Stressors and Coping in Individuals With Chronic Kidney Disease Lori Harwood Barbara Wilson Heather Locking-Cusolito ni the United States, itis estimated that the prevalence of chronic kice ney disease (CKD) has increased 20% to 25% in recent. years, with nificant associated burden of illness Inited States Renal Data System ISRDS), 2008. Jn Canada the inc dens of end stage renal disease isincwasingat a mie of 6.59% year (Canadian Institute for fealth Information [CIHI], 2005), with a 69.7% increase in prevalence since 1997 (CIHIT, 2008). As researchers focus on the prevention ‘Lori Harwoud, MSe RN, san Alsace Practice ‘Niase the Adam Ztan Hemadialas Una, the London Hails Sdences Cente, Landon, Ontario, Canady and is monber ofthe MichigANNA ton on se fer a A TE cd tne il feet i ne nl ile teen Bhs Nase Spal tbe Adan Linen Hono Chl, ‘He Laon Filth Sas Cone, Lon, Ont, Canada PAD, ison Epidemidogit the Merion Heth Shady the Lon ah ‘Sina Conn, Landa, Otay, Cardia, a Sota MSW RI te ine ao “ti es al eye alae en ‘Hentis Unt te Lanne Snes Gs Co, Ours Canad. ‘Noles This stuty was fda by the ANNA 2005 Resardi Grant, Adznowledgments: The authors would tke 1 ‘alee Ka Gallo, RN, cat Lindy Darel maring student, fr Wear asa withthe daa cect an one lak or er asta wth ‘he marci Statements of Disclosure: The author ported ro ‘clad on penal crf of ttre in lation to ‘tas contig asin eda atic, CNE Continuing Nursing Education Jessica Sontrop Joan Spittal ‘The purpose of this study was to develop a valid and reliable instrament to measure ‘stressors of patients with chronic Key disease (CKD), identify thase stressors, and determine which oping strategies were used and effective. The pavticipants reported fatigue, sleep problems, and peripheral as the most, ly experienced ‘sresors. Optimism as a coping stile teas mast commonly used and twas also the mast ‘effective. Stress was inversely associated with age and CKD stage and positively associ - ‘ated with coping, Knowledge from this study can be used to futher patient education and supportice interventions jor patients with CKD. Goat ‘To provide an overview ofa valid and reliable instrument used to measure stressors of patients with chronic kidney disease, identify those stressors, and determine which coping strategies were used and effective in the study. Objectives 1, Define psychological stress. 2, Discuss two instruments used to measure stress and oping of patients with arronic kicney disease. 3, Explain effective coping strategies used by patients with chronic kidney disease, or delay in. rogesion of CD, isciplinary team for care of patients the foetal at Ps by wah CRD, oder adequate med- the Gidense are alst worthy Pe suey ical and, poychosocal preparation, because these, 00, influerice patient patients should be assessed in such a outcomes. Care of individuals with CKD indudes multidisciplinary team inter- ventions to delay the onset of dialysis, encour }OQI Clinical Practice Guidelines (National Kidney Foundaticn, 202) and the Canadian Society’ of ‘Ne= ‘muidetines Htevme ee 3000 recom tt cach center have an established mult- lnic as soon as possible (NKF, 200) or at least 12: months prior to the initiation of cialysis (Churchill, Hake, cab Tlld & Coser 1999), The authors’ clinical experience shows that the stressors experienced in the early stages of CKD are difler- ent than those experienced by indi- eas on days Having Know trig of thesresors and cexpetienced by individuals wit Katy stage CKD will be advantageous in This offering for 14 contact hours i being proved by the Amesican Nephrology Nuises! ‘Associaton (ANNA). ANNA 's accredited as a provder of carthuing nursing education (ONE) by the American Nurses Credentialing Center's Carmission cn Accreditation. ANNA isa provider approved bythe Calforia Board of Registered Nursing, provider ruber cP onto. ‘This CNE artis meets re Nephrology Nursing Oatficatin Conmissonis (NCGS) continu ‘ng rursing ecuication requirments fr ostiicaton and recerfication, NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3‘Stressors and Coping in Individuals with Chromic Kidbuey Disease the, design and delivery of services ive interventions for these ina fuals. This knowledge may also lay the foundation for future suces exploring the influence of stressors on health behaviors and outcomes in Literature Review Early referral to a and CKD clinic has been He slow de mate of progresion of Kidney disease, allow for the ‘anemia, provide for patient: Sten to make decisions regarding modality choices, facilitate access placement, provide dietary education, assure early detection and treatment of sece ‘ondary hyperparathyroidism, reduce cardiovascular risk factors, and offer supportive interventions & Owen, 25 02 Churchill et al, 1999; Levin, 2000; Pereira, 3000). Several studies have demonstrated that carly referral toa nephrologist or CKD dlinic decreases morbidity, (fee 20 Nets et ala, 2025 Mela Manns, Donaldson, & “Taub, 3001; Roubicek a ai improves long-term survival (Jungers tal, Ole reduces the need for emergent dialysis (Schmidt, Domico, Sorkin, & 1988), is associated ‘with ‘superior "patient outcomes (Goldstein, Yass, Dacouris, & McFarlane, 2004), and_ improves healt-related quality of life for 6 months afier the start of dialysis (Korevaar et al 2012), Patients who receive predialysis cclucation have higher mood scores, Tess Jess functional Gfebiites abd alone level oar ety (Klang, Bjorvell, Berglund, Sundstedt, & Clyne, 1998), and are able to make decisions regarding modality (Kkng, Bjirvell, & Clyne, 1999), A multi-centered, randomized, controlled trial examined predialysis tclucatonal interventions (PPI) and styles on initiation of dialysis in 9F individuals with CKD (create nine of 34 mg/dL, or less) (Devins, Mendelssohn, Baré, & Binils 20(3). ‘The PPT group showed a delay in the onsctof dialysis therapy (< (00001) and leamed more about renal disease and the treatment (p< 0.0001). There were no. differences between the pos and control ra ee mapa scl spent ch ti dialysis Participants who used ‘blunt (ihe avoidance of threat-relevant smation) as a coping method had a shorter time to dialysis ther ‘Devins and colleagues’ (2008) con- luded that people who cope by avoidance may be less likely to engge in routine follow up. Sludies have been conducted on stressors and coping in individuals Se eae (Baldree, Murphy, & Power Gurklis” & 1995, Pelleticr Hibbert, & Hodgins, 2006; Mok & Tam, 2001; Wade & Austins 1200) pestooeal, daly (Exel 1986), and renal transplantation (Hayward et aly 1989). One Scandinavian study” (Klang, Bjrvell & Cronqvist, 1996) examined coping stratggies and sense of the Jalowiec ane sae (JCS) Galo Murphy Rowe, 198) ai aes coherence scale, and compared a fas and CKD group. The results of this study indicated that swith CKD who are on ly empoyed very diferent coping strategies The CRD group Nal Tower coping scars and used more emotive coping strate au ia) eb ene conduct etal, (1996 get ty coed oe the study did not identify the stressors these individuals nce and did not report on the effectiveness of the coping strategies wed. The small sample size (n= 25) reduced the gen- eralvabilty ofthe findings. ‘Two qualitative studies (Harwood, ito, Spittal, Wilson, & White abt, Mak Lat) & Zhang 2001) the former conducted by the authors of this study and the latter being a study conducted in Hong Kong provide sme undesancing of ‘CKD experience. Harwood et al ans) interviewed 11 individuals on hemodialysis and. asked them to ctvly what sts matey prior to dinky Shi At 00) deren n individuals with chronic renal failure tg reflect on he past couse of thei illness to explore how they coped what copi jes they used. Mok et al 6008) enti the fob Gace pang was ase ing feelings and concerns, motivation cope yendent relation- ships between patients and their fame ily members. In both stucles, the patients expe- rienced emotional reactions to CKD, such & heldesnes, povalemess feat Shere rs oe pide as. imposed by the illness When first faced with renal failure, they were iy at a loss for what to do and ofien just cried or isolated themselves (Mok et al, 2004), In the study conducted by Harwood et al. (2005), the individuals reported a variety. of physical symptoms, psy- chosocial issues, associated ih he clinic teal Guch a as sheuh ml wait me pe lack of information, ‘They not only identified a wide ra of stressors for themselves, but also identified the impact on family mem- bers. Both stulies provide rich descrip- tions of the experience of patients ‘with CKD but were retrospective in their design occurring once the patients were already on dialysis. To the authors’ knowledge, no tool meas ‘uring stressors to CKD exists. Nor are the aware of a study conducted that measures stressors and coping strategies in a large sam- ple of individuals with CKD not on: dialysis Lack of information about the stressors experienced by individue al wih CRD ad he coping ate Seed ver edational and rtive interventions for these ividuals. Purpose of the Study ‘The purpose of this study was to NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3develop and test an instrument to measute stressors in CKD, quantify nse sressars and dently cops methods used by patients with and thar eflecivenes A secondary ifs avec domowrphic are cr ween ‘clea on anecols and coping in this patient population, Cor Framework Lazarus and Folkman’s (19884) the: ory provided the framework for this stdy, This theory is a cognitive phe nomenological theory of stress, appraisal, and coping, It provides a framework for the” transactional process between apprakal of an event Etermined seth coping and the resulting outeome of the transaction. Definitions Pyychological stress is a relation: ship between the person and the envie ronment, appraised by the pason as taxing or exceeding his or her resources, and enda his or her wellbeing (Lazarus & ISB). Coping is the process through’ which the manages the demands of the pason manages that are appraised as being stressful and which, emotions (Lazarus & Folkman, 1984), The NKDOOL ‘guidelines define CKD asthe presence of kidney damage or decreased evel of kidney function for three months or more irrespective of (NKF, 202s). For this study, the estimated omer kato rate (GFR) was using the CockcroftGault The dace equ (Code & Gault, 1976}. of CKD was determined tng fe cGPR ant be NRE/DOO CKD sixes 1) Methods Sample After ethical al wa recated font the Pea seca ethics board, all adult (18 years of age and olde) who ‘spoke and understood. and attended the CKD diinic during the data collection were assessed by the research, assistant for eligibility in the study. Only those patients with a serum cre- atinine greater than 284 mg/dl. (250 mmoV/L} and/or GFR les than (0 ml/min/1.73n¥, and who were nated asaving CKD by he nephro- ogist were ap] for itthe suche The research asistant approadrd the patients, obtained itfomned ‘consent and assisted in completion of the, questionnaires when neces. Prisha who vo study were given a voucher to pay for one hour of fee ‘The final sample included 226 individuals with CKD not on alysis Instrumentation Participants were asked to com- plete to questionnaires at one in time: the Jalowiec Bre GCS aloe et ly 1981 and CKD. Stress Inventory eens specifically developed for this study. Jalowiec Coping Scale. The tS assesved the coping strategies patients with CKD. Itis a generic tool that assesses a wide range of behaviors and mehods and can be used with diverse in various clinical settings ‘2003a). In addition to the rating of coping methods used, the tool also has an evaluative component that asks the person whether or not a caren med es he a specific situation, The J appeal 10 fo 1 nines 1 complete and is written ata Gth grade reading level. Permission to use the tool was obtained. Jalowiec’s coping scale is based | on Lazarus Folkman’s Coping melds are chssified as either em-oriented (strategies focused on the. situation itsel or alleciveoriented (Strategies that deal with emotions evoked by a Stustion) All 60 items of the JCS are classified into 8 styles or t temscconbosive evasive, clinic fatalistic, emotive, palliative, suppart= ant, and self-reliant. The JCS has been wall studied with people on hemodialysis (Baldree NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3 CNE et al, 1982; Blake & Courts, 1996; Gurklis & Menke, 1995; Lindqvist, Carlsson, & Sjiden, 1998; eae & Sjéden, 1998; Mok & Tam, 2001; ‘Yeh & Chou, 207}, patients on con” tinuous ambulatery’ peritoneal dialy« 83 CAPD) cha, 1986; Linc ‘arlsson & Sjoden, 2000), ly members of individuals with ESRD (Pelletier-Hibbert & Sohi, 2001), and individuals with CKD (Klang et al, 1996). Psychometric testing of the JG has been extensive with both the ‘original 40tem scale (Jalowiec et al, 1984) and the revised 60-item ver Cronbach's alpha is as follows: total coping strategy use, mean 0.88; total coping effectiveness, mean 0.91; cop- we seas men ‘mean 0.71; clieciveness subscales, mean 078 (Jalowiec, Son CKD’ ‘Stress inentory. The CKDST was developed specifically {or this study based on a review of the related research, including published literature on physi and psy helogieal siecewyidenifed By patienis with renal disease on clffer= Sng fms of renal itthera- taldree et Tig iene snesa sees aon (on in-center hemodialysis, and this tepals nl Kans io this ulation (Bil, Ferrans, & Powers, ; Carls & Menke, 1995 Log etal 300, Nok & Eos 20011 & Austin, 1999) as well as the home hemodialysis population Courts, 2000; Courts ote 1998). The tool by Baldree otal (1982) was later adapted by Eichel (1980) for a study ‘examining stressors by individuals on SAPD beso ment entitled the Kidney ‘Transplant Recipient Stress Scalé (Hayward et al, 1989) was also reviewed. Stressors measured in each scale mentioned were examined by the investigators for relevancy to CKD and inclusion in the CKDSL The version of the (CKDSI contained 61 items and was developed with a 4-point Likert scale with items ranging from 0 to 3; the higher the score, the greater thesever ity of the stress experienced. Reade‘Stressors and Coping in Individuals with Chromic Kidbuey Disease lity using Flesch-Kincaid grade level measurement in Micresofi Word ‘was used, and it was determined that the CKDSI had an 8th grade reading Jove. The istument wes protested 2004 with 27 patients wwith CKD, Patients ere asked to is additional sresors they experienced that were not on the C! Their feedback was discussed the inv rs for inclusion into’ the insrugent Comploton Ol the CKDSI during the pre-testing phase took between 2 to 25 minutes, with an average of 1045 minutes, oe validity for the CKDST is yported because the Sroscrs ete were bodon cre ical review of previous research and instruments measuring stres- sors with renal therapies Computations of index of content validity (CVD) (Walt, Stricktnd, & Lenz, 1991) wereabo conducted to test thedegtee to which the tool: the stressors that patients with CKD expaiene, Sunes were mailed 1 expat nurses (RNs and nurse fionerscinical muse specials) social workers who wo with CKD, who were ee score the relevance of each stressor on a 4 t Likert scale from “not relevant” hat eleva” quite relevant.” to “vary relevant” They were alo asked their overall opinion regarding the degree to which the tool represent- ed the stressors experienced by patients with CKD, ‘General com- ‘ments were alo noted. Mean stressors scoringless than “quite relevant” (2 out Of 3} eS wal as mean sores fess than 2, were assessed by the research team, and consideration was given for removal from the list. The index of content validity is the proportion of items (stressors) given a rating scale of jiteery relevant, Those scoring less #5) (kes has 90%) oF ou 3 or ks indicate an unacceptable of content validity (Martuza, 1977). Seven nurses and 6 social workers the content validity. Two (259) individuals were prepared at the baccalaureate level and 11 (85%) ‘were masters” prepared. Sixty-nine percent of the experts scored one Table 1 Demographic Characteristics Highest Level of Completed Education (%) Less then High School High School CollegatUnivesity Employment Stats (2) Employed FulTme Employed PartTime Retired Otert “Treatment History (Mean + SD) Months at KD Clinic * Disabilty, unemployed, student item, “Changes in religious activities” as either not rdevant or somewhat relevant. This item was removed from the instrument. Eight other items had a mean score kes than 2 ‘Twoiitems were removed after discus sion by the investigators and compar- ison to the literature. This resulted in aStitem instrument, Principal Components ‘Analysis of the CKDSI sy lal stessor sce was dived the item soores, where Rigi sores tated eae Toes Of sess. Pincipal components analy- sis with varimax (orthogonal) rotation ‘was used to examine the constructs underlying the full siresor inventory and to determine whether the original S58ritem scale should comprise a sin- gle general scale or whether the scale items would be more meaningfully grouped into smaller, more sub-scales. Therumberandmemba- ship of factors was determined by sette pls and factor loings Inthe interest of reliability, as many items as possible were retained; however, to maximize the convergent and dis Cera) 6 35 422 264 22 634 188 48.72 538 criminant validity of dhe subscales items that had no ladings greater than 0.4 were deleted, as were items with loadings greater than 0.4 on tote ten one face Pearson's correlation coefficients ‘were used to evaluate relationships between CKD stressor scales and coping strategies. Sequential multe linear regressions were per Ried io est shee wal suetar ores associated with socior demographic, nica, and co ‘Four models were evalual- tl in which the dependent variables were the CKD stressor scales: logisti- cal, psychosocial, and physiologic, followed by the total 34-item scale. ‘The independent variables were centered sequentially in 3 steps: socio- demographic variables were entered in the first step, the clinical variables in the step, and average of the total coping score in the third step. Inall analyses, statistical signif- cance was set at) al 05. ‘Means and standard deviations (SD) are reported, Data were analyzed using SPSS 15.0 for Windows, NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3Table 2 CNE Principal Components Analysis on Stressors Experienced by Patients with Chronic Kidney Disease Logistical Psychosocial_| Physiological 45. Waltrg for Galyss close to homme ‘0.0 28. The number of times of dialysis per week 075 41. Not krowing when dialysis willbe needed 74 48, Seeing sick patents in the ric 085 40, Having to use the tol during dialysis 065 27, Having a dalsis access eg, fistula 02 50. Keeping tack of many circ visits gt 22. Rides/aling for dialysis 060 57. Rides/ahing to dinic visits 057 51. Feelingunsure about life with clalysis 056 44, Knowing when to call heath care team 056 49, Not kroning enough about dialysis 055 14, Leng of dialysis treatments 048, 46. Taking in information oat 19, Changes in social fife oz 117, Having to rey on the health care team 070 416, Limits on tis other tren vacations 070 416, Limitson vacations 070 18, Feelingalone or cutoff from others 06 ‘34, Chance of dying i) 25, Changes of roles in farily 054 331. Getting an infection 046 26. Fear of being alone 44 9. Restless legs oe 3, Fatigue 046 £24, Sleep problems 64 2. Muscle cramps 060 ‘38. Numbness or foeling lie pins and needles in hands and fest a) 837. Being short of breath 058 48, Changes in mood 0s 15 Problems staying focused 046, 152, Changes in your desire fr foods 046, 77. ching 045 11. Feeling sick to your stomach oat Eigen values 921 342 228 Peicilty 088, 084 os Percent of vaianoe 2739 1006 665 (Cumuietve peroert of vaiance 2739 S745 44.10 Results linc for an average of 4 years (48.7 On the basis of the item retention cri- months). teria, 24 items were subsequently Demographics . delefed: changes in fluid intake, your ‘Demographic characteristics of the Principal . renal diet, impact on other duties, sample are presented in Table 1, The Analysis and Reduction —_ impact on job, limits on physical activ- rah age was OL) (SD 19) yeas A sree plot of the fll item ity lear of needles or hemody, and 65%% were make. Approximately scale suggested that 3 factors account vomiting, side fects of your pills, 57.80 of participants had completed at ed for much of the variation least high school education, and the majority (63.4%) were retired. Partic= pants had been treated in the CKD the items: Specifying 3 factors prince pal components analysis was used with varimax (orthogonal) rotation, NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3 feeling Sad and blue, cast factors, in soul activi chance of italized, fear t Gre syer health problems at homes‘Stressors and Coping in Individuals with Chromic Kidbuey Disease being a burden to your iy, fe yuent blood draws, feeling helpless, family members teling you wit the are team said fo do, feeling out of control, waiting time for clinic visits, changes in body weight, swollen ankles, weakness, and being able to work around the house. ‘The varimax rotation on the final 3ibitem version of the CKD stressor scale indicated that 44.1% of the total variance was by three fac- tors (ce Table2}. The three subscales ‘were labeled logistical, psychological and physiological. Cronbach's alpha for each subscale, respectively, was (088, 0.84 and 0.8) (see Table 2), and ‘was 0.91 for the entire 34-item scale, ‘Stressors Experienced fndiescuals oath CRD ‘The relative intensity of individual stressors as measured by the CKDST is presented in Table 3. The six strese so1s with the greatest intensity all per= tained to physical symptoms: fatigue, kp problems pepherd neue: msde camps. estes logs m ramps, restless legs, a Uinmesclbeane Seagate A summary of overall coping strategies and their effectiveness as measured by ranked mean scores for subscales ofthe JCS are presented in Table 4. An optimistic coping style was the mast common strategy used and was rated the most effective, Other commonly used and effective srategies included confrontive, sup- portant, and self-reliant. talistic and emotive strategies ‘were less commonly used and also rated less effective. Table 5 presents the top-ranked individual item scores for the JCS as measured by the percentage of is who reported wsinga particu i Gither sometimes orolien. ranked items includ ed trying to keep life as narmal as possible (82%), trying to think posi- tively (80.9%), asense of humor (2.2%), thinking” about the ‘good things in one’s life (72.2), and ety unaectutences cto ens rei Gergen (seston erin se Lista Petar soya (re nar tot Luni en tgs na ete Hinged enthat crt Homacitssaces rear) “ain istrin anys str ey ee des Cameron ‘Donn tine olde peek Finjan ator an bes ‘aoanag ane va Gas armesin erty Far aang ane ourg tenn cate cen Sky ids et Digits Hino weet rds =] w 2 a a5 as wo to handle things one step at a time (72.5%). Peason’s correlation coeflicient CKD stressors scales and coping srategies are presented in Table 6, In general, positive comelations were Observed between coping str and stressors scales. Specifically, the higher the level of logistic, psychoso- cial, and physiological stress, the ‘more the patients used emotive, fatale istic, and evasive coping strategies, 321A Fvlnensty of Ses Multivariate CKD stage and average score on the coping use scales were positive associated’ with each stressor after controlling for socio-demo- graphic and clinical variables. An inverse relationship was observed between age and each stressor scale, This rela was statistically sige nificant for the and total stress gaales however, these relations ficance after controlling Sina voubles and coping (see ‘Table 7). The full model explained 3071 of the variance of total level of NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3Table 4 CNE ‘Summary of Coping Strategies Used and Their Effectiveness Among Patients with CKD as Measured by Subscales of the JCS* a ero} fs ee (eer) ‘Tiedt think positively ‘Tiedto keep a sense of humor ‘Thought about the good things in your life ‘Tied to handle things one step at a time ‘Tiedto keep situation under control “Tiedto keep busy “Tied to keep feelings under control “Tiedto find out more about the problem ™ Jalowiec Coping Scale stress experienced and 31%, 30%, and 29% of the logistic/extemal, chosocial, and physiological bib. scales, respectively Discussion In this study of patients with CKD, the authors have developed and (ested an instrument that was found to be aréiable and valid meas- ‘ure of stressors by this population, quantiied siesors exper rienced by those with CKD, and 1.8 (0.7) Controntive 1307) Supportant 12(07) Self-Reliant 1.4(07) Palliative 0.9 (05) Evasive 0.9 (05) Fatalistic 0.9 (06) Emotive 07 (06) * Jalowiec Coping Scale “Thiedto keep your life as normal as possible ‘Told yourself that things could be much worse Table 5 ‘Top Ranking Coping Strategies Used Either Sometimes or Often as Measured by Individual Items on the JCS* Fatigue, sleep problems, peripher al neuropathy, muscle cramps, resiless legs were the five mest fre quently reported stressors, in terms of coping strategies, ‘was used most ly and considered most effective among this patient - tion. While there are no other studies for comparison, there are a number of studies that report rank- ings of stressors for individuals on hemodialysis (Baldree et al, 1982; NEPHROLOGY NURSING JOURNAL = May-June 2009 « Vol. 36, No. 3 ‘Gurklis & Menke, 1995; Logan et aly 2006; Mok & Tam, 2001; Welch & ‘Austin, 1999) and peritoneal dialysis pe eae pee esac yuently x stressors df ke pease aul ae amma tizedin’ ‘8. Four studies reported fatigue, and in three of these, fatigue was the numberone stressor. This indicates that some stressors are simi- Jar across the continuum of renal dis- ease and treatment. Interestingly, sleep problems and peripheral neu ropathy, common problems. in patients with | y disease, were not Ported inthe 3m jin any, ie niin te pS og 7 )blems can be over‘Stressors and Coping in Individuals with Chromic Kidbuey Disease Table 6 Correlations Between CKD Stressor Scales and Coping Strategies ree Coping Strategies Used Optimistic 01 0.08 one 008 (Confrontive 0.14 o2t" oar 020" Supportant 0.10 025" 020" 023" Sef-Fliant 025" ozre 025" oso Palliative 0.18" 0.18" ae" 016 Beste oar oar oat O55 Fatalstic 028" oem oss ogo" Emotive oman oar oar sr AII60 coping strategies used 02a" os ose" 034" (Coping Strategies Kkientified as Being Elective ‘Optimistic 0.07 0.04 04 002 Contrentive 003 0.09 ang 0.10 Supportant 005 0.13 as, 013 Sef-Feliant 08 0.08 att 013 Palliative a3 0.10 ans 013 Beste ose" one oss as Fataltic x10 og" 7 o2t Emotive 25" oe oss oao™ AIL6D coping strategies identified as being effective 001 oz 22" ona "p< 0.05 p< 0.01 ps 0.001 "Note: Correlation between average use and average effectiveness was 0:1, p < 0.005, sion is cn the population potential loss and/or fear of the — with streswors or This finding assesed the dfniton of rey "unknown, Most recently, small study sts that CKDST measures stres- and ie croning, tol §) used ted that the prevalence of sorsrekted to CKD and not stressors ferson, 3N(B). depressive affect in patents with CKD related to comorbid conditions. In an eatly Sia oF Ob pales wih may be equivalent to that of patients In tems of rekationshi ESRD, 12 of the 17 patients who met _ with chronic medical conditions with- sodordanogerhic diel and cp: the criteria far depression at the time out renal disease (Cohen et al, 2007). ing variables on stressors, there are a developed major depression. before ihe non ot ae seplacnent Smith, Rabson, & peeny ir rthermore, ina study fa ‘s with renal disease, 16 ve fags al inte pe Sion than those already on dialysis (Sacks, Peterson, & Kimmel, 1%0). The authors of this study suggested that depression was a reaction to mm “The authors suggested that it isimpor- tant to diferentiate between the somatic itive symptoms Epresicnand dat is ceeiaion is very difficult in the medically il ‘The Charlston Comorbidity Index adapted for ESRD was used ‘Hemmdgam, ian, and Ghat 8) ase Sonbe id risk, y stage was not associated number of findings to note. Stress was inversely associated with age (see Table 7); older patients experienced fewer stresses than younger patents Gytobecome ee scar aout cyto less stressed about the unknown and uncentrollable, while at the same time, to utilize fewer and strategies that Mone Logan cal 2009 shel tree NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3Table 7 ‘Sequential Multiple Regression of Socio-Demographic, Clinical, and Coping Variables on Stressors Among Patients with CKD rr a Model: To coor Tog =e Poe) autre ela | All Stressors SESoa eo ‘Age me m= os2 |-os2 | a12 | os2 |os |oz7 |oss |sar|11 | 297 Sex(Female) 031 |.032 |.076 |-06 | 001 | 063 | 0.13 | 049 | 178 | 180 |047 | 157 Education 018 | 027 | 02 | a49 ) 029 | a29 | ome |o4s |-034 |-122 |.222 | 200 Months Sesing 004" | 0.04 ‘aot | oot 0.00 |-000 Nephrologist eer me ‘Cause of CKD 025 | 020 003 | 001 024 | att om | 033 Comarbicties os [an 021 |-039 03 |-0.19 213 | 287 Stage of CKD 255 |304" -240* | 253" -2.75 |-2.88" 9.70" |-11.05" (Creatinine (uno) 0.00 | 0.00 ‘cot | oot ot | aot oe | one Hemogboin (units) 000 | oot 0.07" | 005 -0.10" |-0.08" lor? | 0.14 ‘Atumin (units) 020 |.021 -031* | 025 -0.12 |-0.10 loa | 027 Urea (iris) on? | 0.18 003 |-001 -0.06 |-00e 028 | 040 (Coping — Use 296" aie" aq 1129" FY} oto | 027 | 031 | 003 p 030 |o.01 | 0.13 |o22 | 007/023 | 0.36 *p< 005 p< 001 p< 0.001 sors and coping in individuals on found, Thissan aea that requires fur» for this notion, Attendance at CKD hemodialysis who were over 65 years ther investigation, dinic ‘opportunities to Team of age (mean 76.4 years) “using Tn the current study, the stage of about kidney disease and treatment Baldkee and {i9RY) ster CKD was negatively conelated with options Sappetive interventions by sorsstaleand the JCS The findings paceivadsisorsand positively car members ofthe renal care team can demonstrated no’ agerdated ile related wih te use of coping Ste- provide opportuni for patents and ences in stressor scores. Perhaps the gies, suggesting that sage of 16 foes on coping and cop- disparity in findings is elated to dif CKD increased (for example, the ing strategies along the ines tra ferences in patient populations stude ied (sich as CKD vs. HD), In addi- tion, the mean ages of the samples (G4.5,vs. 764 years) was more than 10 years apart, which may further differences in fi The sample in this study contained 657% males and 357% females. A sepa- rate analysis) if males and females experience different stressors and use different coping styles was not ‘conducted since gender was not signif= icant in the regression model (ee Table 7) In the authors’ cuent review of the literature, no studies that exam ined gender differences in CKD with respect to siress and coping were severity of renal function increased), the number of stressors experienced decreased, and the use of coping strategies increased, Intuitively, one might surmise the opposite; as one neared dialysis, the number of stres- sors, ‘increase, particularly as renal funtion declined and patients experienced more symptoms. Per haps the findings of the current study reflect patients understanding oftheir conaition as well as increasing com fort with the care team and educative and supportive interventions over time, Patients had attended the clinic and known their renal care team an average of 4 years, lending support NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3 tory. A longitudinal study be important to study this phenomenon in of coping statesies, tems stm rmism was n y used most ly and was aonsicered the most Spanien epigsokeuce were also used frequently effective. Interestingly, the least used and least effective coping style was emative. lems on the re So nce oneself for omer ai ‘or taking out tensions on embeds Thea Salts neon,‘Stressors and Coping in Individuals with Chromic Kidbuey Disease Table 8 ‘Top Ranking Stressors n= Pair on ncerter HD USA n= 28 Patients wih CKD (non-dialysis) Canada n=0 id limitations Muscle camps Fatigue Fatigue Limitation of physical activity Muscle camps Fat Fluid limiaions Food imitations Fatigue Sleep preblems Petipheral neuropathy Patients over 65 years of ‘age on inoenter HD Canada n=64 Patients on PD Australia n=s0 Patients cn incentter HD Hong Kong n=8 Patients on incenter HD USA ito oe ey by ‘and colleagues (1996), which com JCS ses among 25 rat wih ‘CKD and 25 patients on hemodialysis for 3 to 9 months, The hemodialysis ip usec more fas confonata al pai) vars the CKD group, which used mereemotive st sswory- read geting navou). Klang et al. (it) atred ths dlfence to te ‘uncertainty about how the dialysis ‘aeatment will affect them, In the cu rentstudy, emotive coping styles were ted as the Kast used and the keast fective, However, in multivariate gnabses thas who higher wok of voclolegea nd th stress used more emotive and fatalsic coping strategies. This result could be interpreted tome tat as one experiences greater interst are! Hecpetey of siesars Uae ma Limitations on physical actly Decrease in social lie acivties Uncertainty concering fue id limitations Food liitations Pris Fd limitations Length of alysis treatments, Vacation imiations propersity to with emotive copingstyles, which inthis study, were the least effective. Summary of Results The Stitem CKDSI has been shown to be a reliable and valid tool to measure stressors experienced by individuals with CKD. The resulis from the CKDSI also support previ- ‘ous qualitative research ( et al, 2005) and wide further ‘acknowledgement that stressors pa- taining to I ‘around a meimpurent wells pouesecal are important, as well as psy i and physiological stressors, to individ- uals with CKD, Limitations Several limitations must be con- sidered when interpreting the find- ing of tis such, Fins comer: ence, non-randomized sample was used and limited to patients attending tne CKD cine in che renal in an urban academic center in Canada. ‘Thus, the demographics of this population may not reflect those “abel by papas stressors. identified by participants ‘were collected at one point in time and could ly reflect how the individual was feeling (stressed or not) on a day and may not reflect their general level of stress spe- Giic to their renal condition, Third, while the top 6 stressors were of a physical nature, it cannot be con- firmed that the stressors_ identified many of these par shad other cet ae tions. Implications for Practice and Research, This study provides valuable information for the renal care team to stressors experienced by Pacis with CRD Specie physical stressors like fatigue, sloep per aetchs eh muscle cramps, an shortness of breath were ma offen, reported. Those working with patients with CKD could include questions in their assessments regard- jing these physical symptoms, and if present, reassure patients that these lems have been reported by Other individuals with This may reduce fedings of fusiratin and isolation, and improve optimism, which has been shown to be an effec tive coping strategy. Strategies to eaten with these mpc be included in educational: interventions, which may ultimately contribute to improved quality of life. ‘The fifth most frequently ranked stressor in the curent study was “rest Jess legs” Although it was not cone firmed by the authors if these indlivid- uals were and diggs nosed with restless legs syndrome (RLS), it was that hav resless legs wee sues for this group of individuals. This may be a Contributing factor to the fatigue and NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3problems: as reponted by pa Eopants RIS vey reat son Isis; however, there is a lack of information about the prevalence of RLS in individuals with early CKD (Novaky Menddsohn, = Mucsi, 0s eee YY, anemia, ion and comorbidity are all known to be ‘contributing factors to RLS, and mec ications, calleine, nicotine, and aleo- hol may als a ‘symptoms (Novak eal, 2005. ‘Nursing assesment and history taking shauld explore ifthe patient is having problems with restless legs a ‘ ripheral neuropathy’ because any be all of these ul tribute to sleep fatigue. Ne ine Ne forcast treat exerts Nephrology nurses have a unique role in assessing, fatigue and coordinating the plan of care, (Williams, Crane, & ‘Kring 2007). Patient. education regarding iprove patients? reduce 2S ee ey hemoglobin levels ane an stimulating agent as, gS gent as my mee yo come in thar review of deep in patients on dialysis that there isa su prisingly lack of waledlesigned studies assgsing diferent heaps or fa in patients with ties exist for in this area More fest in the atea of faigie and CKD would increase understanding more filly and may contribute to more successful interventions and improvements in quality of life for patients, Jncividils in the cue study reported using most fre ge coping method and con- it the ment lieve. CKD team members need to develop strategies in their clinics that encaur- age patients to think positively and use humor dfectively, while at the same time, coach patients to. we s that keep life as normal for thames male In addition, CAD team members need to conser that re gresoreand cope les elie by These individuals may beneit from a collaberative team approach with a suppartive and educational phn of care that assists them with coping and managing their CKD. Conclusion The CKDSI developed for this study ia relable and valid mesure sliessors, experienced by patients sped rouped into three stressor subscales: psychological, and physio- lage Fags problems, and pesiphea ny were the most frequently reported Sresors. Opti ism asa coping style was most com- monly used and was also the most clfective. Older individuals and those who had more kidney dhsincien reported kess stress. Siress Was posi- tively associated with tab acter eet seresorsindiv uals with CRD experience and the coping sates they baiee to be fective. Knowledge gained fiom this study can beapplied io ection and supportive interventions for patients wih CKD. References Baldree, K> Mumphy, S, & Powers, M. (1k) Sess entation and op" ing pales in tients en Resa 3A), WPA. ce GW & Counts, NF (1996), strategies and’ styles of heeds tatioasby end. ANNA ra, 299) 177-80, Bin, M.A, Fearans, Cle, & Powers MJ. (Was Compansa, stesso, and yy of life of dialysis 1 jomed oS Bolla, WK & Owen WE (2002, rng the patent for" reel Tepheeneat“theapy,Teanerk Gguimizes ccs Grate Mating, T116), TAUB. Canadian Intute for Health Information (CHI). 05). Renal placement ther « NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3 CNE ‘fy in Crnada in 2003. Ottawa, Canada: Author CCanacian Insitute for Health Information (CIHD. (2008). Armuzd report — ‘Treatment | failure in Seat ke Cece Gaia! 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K/DOQI “is Rit dnl je Evaluation, classification andl strate Gavin Ameria Journal of i Disese, 392, Sapp}, Sk ‘National Kidney Foundation (NKH. (BU). K/DOQI dinical procice son dys Key dese ‘Kine Diss, Sema Shi Novak, eS TS hn, D., Shapiro, ia Mone ED. Dios and management a deep apnea Se an aie Iss in “2102. Paleter-Hibbet, M,, & Sob, P. (DO). Sources of” uncetanty and sttegjes sel by family members cE isha ig wih end seus 2a), Sat i ® a Pein, By, (000) aie SRD Gre tne ey wo inprded Gis otcames Kid halted, Sal, a51-3 ‘antinued on page 301 Jour Eta Board Seinen of Disclosure Inapcrsepuih ANC-COA an emg ues epfucbayNrsiy Jeu Ei Boal temas of isdo- ‘subarejued ih each Ce ofenrg. The seorentsof ccs or fis ofr ae puedo, Pail Duta MSA, AN, CNY, dca ta ste isa consult fr HofinereLa Pact ar hore of inca Tas br Focte, Pia 8. Carey MS, A, NP, lcs te she son tte Corte Prserier Bua for Amgen, Gaze, and Orhotiech, She fsa on he sescry Bord for Amgen, Gerame, ard Roche andis he Feapent of uresircted calor gras fom Ont cB and ote. Holy Faces Martin MSV, Fl, CNN, scsed tt she san aroaye of Det Io. Karn. Roti, MS, RN CAN ced tht she son fhe Speers’ Burau or Watson Pharma, no NEPHROLOGY NURSING JOURNAL = MaysJune2009 = Vol. 36, Na. 3Individuals with Chronic Kidney Disease cated fom page 276 Rages, AE (100), as rea deep disrders: Pat SE. so 3 She ar fg a uso Bet ce ve a By oma of Fate Diss 3), Sad Cl Ten Kine (00. Poplin of ites and dep digas. “hnctan una f Kiln Dies, 131) S130 Eee sea seh eah isimpect on Gat cas atl atin van al Rib Daa, 5D, TRB. Unie Sees Rar Da sem USD. 8, LSD oa - cd ta por of Hah, Site it f Dates ol Date Key wn Crest Shand OL & Ln, ER (100, Massooartn MA: EA. Davis wads CRs J Factors assciaed with trea rea in hemsonlabes pets AN wil nt Coahe Bi, & D, (005), F istan Amat, women on Kenedy. lay van ee Gra tLe 00t) Coping seas and init wih hanocetyss elon Nate, 6, i.ws CNE ANSWER/EVALUATION FORM Stressors and Coping in Individuals with Chronic Kidney Disease Loni Harwood, MSc, RN; Barbara Wilson, MScN, RN; Heather Locking-Gisolito, MScC, RN; Jessica Sontrop, PhD; Joan Spittal, MSW, RSW 7 Contact Hours Complete the Following: Expires: June 30, 2011 Name: ANNA Member Price: $15 Regular Price: $25 Address: Posttest instructions Select te best answer and circle the appropisie tir on hearswer gid Telephone: Emait . Spider ocncen te CNN: __Yes __No CDN: _Yes __No CHT: _Yes __No : angner frm to ‘ANNA Nona foe; East Hoy Payment: ue Bax Se;FYiman, NUOSO/1- NA Merrber: __Yes. __No Member #. (0056; or ex fis form 10 (5) 58+ ees ——__—____ ae eo 1 Oheck Enclosed ‘American Express. 1 Visa MasterCard + Endlosea check or meney order payable ANNA. 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Whal wouldbedforentin your pacts ifyouapaiad whal yuh eaned A fomtisactvy? Evaluation disagree = agree 2. Bycompleting his ofering, I vas able b meet he stated objecthes 4. Define pacholoieal tess, 12 Discuss two insruments use! measure stress and coping of pationts with dvonickiheydisense, = 12 ©. Blain efecihe coping strategies used by patients wih chronic kidnay disease, 12 ‘The content vas cuTent andlreloent. 12 This wasan effectne method learn this content, 12 Time required fo complete reacing assignment minutes. | eify that Lhave completed this activity, (Sonate) NEPHROLOGY NURSING JOURNAL = MaysJune 2009 « Vol. 96, No. 3 mReproduced with permission of the copyright owner. Further reproduction prohibited without permission.