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AAMJ, Vol. 11, N. 3, Juli, 2013
1
PSYCHOLOGICAL STRESS AND COPING STRATEGIES
AMONG CHRONIC HEMODIALYSIS PATIENTS AT EL-
MINIA UNIVERSITY HOSPITAL
Fatma Elzahraa Sayied Bukhary *, Nadia Ebraheem Sayied**,
Manal Hassan Abo -El-Magd***, and Ebtsam Hanafy Saber***
Internal Medicine/ Faculty of Medicine-El-Minia University*,
Psychiatric Nursing, Faculty of Nursing - Assiut University **, and
Psychiatric & Mental Health Nursing, Faculty of Nursing- Minia / Umm
Al Qura Universities***
ABSTRACT
The individual maintained on hemodialysis is facing multiple and
potentially overwhelming stressors which impact the level of social,
psychological, and physical functioning. The patients use various
coping strategies to cope with the stressors related to their disease and
hemodialysis treatment. The study aimed to assess psychological
stress facing the hemodialysis patients, identify the coping strategies
used by these patients and investigate relationship between these
stressors and the coping strategies used by these patients, the study was
done in El-Minia University hospital at Dialysis Unit, in the period
from January 2011 to July 2011.The studied sample included 250
patients. A descriptive correlation design was utilized in this study.
Three tools were used for data collection, first tool included Socio-
Fatma Elzahraa Sayied Bukhary et al
2
demographic data, second tool emotion focused and problem focused
coping, third tool; Psychological stress scale taken from Depression,
Anxiety, Stress scale. The main results yielded by the study proved
that, 36% of patients had moderate level of stress while 14% of them
suffered from severe level of stress. As regards coping; 36% of
patients with age group > 40 years used problem- focused coping while
nearly half 49.6% of males and patients residing in rural areas used
emotion focused coping. The study recommended that programs should
be planned to educate nursing staff about stressors related to
hemodialysis treatment and coping strategies with these stressors, in
order to encourage patients to use more adaptive problem oriented
coping methods.
Key words: Stressors • Coping • Hemodialysis • End-stage renal
disease
Corresponding author: Nadia Ebraheem Sayied , Lecturer of
Psychiatric Nursing , Faculty of Nursing, Assiut University
Email: mailto:nadiaebraheem@ymail.com"
Tel: 01147861138
AAMJ, Vol. 11, N. 3, Juli, 2013
3
INTRODUCTION
Hemodialysis treatment results in many stressors and restrictions.
Patients receiving hemodialysis use various strategies to cope with
stress related to their disease and the treatment procedures. The kind of
coping strategies they use depends on their personal experience, social
support system, individual beliefs, and availability of resources
(Lazarus & Folkman, 1999). Stress is a part of human life and it can
cause either beneficial or detrimental effects on human beings which
can affect physical, emotional, economical, spiritual and social aspects.
Stress in human life is often equated with tension, anxiety, worry and
pressure (Potter & Perry 2001; Carol& Lindeman, 2007) &. (Annual
Report of the Egyptian Society of Nephrology, 2000).
One of the primary ways of people to cope with illness is by using
social support. However; the role of social support in adaptation to
chronic illness is unclear (Jalowiec, 2002; Deridder & Schreurs 2006).
The assumption that the use of social support coping would improve
patient outcomes following exposure to stressors may have ignored the
actual costs associated with using social support. In addition, social
relationships may be conflictual and experienced negatively (Tilden et
al., 2008).
Family members were important providers of social support for
patients (Kara et al., 2007).Adaptation and support can result in
advantageous outcomes and successful relationship within the family
Fatma Elzahraa Sayied Bukhary et al
4
and has a great impact on hemodialysis patients (Cukor etal 2010) .On
the other hand, marital and family connection can be the victim of
maladaptation such as depression, anxiety, sexual dysfunction.
Alternatively, factors associated with marital status seem to differ by
sex, (Finkelstein etal 2002, Takaki etal 2008).
Terry (2009). shows that coping strategies represent emotional,
behavioral and cognitive efforts to deal with stressful encounters Such
strategies had been classified by (Lazarus & Folkman 1999) as either
problem focused or emotion focused, thereby delineating the functions
of coping as dealing directly with the problem or with its emotional and
physiological outcomes, respectively. Other has shown problem
focused coping as more effective than emotion focused coping in terms
of emotional reactions and performance levels in a stressful situation
(Shanan et al., 1997; Zeidner 2010).
Significance of the Study:
There is an association between multiple stressors and coping
abilities was experienced by patients receiving hemodialysis. So that it
seems important to investigate how patients with chronic renal failure
who are treated by permanent hemodialysis cope with their illness and
related stressors. Data generated from this study may be helpful to
implement and evaluate program to increase patient's resiliency in the
AAMJ, Vol. 11, N. 3, Juli, 2013
5
face of stressors and enhance effective way of coping to promote sense
of wellbeing among this group of patient
Aim of the study:
1- Assess psychological stress related to hemodialysis patients.
2- Identify the coping strategies used by these patients when facing
various stressors.
Research design:
A descriptive correlation design was utilized for the study
Setting:
This study was conducted in El-Minia University hospital at
Dialysis Unit. This unit serves El-Minia Governorate and all
surrounding areas. The unit is divided into two sections, one for
hemodialysis patient and the other for peritoneal dialysis .Dialysis unit
includes about 45 beds.
Sample:
A Convenient sample of 250 hemodialysis patients (male and
female) from Dialysis unit at El-Minia University hospital constitutes
the study subjects.
T
To
oo
ol
ls
s
o
of
f
t
th
he
e
s
st
tu
ud
dy
y:
:
Fatma Elzahraa Sayied Bukhary et al
6
1- Sociodemographic characteristics of the studied sample including
sex, age, marital status, educational level, occupation, place of
residence.
2- Coping scale
a) Emotion focused coping or psychological status of the patient: that
includes six questions about change in psychological status of the
hemodialysis patients.
b) Problem focused coping towards physiological changes or problems:
that includes fourteen questions about changes in physiological
functions such as (respiratory functions, circulatory functions,
gastrointestinal, and urinary functions) and ways of coping that patient
used to cope with these problems. Health belief model (Walsh, 1995)
and modified by (Ahmed, 2000) was used. For each item, the
participants replied questions with No or Yes or Sometimes.
2- Psychological stress scale (Depression, Anxiety, and Stress Scale;
DASS )
Psychological stress scale is taken from DASS developed by
Lovibond & Lovibond, 1995. This scale includes three self-
report scales designed to measure the negative emotional states of
depression, anxiety and stress and stress. Each of the three scales
contains 14 items, divided subsequently. Fourteen items about stress
AAMJ, Vol. 11, N. 3, Juli, 2013
7
were used to measure psychological stress among hemodialysis
patients. It assesses difficulty in relaxing, nervous arousal, and being
easily upset/agitated, irritable/over-reactive and impatient. All
questions are rated on a 4-point ranging from (0) didn't apply to me at
all; (1) Applied to me to some degree or some of the time; (2) Applied
to me at considerable degree or good part of time; (3) Applied to me
very much, or most of time. The scoring system of this scale from 0-14
indicate normal , 15-18 mild ,19-25 moderate,26-33 severe and above
34 extremely sever.
Procedure: Preparatory phase:
An official letter was sent from the dean of the Faculty of Nursing,
El-Minia University, to the director of El-Minia university Hospital and
the manager of dialysis unit asking for permission to collect data. The
aim and process of study were briefly explained through direct personal
communication with the patients.
Ethical consideration:
Oral or written informed consent was obtained from the
patients for their approval to participate in this study. The researchers
reassured them about the confidentiality of the information. The
participant's dignity and privacy was maintained and respected
throughout the research process.
Pilot Study:
Fatma Elzahraa Sayied Bukhary et al
8
A pilot study was conducted at the beginning of the study. It included
10% of the total sample to investigate the feasibility of data collection
tools and their clarity. Subjects included in the pilot study were
excluded from the total studied sample.
Data collection:
Data were collected in the period from January 2011to
July2011.The researcher visit to the dialysis unit 4 days per week
(Saturday, and Sunday from 9 am, to 4pm and, Tuesday, and
Wednesday from 3 PM to 8 PM) because most of patients have dialysis
sessions 4 days per week. Patients were interviewed individually and
data were collected. Each interview lasts about 30 minutes.
Statistical Analysis:
The content of each scale was analyzed, categorized and then
coded by investigator. Subjects' responses to each category were
tabulated separately by using statistical package for social science
(SPSS) version 10. Descriptive statistics were calculated as
frequencies, percentage, were also used. P-value is considered
significant at or less than 0.05 and considered highly significant at or
less than 0.001.
AAMJ, Vol. 11, N. 3, Juli, 2013
9
RESULTS
Table (1) showed the socio-demographic data of the studied
sample. Near to half of the studied sample 44.8% were in the age group
that ranged from 20 to 40 years. While 41.6 % of them were married,
51.6% was illiterate. As regards occupation; 47.6 % were unemployed
and 55.2 % of them reside near by the unit when they received
treatment.
The frequency distribution of stress subscale of DASS showed
in Table (2). Questions no (2, 3, 6, 7, 9, 11, 12, 13&14) the patients'
answer by applied to me to some degree or some of the time; with
percentage (34.4%, 36.8%, 38.8%, 36.4%, 35.2%, 30.8%, 33.6,
&33.2). While patients' answer on questions no (5, 10, & 7) by did not
apply to me at all with percentage (55.2%, 40.4 & 36.4%).
Figure (1) demonstrates the distributions of stress levels among
the studied sample. Thirty six percent of the studied sample had
moderate level of stress, while 14% of them suffered from severe level
of stress and the rest of the sample had normal and or mild stress levels.
Table (3) shows that relationship between psychological stress
and socio-demoghraic data among the studied sample. There was
Fatma Elzahraa Sayied Bukhary et al
10
highly significant relation between stress as regards (age, marital status
& educational level) with (P= 0.00, & P= 0.004 respectively).
Meanwhile there was insignificant relation between stress and place of
residence with (P= 0.084). Patients in age group < 20 years, who were
single, had free work, and living in urban areas more susceptible to
suffer from severe and extreme stress than other patients.
Table (4) showed the frequencies distribution of the studied
sample according to their emotional focused coping. More than half of
the studied sample 58.4% satisfied with themselves, while 38.8% of
them sometimes become nervous. About half of the studied sample
50.8% reported that sometimes they fall under stress, fatigue and
tension. Also 61.2% of the studied sample sometimes feel worried, and
51.2% of them sometimes have difficulties in sleep.
Table (5) illustrates the distribution of the studied sample
according to their problem focused coping. The majority of the studied
sample 97.6% suffered from lack of urine output and 62.8% of them
cope with this problem by attention to go to dialysis regularly. As
regards hypertension and hypotension problems, 67.6% of the studied
sample suffered from hypertension, and 45.2% of the patients cope
with hypertension problem through taking the drug prescribed by the
doctor. Also 65.2% of the studied sample reported that they had
shortness of breathing at sleep time, and 54.8% of them taking a deep
breath to get rid of this problem, while 53.6% of the patients suffered
AAMJ, Vol. 11, N. 3, Juli, 2013
11
from the presence of swelling around the eyes, and 53.2% of them
reduced the salt in the food to cope with this problem.
Table (6) presents the relationship between socio-demographic
data and coping strategies among the studied sample. There is
significant relation between age according to emotion –focused coping
with (P= 0.00). Also there was significant relation between place of
residence according to problem- focused coping with (P= 0.04). Thirty
six percent of the patients with age groups > 40 years used problem-
focused coping; about half of males patients used emotion focused
coping while 40.0% of female patient used problem- focused coping.
As regards the place of residence 52.0% of patients residing rural areas
used emotion focused coping to cope with psychological stress.
Fatma Elzahraa Sayied Bukhary et al
12
Table (1): Frequency distribution of the studied sample according to their
Socio-demographic data (n=250):
%
NO.
SOCIO-DEMOGRAPHIC DATA
14.8
37
Age
◘ < 20
44.8
112
◘ 20 – 40
40.4
101
◘ > 40
55.2
138
Sex Male
44.8
112
Female
32.8
82
Marital status
◘ Single
41.6
104
◘ Married
5.2
13
◘ Divorced
20.4
51
◘ Widow
51.6
129
Educational level
◘ Illiterate
19.6
49
◘ Preparatory and secondary school level
26.4
66
◘ University level
2.4
6
◘ Post graduate level
47.6
119
Occupation
◘ Unemployment
11.2
28
◘ Employee
9.2
23
◘ Worker
AAMJ, Vol. 11, N. 3, Juli, 2013
13
9.6
24
◘ Free work
22.4
56
◘ Farmer
44.8
112
Residence
◘ Far from the unit
55.2
138
◘ Near to the unit
Table (2): Frequency Distribution of stress subscale of DASS
among the studied sample (n=250).
3
2
1
0
STRESS ITEMS
No
No
No
No
30.4
76
33.6
84
31.6
79
4.4
11
1.I am unable to
become enthusiastic
about anything after
the occurrence of
this disease
17.6
44
32.0
80
34.4
86
16.0
40
2. I am in a state of
nervous tension after
this disease
13.6
34
15.2
38
36.8
92
34.4
86
3. I felt I was pretty
worthless after this
disease
40.00
100
39.6
99
16.4
41
4.0
10
4. I am intolerant of
anything that kept
me from getting on
with what I was
Fatma Elzahraa Sayied Bukhary et al
14
doing.
1.6
4
11.6
29
31.6
79
55.2
138
5. I felt terrified
from my disease.
10.8
27
22.4
56
38.8
97
28.0
70
6.I could see nothing
in the future to be
hopeful about after
the occurrence of
this disease
6.8
17
20.4
51
36.4
91
36.4
91
7.I found myself
getting agitated
45.2
113
44.0
110
8.8
22
2.0
5
8.I found being
difficult to work up
the initiative to do
things
23.2
58
16.4
41
35.2
88
25.2
63
9.I found it is hard to
calm down after
something upset me
6.8
17
14.0
35
38.8
97
40.4
101
10. I felt that life was
meaningless
10.8
27
28.8
72
30.8
77
29.6
74
11. I am worried
AAMJ, Vol. 11, N. 3, Juli, 2013
15
about situations in
which I might be
panic and make a
fool of myself
12.4
31
24.0
60
33.6
84
30.0
75
12.I feared that I
would be" thrown"
by some trivial but
unfamiliar task
12.8
32
23.2
58
33.6
84
30.4
76
13. I found it is
difficult to tolerate
interruptions to
what I was doing
15.6
39
21.2
53
33.2
83
30.0
75
14. I experienced
trembling (e.g., in
the hands)
Fatma Elzahraa Sayied Bukhary et al
16
Severe
14%
Normal
26%
Extreme
1%
Mild
23%
Moderate
36%
Normal Mild Moderate
Severe Extreme
Figure (1): Frequency distribution levels of stress scale
AAMJ, Vol. 11, N. 3, Juli, 2013
17
among the studied sample (n=250)
Table (3): Relationship between psychological stress and
sociodemoghraic data among the studied sample (n =250).
VARIABLES
TOT
AL
NO
NORM
AL
STRES
S
MILD /
MODER
ATE
STRESS
SEVER
E
/EXTR
EME
STRES
S
X2
P
n
%
N
%
N
%
Sex
Male
138
44
31.
9
78
56.5
16
11.6
7.6
8
.014
*
Female
112
22
19.
6
69
61.6
21
18.8
Age
< 20
37
5
13.
5
20
54.0
12
32.4
34.
80
.000
***
20- 40
112
22
19.
6
68
60.7
22
19.7
Fatma Elzahraa Sayied Bukhary et al
18
> 40
101
40
39.
6
55
54.5
6
5.9
Marital
status
Single
82
10
12.
2
45
54.9
27
32.9
47.
57
.000
***
Married
104
30
28.
8
65
62.5
9
8.6
Divorce
d
13
6
46.
2
7
53.8
0
0.0
Widow
51
20
39.
2
25
49.0
6
11.7
Educat
ional
level
Illiterat
e
129
43
33.
3
75
58.0
11
8.5
29.
24
.004
**
Prepara
tory
&Secon
dary
school
level
49
11
22.
4
26
53.0
12
24.4
Univers
ity level
66
9
13.
6
43
65.0
14
21.0
Postgra
duate
level
6
3
50.
0
3
50.0
0
0.0
Doesn't
119
23
19.
69
58.0
27
22.7
27.
.034
AAMJ, Vol. 11, N. 3, Juli, 2013
19
Occupa
tion
work
3
76
*
Employ
ee
28
8
28.
5
14
50.0
6
21.4
Worker
23
6
26.
0
14
60.8
3
13.0
Free
work
24
6
25.
0
11
45.8
7
29.0
Farmer
56
23
41.
0
25
44.6
8
14.2
Place
of
residen
ce
Urban
102
21
20.
6
64
62.7
17
16.6
8.2
1
.084
Rural
148
45
30.
4
83
56.0
20
13.5
Place
of
home
Far
from
the unit
112
28
25.
0
65
58.0
19
16.9
12.
09
.017
*
Near to
the unit
138
38
27.
5
82
59.4
18
13.0
Fatma Elzahraa Sayied Bukhary et al
20
Table (4): Frequency distribution of emotion focused coping among chronic
hemodialysis patients (n=250).
NO.
ITEMS
8.8
22
1. In general are you satisfied about yourself?
◘ No
32.8
82
◘ Sometimes
58.4
146
◘ Yes
20.0
50
2. Do you feel sad and depressed?
◘ No
54.0
135
◘ Sometimes
26.0
65
◘ Yes
25.6
64
3. Are you nervous?
◘ No
38.8
97
◘ Sometimes
35.6
89
◘ Yes
14.8
37
4. Do you fall under stress or fatigue and tension?
◘ No
50.8
127
◘ Sometimes
34.4
86
◘ Yes
4.4
11
5. Do you feel worried?
◘ No
AAMJ, Vol. 11, N. 3, Juli, 2013
21
61.2
153
◘ Sometimes
34.4
86
◘ Yes
18.8
47
6. Do you find difficulties in sleep?
◘ No
51.2
128
◘ Sometimes
30.0
75
◘ Yes
Table (5) Frequency distribution of problem focused coping among
chronic hemodialysis patients (n=250)
Items
Patients response
No.
%
1. Do you feel nausea?
No
Yes or sometimes
163
87
65.2
34.8
2. If yes, what action they
took to get rid of this
problem?
◘ Reduce the intake of diet
and fluids to get rid of
vomiting
◘ Taking drug against
vomiting as doctor order
◘ Do not do anything
160
18
72
64.0
7.2
28.8
3. Do you have loss of
appetite?
No
Yes or sometimes
77
173
30.8
69.2
4. If yes, what action they
took to get rid of this
◘ Take frequent small meals
◘ Allowing the selection of
116
68
46.4
27.2
Fatma Elzahraa Sayied Bukhary et al
22
problem?
food but within the limits
allowed
◘ Do not do anything
66
26.4
5. Do you suffered from lack
of urine output?
No
Yes or sometimes
6
244
2.4
97.6
6. If yes, what action they
took to get rid of this
problem?
◘ Attention to go to dialysis
◘Taking a diuretic treatment
as doctor order
◘ Do not do anything
57
8
85
62.8
3.2
34.0
7. Do you tell the doctor that
your blood pressure is high?
No
Yes or sometimes
81
169
32.4
67.6
8. If yes, what action they
took to get rid of this
problem?
◘ Reduce the amount of salt
in food
◘ Raising the head by
pillows
◘ Take the drugs as doctor
prescription
◘ Do not do anything
83
36
113
18
33.2
14.4
45.2
7.2
9. Do you tell the doctor that
your blood pressure is low?
No
Yes or sometimes
180
70
72.0
28.0
AAMJ, Vol. 11, N. 3, Juli, 2013
23
10. If yes, what action they
took to get rid of this
problem?
◘ Eating salt plus food
◘ Adequate rest
◘ Take drugs as doctor
prescription
◘ Do not do anything
23
20
178
29
9.2
8.0
71.2
11.6
11. Do you feel shortness of
breath at sleep time?
No
Yes or sometimes
87
163
34.8
65.2
12. If yes, what action they
took to get rid of this
problem?
◘ Taking deep breath
◘ Raising the head by
pillows
◘ Taking a drug for the
expansion of the airways as
doctor order
◘ Do not do anything
137
60
10
43
54.8
24.0
4.0
17.2
13. Are you suffered from
the presence of swelling
around the eyes?
No
Yes or sometimes
134
116
53.6
46.4
14. If yes, what action they
took to get rid of this
problem?
◘ Reduce the salt in the food
◘ Taking drugs as doctor
prescription
◘ Do not do anything
133
35
82
53.2
14.0
32.8
Fatma Elzahraa Sayied Bukhary et al
24
Table (6): Relationship between socio-demographic data and
coping strategies among the studied sample (n=250).
VARIABLES
Emotion
Focused
Coping
X2
P
Problem
Focused
Coping
X2
P
N
%
N
%
Age
< 20
20
8.0
40.74
0.00**
17
6.8
36.30
.637
20- 40
75
30.0
37
14.8
> 40
11
4.4
90
36.0
Sex
Male
124
49.6
13.41
0.20
14
5.6
27.23
.129
Female
12
4.8
100
40.0
AAMJ, Vol. 11, N. 3, Juli, 2013
25
Place of
residence
Urban
10
4.0
10.50
0.39
92
36.8
32.18
.041*
Rural
130
52.0
18
7.2
DISCUSSION
Loss of renal function requiring hemodialysis leads to dramatic
life changes that would be expected to be stressful and to require major
coping efforts. The patient's ability to cope with the disease is
influenced by many factors such as the quality of family relationship,
life development stage, cultural values, beliefs, communications,
technological development and economic status (Devins etal 2010)
In the current study results revealed that male patients constituted
more than half of studied sample. This could be attributed to many
factors among them as health seeking behavior which is more common
among male than female in our culture, or might be attributed to culture
aspects as male is the dominant person in the family. Also it may be
attributed to certain associated problems that affect on renal function
such as hypertension which is prevalent in males (Gurklis &Menke
2008). These results are consistent with those of (Yeh & Chou 2009)
who found that hypertension plays an important role in affection of the
renal function and is more common among males than females.
Fatma Elzahraa Sayied Bukhary et al
26
The results of the current study found that about half of the
studied sample had moderate to severe level of stress. The study
results are congruent with the study of (Stapleton 2004) who found
that 55 % of patients had moderate to severe level of stress. They
categorized stressors faced by patients with chronic hemodialysis as
being related to physiological need, psychological need, role
disturbance, and daily activity. Also (Zeidner 2010) mentioned that
hemodialysis patients are subjected to multiple psychosocial and
physiological stressors and may be threatened with many potential
losses and lifestyle changes.
Ali (2006) Stated that this may be related to many factors such
as duration of dialysis which is a crucial determinant in perceived
stress and coping strategies. Also (Takaki et al., 2008) added that it
may be related to long-term restriction of food and fluid which is
difficult challenge for patients receiving hemodialysis, or
dependency on machine for life & dependency on others.
In this respect (Hafez 2006) reported that patients with hemodialysis
reported elevated level of stress because the difficulties on patient must
endure in having a chronic illness, and undergoing frequent
hemodialysis treatments that can be extremely stressful. Also the
secondary complications that hemodialysis treatment yield ,loss of
ability to work, transportation difficulties ,financial concerns, loss of
access to preferred activities and social experiences (Friedman 2007).
AAMJ, Vol. 11, N. 3, Juli, 2013
27
There was a wide variety of psychosocial and physical
problems faced by hemodialysis patients. (Abu Abdullah 2002) found
that the top three stressors experienced by hemodialysis patients were
uncertainty about the future, lack of economic resources, and changes
in life style. Also (Mohamed 2010) added that fluid limitation, muscle
cramps and fatigue considered the top physiological stressors.
The present study findings showed that female patients; were
more susceptible to suffer from severe and extreme level of stress than
male patients. This may related to female being more feeling stressed;
where male may consider this as showing weakness hence deny
reporting actual levels. Also natures of women are more fragile and
more liable for stress than men or it may be related to the impairment
in her social role as a mother, wife and her family role and
responsibilities. Another explanation by (Takaki et al 2008)who
reported that hemodialysis treatment affect on patient's body image
which may considered a source of stress for female more than male.
These results are congruent with (Youssef 2005) who indicated
that, female hemodialysis patients were more likely to report higher
level of stress than male. He added that female undergoing
hemodialysis treatment is more vulnerable to psychosocial disorders
than male, because of loneliness and life stresses. Psychological
problems such as depression and anxiety may be increased in female
patients group and this can affect the ESRD therapy and outcome while
Fatma Elzahraa Sayied Bukhary et al
28
male patients reported greater stress related to reproductive system
functioning than female.
In the same aspect (Ali 2006) mentioned that hemodialysis
female reported being significantly more stressed than male, even when
controlling for the number of life events and changes. In addition,
female were also more likely to feel that the major life events outside
of their control. Also (Hurst etal 2008) added that hemodialysis male
patient were more likely to be stressed by work, unemployment, living
situation, and conflict with friends and work, where as female were
more likely to be stressed by the health of family and her body image
change as a result of hemodialysis treatment.
In relation to age, marital status; patients with age group less
than 20 years and single; were more susceptible to suffer from severe
and extreme stress than other patient's .This could be attributed to many
factors among them. These patients perceive a threat to their life; feel
distress regarding their state of dependency on other family members,
reduction in ability to participate in social and enjoyment activities,
feeling of isolation and being tied to the machine during hemodialysis
hours.
Another explanation; ESRD and hemodialysis treatment affect
on reproductive function and other systems in the body which is
considered a source of stress for these patients as they feel a threat to
AAMJ, Vol. 11, N. 3, Juli, 2013
29
their roles as a partner, and later as a parent (Petrie & Weinman
2007;Pereira 2009). As regards occupation and place of residence;
patients had free work, reside urban areas, had more exposure for
severe and extreme stress than other patients .This might be related to
patient's ability to work affected with hemodialysis treatment. These
patients may vulnerable for loss of their job and economic resources in
addition to increase cost of treatment which may lead to increase level
of patient's stress (Daugirdas et al., 2007). Also (Eichel 2009)
physical and psychological problems that patients suffer as a result of
ESRD and hemodialysis may have a reduction in work enthusiasm.
This may be lead to feeling of failure and defect.
In relation to patients residing urban areas (Rashad, 2002 )
stated that, culture custom, beliefs and values that are different in
village than city. The patient reside urban areas may consider this
disease affects the social appearance, social role as a husband and as a
father. (Ali, 2006) added that ,it could be attributed to; low health
facilities in villages than cities which make patients unable to receive
care when they needed, also related to life style by it self is a stressful
in urban areas. .
In relation to emotion focused coping; more than half of the
studied sample had feeling of sadness, depression, feeling of worry,
and about half of them fall under stress, fatigue and had difficulties in
sleep. This result is consistent with previous studies of (Numan et al.,
1997and Peterson et al., 2001) they reported that, hemodialysis
Fatma Elzahraa Sayied Bukhary et al
30
patients had common feeling of depression, anxiety and uncertainty
about the future with an awareness of losses in quality of life. In this
respect (Nelson 2001) reported that this could be related to the physical
limitations due to extreme fatigue after dialysis treatment or to a
change in mood and loss of authority within the family or social
limitations. Another explanation by (Saleh 2003) who stated that, this
may be related to the change in the patient's life-style since the
commencement of dialysis and impact on his lives. Also patient's
nervousness could be attributed to his role change in the family from
independence to one of dependence.
Moreover (Lazarus & Folkman, (1998) suggested that emotion-
focused coping occurs primarily when an appraisal suggests nothing
can be done to alter or modify conditions. Also (Yeh &Chou 2009)
added that fluid and food restrictions and ambiguity-related stressors
among hemodialysis patient; were positively associated with coping
strategies that were emotion-oriented, involved avoidance, or isolated
thoughts (Table 5).
As regards problem –focused coping related to physiological
problem; results of the present study revealed that, about two thirds of
patients suffered from loss of appetite, while the majority of patients
suffered from lack of urine output. Also, more than half of the studied
sample had hypertension, dyspnea, while near to half of them suffered
from eye puffiness. These results are congruent with results of
AAMJ, Vol. 11, N. 3, Juli, 2013
31
(Mahmoud 2003) who found that, anorexia, nausea and vomiting are
the most common health deviation problems among hemodialysis
patients. However these results didn't agree with those of (Baldree et
al., 2001; Gurkils & Menke 2008) who reported that psychosocial
stressors such as decrease in social life and uncertainty about the
future; ranked highly frequent among patients undergoing
hemodialysis.
Also (Lok, 2002) attributed these symptoms to the disturbances
in body hemodynamic as results of renal failure disease and
hemodialysis treatment. Another explanation could be attributed to hot
weather in Upper Egypt with increased thirst sensation and
uncontrolled behavior related to fluid restriction. This is due to feeling
of dyspnea and eye puffiness (Ali, 2006). As regards GIT problems as
(anorexia, nausea & vomiting); the studied patients cope with these
problems through intake of small frequent meals, and reduce intake of
and fluids to get rid of vomiting. (Simpson et al., 2000) advised the
patient to take antiemetic medications to cope with nausea and
vomiting problems. (Youssef 2005) found that point of control was
linked only to dietary and eating habits. Also (Churchill et al., 2008)
added that the patterns of meals during the day are matter of personal
preference to improve anorexia, nausea, and vomiting problems among
chronic hemodialysis patients.
In relation to patients coping with oliguria, hypertension and
dyspnea; results revealed that there are increase in the number of
Fatma Elzahraa Sayied Bukhary et al
32
patients maintained regularly dialysis to cope with lack of urine output
problem, while about half of them follows doctors' orders as taking
medication to control hypertension, and more than half of them taking
a deep breath to relive dyspnea. All of these measures are considered as
the general pattern reaction used by patients automatically. In this
aspect (Hussein et al., 2008) mentioned that, dietary sodium restriction
is essential for controlling and coping with hypertension problems in
patients with chronic kidney disease. Also (Strippoli et al., 2006)
recommended that multiple antihypertensive agents are required for
management of hypertension in patients with chronic kidney disease .
The study results show that 36% of the studied sample with
age group > 40 years used problem focused coping. These results are
congruent with those of (Logan et al., 2006) who found that the
hemodialysis patient with ≥ 50 years experienced fewer stressors than
younger patients. Perhaps on aging , there is a tendency to become less
stressed about their disease, while at the same time utilize more
familiar and effective coping strategies that worked successfully during
past situations.(Felder, 2004) reported that, this could be attributed to
patients in this age may continuously appraising the disease
symptoms and progression with respect to their significance for well-
being, and survival. Therefore, different coping strategies will appear
inter-changeably. Also (Felton etal 2006) stated that patients with age
group > 40 years may experience less stressors, more adaptation and
AAMJ, Vol. 11, N. 3, Juli, 2013
33
used more effective coping strategies with their disease and stressors
than younger patients. Also patients in this stage of age trying to keep
life as normal as possible, trying to think positively, maintaining a
sense of humor, thinking about the good things in one’s life and trying
to handle things with less distress.
Concerning gender differences in relation to coping; the study
results showed that about half of male patient used emotion focused
coping while female patient used problem focused coping. This could
be related to specialized biological differences in the genders. Female
produce hormone called oxytocin in far greater abundance than do
male. This hormone is secreted in large amounts right before childbirth
and when women are breast feeding children. It's also present at other
times and may prove an additional help when a female cope with
stress. Also secretion of this hormone tends to create a sense of calm,
comfort and might explain why female used effective coping (problem
focused coping) than male (Hafez, 2006).
(Guerin etal 2009) added that female undergoing hemodialysis
may be protected against disease and hemodialysis stressors. This
could be related to the way of upbringing female. This way may
encourage them to discuss their feelings better than male, which can
help them to avoid the sensation that stress is overwhelming and may
make them more able to cope with stress with greater ease than male.
Fatma Elzahraa Sayied Bukhary et al
34
In this respect (Matheny etal 2005) mentioned that female
undergoing hemodialysis treatment using adaptive coping strategies,
while male were more likely to use maladaptive and avoidance coping
strategies. Also they added that female were more likely to eat, pray,
and talk to friends and families to cope with hemodialysis stressors,
while male were more likely to drink alcohol, smoke, drug abuse, and
ignore the problem when faced with a stressful situation.
However, these results disagree with the study of (Ptacek etal
2006) who found that chronic hemodialysis males more use problem-
oriented coping strategies than female. However, the male were more
likely to use coping strategies that involved avoidance than female.
This avoidance behavior included heavy smoking, irregular over-
eating, and getting drunk more often than before hemodialysis
treatment. The behavior commonly has gender stigma on male than
female. In this respect (Coelho etal 2008) added that hemodialysis
female tended to use social support and help-seeking behaviors to cope
with stress, which may be protective factors against the incidence of
depression and anxiety disorders where as male were more likely to use
maladaptive and avoidance coping strategies.
On the other hand (Pereira 2009) found that there are some
factors affecting the way of coping with stress among chronic
hemodialysis male and female. These factors such as perceived social
support and reliance on religion and spirituality may influence female
AAMJ, Vol. 11, N. 3, Juli, 2013
35
more than male. They also added that male and female undergoing
hemodialysis may attribute different values to elements of health, such
as physical strength or the impact of health on independence. They
showed that important insights are gained by considering health
outlook and treatment preferences among females and males with
hemodialysis affecting on coping strategies.
As regards place of residence; the results revealed that more than
half of the patients residing rural areas used emotion – focused coping,
while less than half of patients residing urban areas used problem
focused coping. This may be related to biologic, and socio-culture
differences such as; family and community influences that generate
greater perception of social support and spiritual resources. There are
differential experience between urban and rural patient before dialysis
start, as well as differential use of cognitive strategies that facilitate
coping with stressors (Ali, 2006).
Fatma Elzahraa Sayied Bukhary et al
36
CONCLUSION
The main results yielded by the study proved that 36% of patients
had moderate level of stress while 14% of them suffered from severe
level of stress. As regards coping; patients with age group > 40 years
used problem- focused coping while males and patients residing in
rural areas used emotion focused coping.
RECOMMENDATION
The study recommends that programs should be planned to educate
nursing staff about stressors related to hemodialysis treatment and
coping strategies with these stressors, in order to encourage patients to
use more adaptive problem oriented coping methods.
Liaison psychiatric nurse should be available to deal with the
psychiatric problems of these patients with chronic hemodialysis
patients.
AAMJ, Vol. 11, N. 3, Juli, 2013
37
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