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Saudi J Kidney Dis Transpl 2015;26(2):255-262

2015 Saudi Center for Organ Transplantation Saudi Journal

of Kidney Diseases
and Transplantation

Original Article

Coping Methods to Stress Among Patients on Hemodialysis

and Peritoneal Dialysis
Kobra Parvan1, Ronak Ahangar1, Fahimeh Alsadat Hosseini2, Farahnaz Abdollahzadeh1,
Morteza Ghojazadeh3, Madineh Jasemi1
Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz, 2Department
of Medical-Surgical Nursing, School of Nursing and Midwifery, Student Research Committee,
Shiraz University of Medical Sciences, Shiraz, 3Department of Physiology, Tabriz University of
Medical Sciences, Tabriz, Iran

ABSTRACT. Dialysis patients need to deal and cope with various aspects of their disease.
Identifying the adaptation methods provides valuable information for planning specific treatment
and medical care delivery and improving the performance of medical teams. The present study
aims to evaluate the coping strategies to stress among patients undergoing hemodialysis (HD) and
peritoneal dialysis (PD) at the Imam Reza Educational-Medical Hospital, Tabriz, West Azarbaijan,
Iran. This descriptive and analytical study was conducted on 70 patients in the year 2012. The
subjects were selected through census method and simple random sampling method. Data were
collected using a customized questionnaire and consisted of demographic information and the
Jalowiec Coping Scale (JCS) through a structured interview. Descriptive and inferential statistics
were used to analyze the data in SPSS (version 13). The mean score of frequency of use of the
coping strategy as sometimes used for the HD patients was 70.94 18.91 and also for PD
patients as seldom used was 58.70 12.66. The mean score of helpfulness of coping strategies
in the HD group was 49.57 19.42 as slightly helpful, whereas in the PD group it was 37.21
14.38 as slightly helpful Furthermore, both groups used the emotion-oriented coping styles
more frequently than the problem-oriented methods. HD patients used coping methods more
frequently than the PD patients. The majority of patients used emotion-oriented coping strategies
to deal with stress factors. Use of educational, counseling and supportive programs to assist in
coping techniques can facilitate the coping process with stress factors in dialysis patients.

Correspondence to: Introduction

Fahimeh Alsadat Hoseini End-stage renal disease (ESRD) is an irrever-

Department of Medical-Surgical Nursing, sible clinical condition with loss of kidney
School of Nursing and Midwifery, function resulting in dependence on renal re-
Student Research Committee, Shiraz placement therapy.1,2 There are three types of
University of Medical Sciences, Shiraz, Iran renal replacement techniques, including hemo-
E-mail: dialysis (HD), peritoneal dialysis (PD) and kid-
256 Parvan K, Ahangar R, Hosseini FA, et al

ney transplantation.1 Materials and Methods

According to a report of the Kidney Patients
and Renal Transplantation Research Center in Research design
Iran, 2007, about 29,000 patients are suffering An analytical, cross-sectional study was per-
from chronic kidney failure in this country; formed to evaluate the coping strategies at the
50% of them are receiving HD, 47.5% are re- Imam Reza Educational-Medical Hospital
ceiving transplantation and the remaining (Tabriz, Iran) among patients undergoing HD
2.5% are undergoing PD.3 and PD in 2011.
Each treatment method has some require-
ments, benefits and considerations.4 They help Population and sample
patients with ESRD; however, they are con- The study patients included those undergoing
sidered as a source of stress.5 HD treatment is HD and PD at the Imam Reza Educational-
highly inflexible and patients, in addition, Medical Hospital, Tabriz, Iran. Census sam-
need to cope with various aspects of their di- pling was applied on HD patients and all
sease. These patients often have difficulty in interested patients were included in the study.
coping with the diseases stress factors.6 Typi- Simple random sampling was applied for PD
cal HD stress factors include physical depen- patients. A total of 70 patients undergoing HD
dence on devices, limitations in physical func- and 70 other patients on PD were selected by
tion, changes in sexual function and diet, fluid the simple random sampling method.
restriction, taking large doses of drugs for Inclusion criteria included age 14 years,
treatment and loss of appetite and energy. absence of cognitive impairment or psycho-
Psychosocial stress factors include not having logical disease such as depression, absence of
adequate time to perform dialysis, loss of job, acute diseases, physical and mental capability
loss of independence, changes in self-percep- to answer the questions, on hospital HD for at
tion and fear of death.6 Like HD, there are some least six months and two to three times a week
stress factors for PD also. The complex the- and PD for at least six months and four times
rapy severely restricts the patients' activities in replacement of the solution per day.
ambulatory PD and causes loss of independence, For data collection, a two-part questionnaire
financial stress, changing roles, changing self- was used; personalsocial characteristics and
esteem and breakdown of family life.7 the Jalowiec Coping Scale. The first part con-
Coping with chronic illness is always a chal- sisted of six questions regarding the personal
lenging and threatening process, and health- social characteristics of HD and PD patients,
care providers need to be aware of these including age, gender, job status, income, ma-
conditions.8 If coping strategies are used effec- rital status and dialysis duration.
tively, they can help in improving the per- The second part comprised of the Jalowiec
formance and well being of individuals. Un- Coping Scale. The 60-item scale (representing
derstanding the processes that dialysis patients eight coping styles) was applied to determine
pass through can help the health-care pro- the coping strategies of dialysis patients.
viders to efficiently manage their patients.8,9 The eight coping styles comprised of the fol-
Studies on the coping strategies are required lowing: Confrontive (10 items/strategies); eva-
because of the following reasons: (a) The con- sive (13 items/strategies); optimistic (nine items/
flicting findings of the published studies on strategies); fatalistic (four items/strategies);
this topic,4,10-12 (b) the impact of cultural dif- emotive (five items/strategies); palliative (seven
ferences in experiencing stress factors in diffe- items/strategies); supportive (five items/strate-
rent communities13 and (c) the limitations of gies) and self-reliant (seven items/strategies).
the studies regarding the adaptation strategies, Confrontive and supportive items were classi-
particularly in patients on PD. The current fied as problem-oriented coping styles. Eva-
study aimed to evaluate the coping strategies sive, optimistic, palliative, emotive, fatalistic and
of HD and PD patients. self-reliant items were attributed to emotion-
Coping methods to stress among HD and PD patients 257

oriented coping styles. In the current study, 37 The validity and reliability of the question-
items were categorized as emotion-oriented naire has been assessed in other studies.
coping styles and 23 as problem-oriented co- Twenty-five nurse researchers familiar with
ping styles. Participants answered each item in the literature about stress and coping methods
two ways: (a) frequency of use and (b) per- approved the Jaloweics Coping Scale.14,15 A
ceived helpfulness. In this regard, the ques- Cronbachs Alfa coefficient of 0.86 for total
tionnaire consisted of two parts, A and B. questionnaire was obtained in the study of
Part A consisted of questions related to fre- Burns.16
quency of use of coping strategies (never, sel- However, the validity and reliability of the
dom, sometimes and often) based on a four- questionnaire has not been studied in the
item scale. The score of each of the response Iranian society. A forwardbackward transla-
was 0 to 3. The scores ranged from 0 to 180. tion method was used to translate the original
In part A of the questionnaire, a total score of English version of this questionnaire to
0 meant never used, 160 meant seldom Persian language. A literature review and stan-
used, 61120 meant sometimes used and dard questionnaire was utilized to assess the
121180 meant often used. The highest validity of the instrument. Also, a total of
score showed the highest rank of coping stra- seven faculty members of nursing and
tegies. Part B was dedicated to the questions midwifery schools of the Tabriz University
on quality of the coping strategies by the pa- Medical Sciences assessed the intelligibility of
tient. The answers included helpful, slightly the instruments content. Revisions were made
helpful, fairly helpful and very helpful. The according to the suggestions received. The
scores were based on a four-item scale. The reliability of the data collection measure was
score of each of the response was 03. The determined using testretest. Ten eligible pa-
scores ranged from 0 to 180. In part B of the tients were interviewed, and, after two weeks,
questionnaire, a total score of 0 meant not the same people were interviewed again. The
helpful, 160 meant slightly helpful, 61 responses were then compared and the corre-
120 meant fairly helpful and 121180 meant lation coefficient was measured. The corre-
very helpful. The highest score showed the lation coefficient of the Jalowiec Coping Scale
highest rank of coping strategies. was 0.81.
Table 1. The demographic characteristics of the study participants.
Peritoneal dialysis Hemodialysis
Variable Group
number (%) number (%)
Age (years) 43.67 14.96 50.71 16.16
Male 29 (41.4) 47 (67.1)
Female 41 (58.60) 23 (32.9)
Unemployed 8 (11.4) 19 (27.1)
Employed 5 (7.1) -
Self-employed 14 (20) 19 (27.10)
Housewife 36 (51.4) 22 (31.40)
Retired 1 (1.4) 5 (7.1)
Other 6 (8.6) 5 (7.1)
Income less than expenses 30 (60) 34 (64.2)
Income Income = expenses 20 (40) 16 (30.1)
Income more than expenses 0 (0) 3 (5.7)
Single 7 (10) 4 (5.7)
Married 61 (87.1) 65 (92.9)
Marital status
Divorced 0 (0) 1 (1.4)
Widow 2 (2.9) -
Dialysis treatment
23.84 15.35 34.39 21.71
duration (months)
258 Parvan K, Ahangar R, Hosseini FA, et al

The data were collected using a structured tistics (frequency, percent and mean and stan-
interview by the questionnaire. The researcher dard deviation) and non-parametric inferential
was referred to the HD and PD departments of statistics (KruskalWallis, U-MannWhitney)
the Imam Reza Educational-Medical Hospital, and Spearman correlation coefficient were
Tabriz, Iran to interview the patients and ask applied. The significance level was P <0.05.
them to complete the questionnaires.
Ethical consideration
Approval of the current study was obtained The demographic characteristics of the pa-
from the Research Deputy of the Nursing tients who participated in the study are pre-
School of the Medical Sciences of Tabriz sented in Table 1. The priority of coping stra-
University and the Ethical Committee. Because tegies based on the most frequent use and
the data collection method was based on helpfulness in patients undergoing HD and PD
interview, patients were explained about the are shown in Tables 2 and 3.
study details and full confidentiality of the The mean score of usage of coping strategies
information was ensured. Also, return of the in the HD group was 70.94 18.91 as some-
completed questionnaire was identified as times used. The mean score of usage of co-
giving consent to participate in the study. ping strategies in the PD group was 58.70
The data were analyzed using statistical 12.66 as seldom used.
package of SPSS (version 13). Descriptive sta- About the helpfulness of the applied coping
Table 2. Respective ranking for use and helpfulness of items from the Jalowiec coping scale, based
on highest mean scores in hemodialysis patients (N = 70).
Coping strategies
Use Mean (SD) Helpfulness Mean (SD)
17 - Prayed or put your trust 17 - Prayed or put your trust in
1 2.97 0.02 2.96 0.03
in God God
12 - Accepted the situation 36 - Tried to distract yourself
2 because very little could be 2.19 0.06 by doing something that you 2.02 0.09
done enjoy
58 - Hoped that things would 3 - Ate or smoked more than
3 1.97 1.09 2 0.25
get better usual
21 - Waited to see what 39 - Tried to keep a sense of
4 1.96 0.1 1.96 0.09
would happen humor
42 - Talked the problem over
52 - Preferred to work things
5 1.96 0.92 with someone who had been 1.94 0.11
out yourself
in a similar situation
23 - Resigned yourself to the
58 - Hoped that things would
6 situation because things 1.9 0.08 1.86 1.07
get better
looked hopeless
49 - Compared yourself with
18 - Tried to get out of the
7 1.9 0.11 other people who were in the 1.79 0.19
same situation
1 - Worried about the 34 - Took a drink to make
8 1.9 0.12 1.73 0.08
problem yourself feel better
45 - Learned something new
2 - Hoped that things would
9 1.79 0.11 in order to deal with the 1.71 0.28
get better
36 - Tried to distract yourself 32 - Told yourself not to
10 by doing something that you 1.77 0.11 worry because everything 1.68 0.12
enjoy would work out fine
Coping methods to stress among HD and PD patients 259

Table 3. Respective ranking for use and helpfulness of items from the Jalowiec Coping Scale based
on the highest mean scores in peritoneal patients (N = 70).
Coping strategies
Use Mean (SD) Helpfulness Mean (SD)
17 - Prayed or put your trust 17 - Prayed or put your trust in
1 2.94 0.03 2.9 0.05
in God God
25 - Tried to change the 3 - Ate or smoked more than
2 1.97 0.04 2 0.2
situation usual
2 - Hoped that things would 52 - Preferred to work things
3 1.96 0.09 1.63 0.48
get better out yourself
52 - Preferred to work things 9 - Expected the worst that
4 1.9 0.74 1.61 0.08
out yourself could happen
18 - Tried to get out o f the 5 - Told yourself that things
5 1.9 0.07 1.6 0.07
situation could be much worse
30 - Tried to keep your life as
14 - Daydreamed about a
6 1.89 0.09 normal as possible and not let 1.51 0.07
better life
the problem interfere
30 - Tried to keep your life as
39 - Tried to keep a sense of
7 normal as possible and not let 1.89 0.04 1.46 0.08
the problem interfere
12 - Accepted the situation
53 - Took medications to
8 because very little could be 1.86 0.08 1.45 0.57
reduce tension
49 - Compared yourself with
4 - Thought out different
9 1.7 0.09 other people who were in the 1.43 0.29
ways to handle the situation
same situation
58 - Hoped that things would 21 - Waited to see what would
10 1.64 0.72 1.42 0.07
get better happen

strategies, the mean score of the HD group tegies in the two groups of dialysis patients.
was 49.57 19.42 as slightly helpful. The The use and helpfulness of coping strategies in
mean score of the PD group was 37.21 HD patients were more than in patients under-
14.38as slightly helpful. going PD (Table 4).
The U-MannWhitney test showed a signi- The Spearman correlation test showed a
ficant difference between the use of coping direct and strong relationship between the use
strategies and the helpfulness of coping stra- and helpfulness of the coping methods in both

Table 4. The comparison of the mean score of the use and helpfulness of coping strategies in hemodialysis and
peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.
Coping strategies
The use of coping strategies Helpfulness of coping strategies
Mean SD Mean SD
Group The use of The use of Helpfulness Helpfulness of
problem- emotional- of problem- emotion- Sum of
Sum of scores
oriented oriented oriented oriented scores
method method method method
Hemodialysis 17.46 4.08 53.07 14.11 70.49 1 8.19 13.18 5.29 36.39 14.3 49.57 19.42
16.93 3.27 41.76 9.39 58.70 12.66 10.09 3.9 24.13 10.48 37.21 14.38
U = 1534 U = 1531
Statistical results
P 0.001* P <0.001*
*P 0.05 is considered significant.
260 Parvan K, Ahangar R, Hosseini FA, et al

Table 5. The association between the score and the effect of coping strategies among hemodialysis and
peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.
Coping strategies
The correlation between the use and
The use of coping Helpfulness of
Group helpfulness of coping strategies
strategies coping strategies
Statistical relationship
Mean SD Mean SD
P n rs
Hemodialysis 70.49 18.19 49.57 19.42 0.001* 70 0.87
Peritoneal dialysis 58.70 12.66 37.21 14.38 0.001* 70 0.80
*P 0.05 is considered as significant.

groups (Table 5). There was a weak and nega- emotion-oriented styles more often in coping
tive correlation between age of the patient and with the challenges and stresses related to the
use of coping strategies in HD patients. The disease and treatment.1,19-22 The findings of the
older the patient, the lower was the use of co- present study are in accordance with the results
ping strategies (r = -0.31, P = 0.008). Similar of many previous studies. However, the study
findings were seen among PD patients as well; performed by Ghaffari et al showed that the
older the patient, lower was the use of coping majority of HD patients used problem-oriented
strategies (r = -0.23, P = 0.05). There was no coping strategies to deal with stress factors;12
significant association in the other variables. this finding is inconsistent with the results of
the current study. The reasons for the discre-
Discussion pancy between these findings can be the diffe-
rent research methodology used as well as the
The present study aimed to evaluate the co- different study population.
ping strategies in two groups of patients In this study, patients on HD and PD used
undergoing HD and PD. Also, the association coping methods sometimes and seldom,
between the methods was compared in the two respectively, for coping with the existing con-
groups of patients. ditions. Coping methods were slightly helpful
Among the 10 most frequently used com- in both groups of patients, and emotion-orien-
ponents, the highest coping strategy in both ted coping strategies were more frequently
groups was Prayer and trust in God. Like the used than problem-oriented coping methods by
present study, in many previous studies, both groups of dialysis patients. In earlier
Prayer and trust in God has been rated studies,23 problem-oriented styles were more
highly in HD patients.16-18 One of the most helpful than emotion-oriented styles in dealing
important coping strategies of PD patients in with stress factors. On the other hand, accor-
the study of Zimmer was Prayed or put your ding to Miller, the emotion-oriented coping
trust in God.1 mechanism is used when the stress events
Generally, in the present study, the religious cannot be controlled with other methods.24
aspect, including praying or trust in God, was However, limited use of the problem-oriented
the most frequently used and helpful coping coping strategies by the patients can, at times,
strategy in HD and PD patients; this is largely be due to lack of patients knowledge on the
related to the prominent position of religious helpfulness of these mechanisms in stress ma-
beliefs in the culture and life of Iranian people. nagement. Additionally, because the individuals
The mean score of dialysis patients (HD and are not required to learn and apply special skills
PD) regarding the use and helpfulness of to use specific emotion-oriented coping strate-
emotion-oriented coping strategies was higher gies, problem-oriented coping methods are rarely
than problem-oriented coping methods. Based adapted. Thus, organized planning and training
on the studies performed by many researchers, as well as assessment of problem-oriented
it was found that HD and PD patients use the coping strategies in patients are required.
Coping methods to stress among HD and PD patients 261

There was a significant association between Conclusions

the use and helpfulness of coping strategies in
both groups. Their use was more beneficial in The majority of patients in the current study
the HD patients than in the PD patients. used emotion-oriented coping strategies to
Previous studies have shown that patients deal with the stress factors. Although many of
treated with HD experience significantly the emotion-oriented coping strategies were
higher stress levels than patients undergoing identified as helpful coping strategies by the
PD (P <0.001).25,26 Goker showed that 65.2% patients, because the problem-oriented coping
of HD patients had an associated psychiatric strategies are more difficult to respond, these
disorder, the most common being depression methods were not adequately applied, which
and/or anxiety.22,27 Studies have shown that the could be due to lack of knowledge among the
level of depression among patients undergoing patients. Furthermore, considering the impor-
HD was higher than in patients undergoing tance of understanding all aspects of stress
PD.22,28-30 It could be because PD is less inva- factors and coping strategies, regular psychia-
sive and less restrictive than HD.22 tric assessment and counseling could facilitate
In the current study, there was a strong and the coping process of dialysis patients with the
direct association between the use and helpful- stress factors and lead to improvement in the
ness of coping strategies in both patent-groups. quality of life as well as promoting physical
Despite the frequent use of emotion-oriented and mental health of these patients.
coping strategies, indeed greater use of coping
strategies (emotion-oriented or problem-orien- Conflict of interest: None declared.
ted coping methods) was found to lead to
higher and helpful coping strategies in both Neither this manuscript, nor one with subs-
groups of dialysis patients. tantially similar content under my authorship,
We also found that with an increase in the has been published or is being considered for
age in patients treated with PD or HD, the use publication elsewhere, and all the data col-
of coping strategies was significantly lower. In lected during the study is presented in this
the study performed by Logan et al and Cheng manuscript and no data from the study has
et al, similar results were obtained in patients been or will be published separately.
undergoing HD and PD.18,31 It is likely that
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