.J.Y.) from the National Science of Council of Taiwan.
DOI:10.1097/PSY.0b013e318031cdcc
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