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. 3develop 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