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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

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