Stressors and Coping in Individuals With Chronic Kidney Disease
Stressors and Coping in Individuals
With Chronic Kidney Disease Continuing Nursing
Lori Harwood Jessica Sontrop
Barbara Wilson Joan Spittal
n the United States, it is estimated
The purpose of this study was to develop a valid and reliable instrument to measure
that the prevalence of chronic kid-
stressors of patients with chronic kidney disease (CKD), identify those stressors, and
ney disease (CKD) has increased
determine which coping strategies were used and effective. The participants reported
20% to 25% in recent years, with
fatigue, sleep problems, and peripheral neuropathy as the most frequently experienced
significant associated burden of illness
stressors. Optimism as a coping style was most commonly used and was also the most
(United States Renal Data System
effective. Stress was inversely associated with age and CKD stage, and positively associ-
[USRDS], 2008). In Canada, the inci-
ated with coping. Knowledge from this study can be used to further patient education
dence of end stage renal disease
and supportive interventions for patients with CKD.
(ESRD) is increasing at a rate of 6.5%
per year (Canadian Institute for Goal
Health Information [CIHI], 2005), To provide an overview of a valid and reliable instrument used to measure stressors
with a 69.7% increase in prevalence of patients with chronic kidney disease, identify those stressors, and determine which
since 1997 (CIHI, 2008). As coping strategies were used and effective in the study.
researchers focus on the prevention
Lori Harwood, MSc, RN, is an Advanced Practice 1. Define psychological stress.
Nurse, the Adam Linton Hemodialysis Unit, the 2. Discuss two instruments used to measure stress and coping of patients with
London Health Sciences Centre, London, Ontario, chronic kidney disease.
Canada, and is a member of the MichigANNA
Chapter. 3. Explain effective coping strategies used by patients with chronic kidney disease.
Barbara Wilson, MScN, RN, is an Advanced
Practice Nurse, the Adam Linton Hemodialysis or delay in the progression of CKD, disciplinary team for care of patients
Unit, the London Health Sciences Centre, London, the psychosocial aspects imposed by with CKD. To deliver adequate med-
Ontario, Canada, and is a member of the the disease are also worthy of study ical and psychosocial preparation,
because these, too, influence patient patients should be assessed in such a
Heather Locking-Cusolito, MScN, RN, at the time outcomes. clinic as soon as possible (NKF,
of data collection, was a Nurse Practitioner/Clinical Care of individuals with CKD 2002b) or at least 12 months prior to
Nurse Specialist, the Adam Linton Hemodialysis Unit, includes multidisciplinary team inter- the initiation of dialysis (Churchill,
the London Health Sciences Centre, London, Ontario,
ventions to delay the onset of dialysis, Blake, Jindal, Toffelmire, & Goldstein,
encourage self-management, and pre- 1999).
Jessica Sontrop, PhD, is an Epidemiologist, the pare and support patients for dialysis The authors’ clinical experience
Walkerton Health Study, the London Health and/or transplantation. The NKF/ shows that the stressors experienced
Sciences Centre, London, Ontario, Canada. KDOQI Clinical Practice Guidelines in the early stages of CKD are differ-
Joan Spittal, MSW, RSW, at the time of data col- (National Kidney Foundation, 2002b) ent than those experienced by indi-
lection, was a Social Worker, the Adam Linton and the Canadian Society of Ne- viduals on dialysis. Having knowl-
Hemodialysis Unit, the London Health Sciences phrology clinical practice guidelines edge of the stressors and coping skills
Centre, London, Ontario, Canada. (Levin et al., 2008) recommend that experienced by individuals with early
Note: This study was funded by the ANNA 2005
each center have an established multi- stage CKD will be advantageous in
Acknowledgments: The authors would like to
acknowledge Kerri Gallo, RN, and Lindsay Daniel, This offering for 1.4 contact hours is being provided by the American Nephrology Nurses’
nursing student, for their assistance with the data Association (ANNA).
collection; and Joanne Clark, for her assistance with ANNA is accredited as a provider of continuing nursing education (CNE) by the American
Nurses Credentialing Center’s Commission on Accreditation.
Statements of Disclosure: The authors reported no ANNA is a provider approved by the California Board of Registered Nursing, provider number
actual or potential conflict of interest in relation to CEP 00910.
this continuing nursing education article.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 265
Stressors and Coping in Individuals with Chronic Kidney Disease
the design and delivery of services onset of dialysis therapy (p < 0.00001) hemodialysis and asked them to
and supportive interventions for these and learned more about renal disease describe retrospectively what stres-
individuals. This knowledge may also and the treatment (p < 0.0001). There sors they experienced prior to dialy-
lay the foundation for future studies were no differences between the sis. Mok et al. (2004) interviewed 11
exploring the influence of stressors on intervention and control group individuals with chronic renal failure
health behaviors and outcomes in regarding the impact of depression, to reflect on the past course of their
CKD. anxiety, and social support on time to illness to explore how they coped and
dialysis. Participants who used ‘blunt- what coping strategies they used.
ing’ (the avoidance of threat-relevant Mok et al. (2004) identified the fol-
information) as a coping method had lowing themes: coping with fluctuat-
Early referral to a nephrologist a shorter time to dialysis therapy. ing feelings and concerns, motivation
and CKD clinic has been shown to Devins and colleagues (2003) con- to cope, and interdependent relation-
slow the rate of progression of kidney cluded that people who cope by ships between patients and their fam-
disease, allow for the management of avoidance may be less likely to ily members.
anemia, provide for patient education engage in routine follow up. In both studies, the patients expe-
to make decisions regarding modality Studies have been conducted on rienced emotional reactions to CKD,
choices, facilitate access placement, stressors and coping in individuals such as helplessness, powerlessness,
provide dietary education, assure with renal disease on hemodialysis sadness, anger, fear, guilt, and indebt-
early detection and treatment of sec- (Baldree, Murphy, & Powers, 1982; edness, as they dealt with the losses
ondary hyperparathyroidism, reduce Gurklis & Menke, 1995; Logan, and changes imposed by the illness.
cardiovascular risk factors, and offer Pelletier-Hibbert, & Hodgins, 2006; When first faced with renal failure,
supportive coping interventions Mok & Tam, 2001; Welch & Austin, they were frequently at a loss for what
(Bolton & Owen, 2002; Churchill et 1999), peritoneal dialysis (Eichel, to do and often just cried or isolated
al., 1999; Levin, 2000; Pereira, 2000). 1986), and renal transplantation themselves (Mok et al., 2004). In the
Several studies have demonstrated (Hayward et al., 1989). One study conducted by Harwood et al.
that early referral to a nephrologist or Scandinavian study (Klang, Björvell (2005), the individuals reported a
CKD clinic decreases morbidity, & Cronqvist, 1996) examined coping variety of physical symptoms, psy-
mortality, and health care costs strategies and sense of coherence in chosocial issues, logistics associated
(Kinchen et al., 2002; McLaughlin, patients with CKD using the Jalowiec with the clinic itself (such as schedul-
Manns, Culleton, Donaldson, & Coping Scale ( JCS) ( Jalowiec, ing, multiple appointments, and wait-
Taub, 2001; Roubicek et al., 2000), Murphy, & Powers, 1984) and a sense ing times), and lack of information.
improves long-term survival ( Jungers of coherence scale, and compared a They not only identified a wide range
et al., 2001), reduces the need for hemodialysis and CKD group. The of stressors for themselves, but also
emergent dialysis (Schmidt, Domico, results of this study indicated that identified the impact on family mem-
Sorkin, & Hobbs, 1998), is associated patients with CKD who are on bers.
with superior patient outcomes hemodialysis employed very different Both studies provide rich descrip-
(Goldstein, Yass, Dacouris, & coping strategies. The CKD group tions of the experience of patients
McFarlane, 2004), and improves had lower coping scores and used with CKD but were retrospective in
health-related quality of life for 6 more emotive coping strategies. their design occurring once the
months after the start of dialysis Although the study conducted by patients were already on dialysis. To
(Korevaar et al., 2002). Klang et al. (1996) examined coping the authors’ knowledge, no tool meas-
Patients who receive pre-dialysis methods with individuals with CKD, uring stressors specific to CKD exists.
education have higher mood scores, the study did not identify the stressors Nor are the authors aware of a study
less mobility problems, less functional these individuals experience and did conducted that measures stressors
disabilities, and a lower level of anxi- not report on the effectiveness of the and coping strategies in a large sam-
ety (Klang, Björvell, Berglund, coping strategies used. The small ple of individuals with CKD not on
Sundstedt, & Clyne, 1998), and are sample size (n = 25) reduced the gen- dialysis. Lack of information about
able to make decisions regarding eralizability of the findings. the stressors experienced by individu-
modality (Klang, Björvell, & Clyne, Two qualitative studies (Harwood, als with CKD and the coping strate-
1999). A multi-centered, randomized, Locking-Cusolito, Spittal, Wilson, & gies they employ make it difficult to
controlled trial examined pre-dialysis White, 2005; Mok, Lai, & Zhang, design and deliver educational and
educational interventions (PPI) and 2004), the former conducted by the supportive interventions for these
coping styles on initiation of dialysis authors of this study and the latter individuals.
in 297 individuals with CKD (creati- being a study conducted in Hong
nine of 3.4 mg/dL or less) (Devins, Kong, provide some understanding of Purpose of the Study
Mendelssohn, Barré, & Binik, 2003). the CKD experience. Harwood et al.
The PPI group showed a delay in the (2005) interviewed 11 individuals on The purpose of this study was to
266 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
develop and test an instrument to period were assessed by the research et al., 1982; Blake & Courts, 1996;
measure stressors in CKD, quantify assistant for eligibility in the study. Gurklis & Menke, 1995; Lindqvist,
those stressors, and identify coping Only those patients with a serum cre- Carlsson, & Sjöden, 1998; Lindqvist
methods used by patients with CKD atinine greater than 2.84 mg/dL (250 & Sjöden, 1998; Mok & Tam, 2001;
and their effectiveness. A secondary mmol/L), and/or GFR less than 60 Yeh & Chou, 2007), patients on con-
objective was to examine relation- ml/min/1.73m2, and who were desig- tinuous ambulatory peritoneal dialy-
ships between demographic and clin- nated as having CKD by the nephrol- sis (CAPD) (Eichel, 1986; Lindqvist,
ical variables on stressors and coping ogist were approached for inclusion Carlsson & Sjoden, 2000), family
in this patient population. in the study. The research assistant members of individuals with ESRD
approached the patients, obtained (Pelletier-Hibbert & Sohi, 2001), and
informed consent, and assisted in individuals with CKD (Klang et al.,
completion of the questionnaires 1996). Psychometric testing of the
Lazarus and Folkman’s (1984) the- when necessary. Participants who vol- JCS has been extensive with both the
ory provided the framework for this unteered for the study were given a original 40-item scale ( Jalowiec et al.,
study. This theory is a cognitive phe- voucher to pay for one hour of free 1984) and the revised 60-item ver-
nomenological theory of stress, parking. The final sample included sion. Homogeneity reliability using
appraisal, and coping. It provides a 226 individuals with CKD not on Cronbach’s alpha is as follows: total
framework for the transactional dialysis. coping strategy use, mean 0.88; total
process between appraisal of an event coping effectiveness, mean 0.91; cop-
determined stressful, coping, and the Instrumentation ing use subscales, mean 0.71; coping
resulting outcome of the transaction. Participants were asked to com- effectiveness subscales, mean 0.73
plete two questionnaires at one point ( Jalowiec, 2003b).
in time: the Jalowiec Coping Scale CKD Stress Inventory. The
( JCS) ( Jalowiec et al., 1984) and a CKDSI was developed specifically
Psychological stress is a relation- CKD Stress Inventory (CKDSI) for this study based on a review of the
ship between the person and the envi- specifically developed for this study. related research, including published
ronment, appraised by the person as Jalowiec Coping Scale. The JCS literature on physiological and psy-
taxing or exceeding his or her assessed the coping strategies used by chological stressors identified by
resources, and endangering his or her patients with CKD. It is a generic tool patients with renal disease on differ-
well-being (Lazarus & Folkman, 1984). that assesses a wide range of coping ing forms of renal replacement thera-
Coping is the process through which behaviors and coping methods, and pies. Baldree et al. (1982) developed
the person manages the demands of can be used with diverse populations and tested a stressors scale for patients
the person-environment relationship in various clinical settings ( Jalowiec, on in-center hemodialysis, and this
that are appraised as being stressful 2003a). In addition to the rating of tool has been well used to study this
and which generate emotions (Lazarus coping methods used, the tool also population (Bihl, Ferrans, & Powers,
& Folkman, 1984). The NKF/DOQI has an evaluative component that 1988; Gurklis & Menke, 1995; Logan
guidelines define CKD as the presence asks the person whether or not a par- et al., 2006; Mok & Tam, 2001; Welch
of kidney damage or decreased level ticular coping method was helpful in & Austin, 1999) as well as the home
of kidney function for three months or a specific situation. The JCS takes hemodialysis population (Courts,
more irrespective of diagnosis (NKF, approximately 10 to 15 minutes to 2000; Courts & Boyette, 1998). The
2002a). For this study, the estimated complete and is written at a 6th grade tool by Baldree et al. (1982) was later
glomerular filtration rate (eGFR) was reading level. Permission to use the adapted by Eichel (1986) for a study
calculated using the Cockcroft-Gault tool was obtained. Jalowiec’s coping examining stressors experienced by
equation (Cockcroft & Gault, 1976). scale is based on Lazarus and individuals on CAPD. An instrument
The degree of CKD was determined Folkman’s theory. entitled the Kidney Transplant
using the eGFR and the NKF/DOQI Coping methods are classified as Recipient Stress Scale (Hayward et
CKD stages (I to IV). either problem-oriented (strategies al., 1989) was also reviewed. Stressors
focused on the situation itself) or measured in each scale mentioned
Methods affective-oriented (strategies that deal were examined by the investigators
with emotions evoked by a situation). for relevancy to CKD and inclusion
Sample All 60 items of the JCS are classified in the CKDSI.
After ethical approval was into 8 coping styles or coping pat- The original version of the
received from the local research terns: confrontive, evasive, optimistic, CKDSI contained 61 items and was
ethics board, all adult (18 years of age fatalistic, emotive, palliative, support- developed with a 4-point Likert scale
and older) patients who spoke and ant, and self-reliant. with items ranging from 0 to 3; the
understood English and attended the The JCS has been well studied higher the score, the greater the sever-
CKD clinic during the data collection with people on hemodialysis (Baldree ity of the stress experienced. Reada-
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 267
Stressors and Coping in Individuals with Chronic Kidney Disease
bility using Flesch-Kincaid grade Table 1
level measurement in Microsoft Word Demographic Characteristics
was used, and it was determined that
the CKDSI had an 8th grade reading Characteristic n = 226
level. The instrument was pre-tested Age (Mean + SD) 64.5 + 14.9
in September 2004 with 27 patients Gender
with CKD. Patients were asked to list
Male % 65
additional stressors they experienced
that were not on the CKDSI. Their Female % 35
feedback was discussed among the Highest Level of Completed Education (%)
investigators for inclusion into the Less than High School 42.2
instrument. Completion of the
CKDSI during the pre-testing phase High School 31.7
took between 2 to 25 minutes, with an College/University 26.1
average of 10.6 minutes. Employment Status (%)
Content validity for the CKDSI is
empirically supported because the Employed Full Time 15.6
stressors identified were based on crit- Employed Part Time 2.2
ical review of previous research and Retired 63.4
existing instruments measuring stres-
sors with renal replacement therapies.
Computations of index of content Treatment History (Mean + SD)
validity (CVI) (Waltz, Strickland, & Months at CKD Clinic 48.7 + 53.8
Lenz, 1991) were also conducted to test
the degree to which the tool represents * Disability, unemployed, student
the stressors that patients with CKD
experience. Surveys were mailed to
expert nurses (RNs and nurse practi- item, “Changes in religious activities,” criminant validity of the sub-scales,
tioners/clinical nurse specialists) and as either not relevant or somewhat items that had no loadings greater
social workers who work with patients relevant. This item was removed than 0.4 were deleted, as were items
with CKD, who were asked to score from the instrument. Eight other with loadings greater than 0.4 on
the relevance of each stressor on a 4- items had a mean score less than 2. more than one factor.
point Likert scale from “not relevant,” Two items were removed after discus- Pearson’s correlation coefficients
“somewhat relevant,” “quite relevant,” sion by the investigators and compar- were used to evaluate relationships
to “very relevant.” They were also ison to the literature. This resulted in between CKD stressor scales and
asked their overall opinion regarding a 58-item instrument. coping strategies. Sequential multi-
the degree to which the tool represent- ple linear regressions were per-
ed the stressors experienced by Principal Components formed to test whether total stressor
patients with CKD. General com- Analysis of the CKDSI scores were associated with socio-
ments were also noted. Mean stressors A total stressor scale was derived demographic, clinical, and coping
scoring less than “quite relevant” (2 out by summing the item scores, where variables. Four models were evaluat-
of 3), as well as mean scores less than higher scores indicated greater levels ed in which the dependent variables
2, were assessed by the research team, of stress. Principal components analy- were the CKD stressor scales: logisti-
and consideration was given for sis with varimax (orthogonal) rotation cal, psychosocial, and physiologic,
removal from the list. The index of was used to examine the constructs followed by the total 34-item scale.
content validity is the proportion of underlying the full stressor inventory The independent variables were
items (stressors) given a rating scale of and to determine whether the original entered sequentially in 3 steps: socio-
quite/very relevant. Those scoring less 58-item scale should comprise a sin- demographic variables were entered
than 0.50 (less than 50%) or 2 out of 3 gle general scale or whether the scale in the first step, the clinical variables
or less indicate an unacceptable level items would be more meaningfully in the second step, and average of
of content validity (Martuza, 1977). grouped into smaller, more specific the total coping score in the third
Seven nurses and 6 social workers sub-scales. The number and member- step. In all analyses, statistical signif-
completed the content validity. Two ship of factors was determined by icance was set at alpha = 0.05.
(15%) individuals were prepared at scree plots and factor loadings. In the Means and standard deviations (SD)
the baccalaureate level and 11 (85%) interest of reliability, as many items as are reported. Data were analyzed
were masters’ prepared. Sixty-nine possible were retained; however, to using SPSS 15.0 for Windows.
percent of the experts scored one maximize the convergent and dis-
268 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
Principal Components Analysis on Stressors Experienced by Patients with Chronic Kidney Disease
Stressor Logistical Psychosocial Physiological
45. Waiting for dialysis close to home 0.80
28. The number of times of dialysis per week 0.75
41. Not knowing when dialysis will be needed 0.74
48. Seeing sick patients in the clinic 0.65
40. Having to use the toilet during dialysis 0.65
27. Having a dialysis access e.g. fistula 0.62
50. Keeping track of many clinic visits 0.61
22. Rides/driving for dialysis 0.60
57. Rides/driving to clinic visits 0.57
51. Feeling unsure about life with dialysis 0.56
44. Knowing when to call health care team 0.56
49. Not knowing enough about dialysis 0.55
14. Length of dialysis treatments 0.48
46. ‘Taking in’ information 0.41
19. Changes in social life 0.77
17. Having to rely on the health care team 0.70
16. Limits on trips other than vacations 0.70
15. Limits on vacations 0.70
18. Feeling alone or ‘cut off’ from others 0.65
34. Chance of dying 0.60
25. Changes of roles in family 0.54
31. Getting an infection 0.46
26. Fear of being alone 0.44
9. Restless legs 0.69
3. Fatigue 0.65
24. Sleep problems 0.64
2. Muscle cramps 0.60
38. Numbness, or feeling like pins and needles in hands and feet 0.60
37. Being short of breath 0.58
43. Changes in mood 0.50
55. Problems staying focused 0.46
52. Changes in your desire for foods 0.46
7. Itching 0.45
11. Feeling sick to your stomach 0.41
Eigen values 9.31 3.42 2.26
Reliability 0.88 0.84 0.80
Percent of variance 27.39 10.06 6.65
Cumulative percent of variance 27.39 37.45 44.10
Results clinic for an average of 4 years (48.7 On the basis of the item retention cri-
months). teria, 24 items were subsequently
Demographics deleted: changes in fluid intake, your
Demographic characteristics of the Principal Components renal diet, impact on other duties,
sample are presented in Table 1. The Analysis and Item Reduction impact on job, limits on physical activ-
mean age was 64.5 (SD ± 14.9) years A scree plot of the full 58-item ities, fear of needles for hemodialysis,
and 65% were male. Approximately scale suggested that 3 factors account- vomiting, side effects of your pills,
57.8% of participants had completed at ed for much of the variation among feeling sad and blue, cost factors,
least high school education, and the the items. Specifying 3 factors, princi- changes in sexual activity, chance of
majority (63.4%) were retired. Partici- pal components analysis was used being hospitalized, fear of pain, taking
pants had been treated in the CKD with varimax (orthogonal) rotation. care of your health problems at home,
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 269
Stressors and Coping in Individuals with Chronic Kidney Disease
being a burden to your family, fre- Table 3
quent blood draws, feeling helpless, Relative Intensity of Stressors
family members telling you what the
health care team said to do, feeling Fatigue
out of control, waiting time for clinic Sleep problems
visits, changes in body weight, Numbness or feeling like pins and needles in hands and feet
swollen ankles, weakness, and being Muscle cramps
able to work around the house. Restless legs
The varimax rotation on the final Being short of breath
34-item version of the CKD stressor Feeling unsure about life with dialysis
scale indicated that 44.1% of the total Itching
variance was explained by three fac- Not knowing when dialysis is needed
tors (see Table 2). The three sub-scales Getting an infection
Changes in mood
were labeled logistical, psychological,
Changes in social life
and physiological. Cronbach’s alpha
Limits on vacation
for each subscale, respectively, was
Problems staying focused
0.88, 0.84 and 0.80 (see Table 2), and
Change in your desire for food
was 0.91 for the entire 34-item scale.
Limits on trips other than vacation
Having to rely on the health care team
Stressors Experienced by
Having a dialysis access (for example, fistula)
Individuals with CKD
Taking in information
The relative intensity of individual
Feeling sick to your stomach
stressors as measured by the CKDSI Not knowing enough about dialysis
is presented in Table 3. The six stres- Chance of dying
sors with the greatest intensity all per- The number of times of dialysis per week
tained to physical symptoms: fatigue, Feeling alone or ‘cut-off’ from others
sleep problems, peripheral neuropa- Rides/driving to clinic visits
thy (numbness/pins and needles), Changes of roles in family
muscle cramps, restless legs, and Fear of being alone
shortness of breath. Knowing when to call health care team
Seeing sick patients in the clinic
Coping Styles Used and Keeping track of many clinic visits
Effectiveness Length of dialysis treatments
A summary of overall coping Waiting for dialysis closer to home
strategies and their effectiveness as Dialysis rides
measured by ranked mean scores for Having to use the toilet during dialysis
subscales of the JCS are presented in 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8
Table 4. An optimistic coping style Relative Intensity of Stressor
was the most common strategy used
and was rated the most effective.
Other commonly used and effective
strategies included confrontive, sup-
portant, and self-reliant. Fatalistic trying to handle things one step at a Multivariate Analyses
and emotive strategies were less time (72.5%). CKD stage and average score on
commonly used and also rated less Pearson’s correlation coefficient the coping-use scales were positively
effective. for overall coping-use and coping- associated with each stressor scale
Table 5 presents the top-ranked effectiveness was 0.91 (p < 0.005). after controlling for socio-demo-
individual item scores for the JCS as Correlation coefficients between graphic and clinical variables. An
measured by the percentage of CKD stressors scales and coping inverse relationship was observed
patients who reported using a particu- strategies are presented in Table 6. In between age and each stressor scale.
lar coping method either sometimes general, positive correlations were This relationship was statistically sig-
or often. Highest ranked items includ- observed between coping strategies nificant for the logistic and total stress
ed trying to keep life as normal as and stressors scales. Specifically, the scales; however, these relationships
possible (82%), trying to think posi- higher the level of logistic, psychoso- lost significance after controlling for
tively (80.9%), maintaining a sense of cial, and physiological stress, the clinical variables and coping (see
humor (79.2%), thinking about the more the patients used emotive, fatal- Table 7). The full model explained
good things in one’s life (79.2), and istic, and evasive coping strategies. 36% of the variance of total level of
270 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
Summary of Coping Strategies Used and Their Effectiveness Among Patients with CKD
as Measured by Subscales of the JCS*
Coping Use Effectiveness
Strategies Rank Mean (SD) Min-Max N Rank Mean (SD) Min-Max n
Optimistic 1 1.8 (0.7) 0.0-3.0 185 1 1.7 (0.7) 0.0-3.0 146
Confrontive 2 1.3 (0.7) 0.0-2.9 178 3 1.2 (0.7) 0.0-2.9 146
Supportant 3 1.2 (0.7) 0.0-2.8 188 2 1.3 (0.7) 0.0-3.0 155
Self-Reliant 4 1.4 (0.7) 0.0-3.0 188 4 1.2 (0.7) 0.0-2.9 151
Palliative 5 0.9 (0.5) 0.0-2.1 144 5 0.9 (0.5) 0.0-2.1 181
Evasive 6 0.9 (0.5) 0.0-2.5 166 6 0.7 (0.5) 0.0-2.5 130
Fatalistic 7 0.9 (0.6) 0.0-2.8 177 7 0.7 (0.6) 0.0-2.8 149
Emotive 8 0.7 (0.6) 0.0-3.0 189 8 0.4 (0.4) 0.0-2.0 154
* Jalowiec Coping Scale
Table 5 Gurklis & Menke, 1995; Logan et al.,
Top Ranking Coping Strategies Used Either Sometimes or 2006; Mok & Tam, 2001; Welch &
Often as Measured by Individual Items on the JCS* Austin, 1999) and peritoneal dialysis
(Eichel, 1986; Lok, 1996). The most
Percent frequently reported stressors for each
Coping Strategy Used n Using Strategy of the previous studies are summa-
Tried to keep your life as normal as possible 169 82.0 rized in Table 8. Four studies reported
fatigue, and in three of these, fatigue
Tried to think positively 161 80.9 was the number-one stressor. This
Tried to keep a sense of humor 160 79.2 indicates that some stressors are simi-
Thought about the good things in your life 160 79.2
lar across the continuum of renal dis-
ease and treatment. Interestingly,
Tried to handle things one step at a time 150 72.5 sleep problems and peripheral neu-
Tried to keep situation under control 141 68.8 ropathy, common problems in
patients with kidney disease, were not
Tried to keep busy 136 68.7
reported in the top 3 rankings in any
Tried to keep feelings under control 136 68.3 of the previous studies.
Tried to find out more about the problem 135 65.9 Fatigue and sleep problems can be
very disruptive and debilitating over
Told yourself that things could be much worse 135 64.6 time, and therefore, warrant further
* Jalowiec Coping Scale assessment of patients with CKD
when these problems are reported. A
recent study of patients with early
stress experienced and 31%, 30%, and identified coping strategies used and CKD reported that as many as 55% of
22% of the logistic/external, psy- their effectiveness. those studied reported disordered
chosocial, and physiological sub- Fatigue, sleep problems, peripher- sleep; however, the authors point out
scales, respectively. al neuropathy, muscle cramps, and that the proportion of patients who
restless legs were the five most fre- experienced disordered sleep may be
quently reported stressors. In terms of similar to outpatients with other
coping strategies, optimism was used chronic medical conditions (Cohen,
In this study of patients with most frequently and considered most Patel, Khetpal, Peterson, & Kimmel,
CKD, the authors have developed effective among this patient popula- 2007). Fatigue and sleep problems
and tested an instrument that was tion. While there are no other CKD may also be a sign of depression, and
found to be a reliable and valid meas- studies for comparison, there are a this should also be explored with
ure of stressors experienced by this number of studies that report rank- patients. Few data exist on the pres-
population, quantified stressors expe- ings of stressors for individuals on ence of depression in patients with
rienced by those with CKD, and hemodialysis (Baldree et al., 1982; CKD, and the prevalence of depres-
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 271
Stressors and Coping in Individuals with Chronic Kidney Disease
Correlations Between CKD Stressor Scales and Coping Strategies
CKD Stressor Scales
Logistical Psychosocial Physiological All 34 stressors
Coping Strategies Used
Optimistic 0.01 0.08 0.12 0.08
Confrontive 0.14 0.21* 0.17* 0.20*
Supportant 0.10 0.28*** 0.20* 0.23*
Self-Reliant 0.25** 0.27** 0.25** 0.33***
Palliative 0.18* 0.18* 0.18* 0.16
Evasive 0.41*** 0.47*** 0.41*** 0.55***
Fatalistic 0.28** 0.42*** 0.33*** 0.39***
Emotive 0.42*** 0.47*** 0.47*** 0.57***
All 60 coping strategies used 0.24* 0.35*** 0.32** 0.34**
Coping Strategies Identified as Being Effective
Optimistic -0.07 -0.04 0.04 -0.02
Confrontive 0.03 0.09 0.12 0.10
Supportant 0.05 0.13 0.13 0.13
Self-Reliant 0.08 0.08 0.11 0.13
Palliative 0.13 0.10 0.13 0.13
Evasive 0.32** 0.36*** 0.33*** 0.45***
Fatalistic 0.10 0.19* 0.17 0.21*
Emotive 0.25** 0.36*** 0.34*** 0.40***
All 60 coping strategies identified as being effective -0.01 0.17 0.22* 0.12
*p < 0.05
**p < 0.01
***p < 0.001
Note: Correlation between average use and average effectiveness was 0.91, p < 0.005.
sion is dependent on the population potential loss and/or fear of the with stressors or coping. This finding
assessed, the definition of depression, unknown. Most recently, a small study suggests that CKDSI measures stres-
and the screening tool(s) used suggested that the prevalence of sors related to CKD and not stressors
(Kimmel, Cohen, & Peterson, 2008). depressive affect in patients with CKD related to comorbid conditions.
In an early study of 60 patients with may be equivalent to that of patients In terms of relationships between
ESRD, 12 of the 17 patients who met with chronic medical conditions with- socio-demographic, clinical, and cop-
the criteria for depression at the time out renal disease (Cohen et al., 2007). ing variables on stressors, there are a
developed major depression before The authors suggested that it is impor- number of findings to note. Stress was
the initiation of renal replacement tant to differentiate between the inversely associated with age (see
therapy (Hong, Smith, Robson, & somatic and cognitive symptoms of Table 7); older patients experienced
Wetzel, 1987). Furthermore, in a study depression and that this differentiation fewer stressors than younger patients.
of 73 patients with renal disease, 16 is very difficult in the medically ill Perhaps as one ages, there is a tenden-
with CKD reported a greater negative population. cy to become less stressed about the
perception of illness and more depres- The Charlston Comorbidity Index unknown and uncontrollable, while at
sion than those already on dialysis adapted for ESRD was used the same time, to utilize fewer and
(Sacks, Peterson, & Kimmel, 1990). (Hemmelgarn, Manns, Quan, and more familiar coping strategies that
The authors of this study suggested Ghali, 2003) to assess comorbid risk. worked successfully during past situa-
that depression was a reaction to Comorbidity stage was not associated tions. Logan et al. (2006) studied stres-
272 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
Sequential Multiple Regression of Socio-Demographic, Clinical, and Coping Variables on
Stressors Among Patients with CKD
Model 1: Model 2: Model 3: Model 4:
Logistic/External Psychosocial Physiological All Stressors
Predictors Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3
Age -2.36** -0.03 0.52 -0.92 0.12 0.52 -0.89 0.27 0.88 -5.11* 1.1 2.97
Sex (Female) 0.31 -0.32 -0.76 -0.65 0.01 0.63 0.13 0.49 1.78 1.80 -0.47 1.57
Education 0.18 0.27 0.25 0.49 0.29 0.29 0.02 -0.44 -0.34 -1.22 -2.22 -2.00
Months Seeing 0.04** 0.04** 0.01 0.01 0.00 -0.00
Cause of CKD 0.25 0.20 0.03 -0.01 0.24 0.11 0.52 0.33
Comorbidities -0.91 -1.11 -0.21 -0.39 0.13 -0.19 -2.13 2.87
Stage of CKD -2.55 -3.04** -2.40* -2.53* -2.75 -2.88* -9.70* -11.05**
Creatinine (umol/L) 0.00 0.00 0.01 0.01 0.01 0.01 0.02 0.02
Hemoglobin (units) 0.00 0.01 -0.07* -0.05 -0.10* -0.08* -0.17 -0.14
Albumin (units) -0.20 -0.21 -0.31** -0.29* -0.12 -0.10 -0.24 -0.27
Urea (units) 0.17 0.18 -0.03 -0.01 -0.05 -0.02 0.38 0.40
Coping – Use 2.96* 3.12** 4.77** 11.39**
R 0.10 0.27 0.31 0.03 0.24 0.30 0.01 0.13 0.22 0.07 0.23 0.36
*p < 0.05
**p < 0.01
***p < 0.001
sors and coping in individuals on found. This is an area that requires fur- for this notion. Attendance at CKD
hemodialysis who were over 65 years ther investigation. clinic provides opportunities to learn
of age (mean 76.4 years) using In the current study, the stage of about kidney disease and treatment
Baldree and colleagues’ (1982) stres- CKD was negatively correlated with options. Supportive interventions by
sors scale and the JCS. Their findings perceived stressors and positively cor- members of the renal care team can
demonstrated no age-related differ- related with the use of coping strate- provide opportunities for patients and
ences in stressor scores. Perhaps the gies, suggesting that as the stage of families to focus on coping and cop-
disparity in findings is related to dif- CKD increased (for example, the ing strategies along the illness trajec-
ferences in patient populations stud- severity of renal function increased), tory. A longitudinal study would be
ied (such as CKD vs. HD), In addi- the number of stressors experienced important to study this phenomenon
tion, the mean ages of the samples decreased, and the use of coping in more detail.
(64.5 vs. 76.4 years) was more than 10 strategies increased. Intuitively, one In terms of coping strategies, opti-
years apart, which may further might surmise the opposite; as one mism was reportedly used most fre-
explain the differences in findings. neared dialysis, the number of stres- quently and was considered the most
The sample in this study contained sors might increase, particularly as effective. Confrontive (tackling a stres-
65% males and 35% females. A sepa- renal function declined and patients sor head on) and supportant (gaining
rate analysis exploring if males and experienced more symptoms. Per- support from others) coping styles were
females experience different stressors haps the findings of the current study also used frequently and considered
and use different coping styles was not reflect patients’ understanding of their effective. Interestingly, the least used
conducted since gender was not signif- condition as well as increasing com- and least effective coping style was
icant in the regression model (see fort with the care team and educative emotive. Items on the JCS pertaining
Table 7). In the authors’ current review and supportive interventions over to an emotive coping style included
of the literature, no studies that exam- time. Patients had attended the clinic worrying and/or blaming oneself for
ined gender differences in CKD with and known their renal care team an the problem, or taking out tensions on
respect to stress and coping were average of 4 years, lending support someone else. These results are in con-
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 273
Stressors and Coping in Individuals with Chronic Kidney Disease
Table 8 ience, non-randomized sample was
Top Ranking Stressors used and limited to patients attending
one CKD clinic in one renal program
Author(s) Sample/Country Stressors in an urban academic center in
Baldree et al. n = 35 Fluid limitations Canada. Thus, the demographics of
(1982) Patients on incenter HD Muscle cramps this population may not reflect those
USA Fatigue of other dialysis centers. Second, the
Eichel n = 30 Fatigue stressors identified by participants
(1986) Patients on CAPD Limitation of physical activity were collected at one point in time
USA Muscle cramps and could potentially reflect how the
individual was feeling (stressed or
Gurklis & Menke n = 120 Fatigue
(1995) Patients on incenter HD Fluid limitations not) on a particular day and may not
USA Food limitations reflect their general level of stress spe-
cific to their renal condition. Third,
Harwood et al. n = 226 Fatigue while the top 6 stressors were of a
(2009) Patients with CKD Sleep problems physical nature, it cannot be con-
(non-dialysis) Peripheral neuropathy
firmed that the stressors identified
pertain exclusively to CKD, since
Logan et al. n = 50 Vacation limitations many of these participants had other
(2006) Patients over 65 years of Fatigue concurrent comorbid medical condi-
age on incenter HD Decrease in social life tions.
Lok n = 64 Limitations on physical activity Implications for Practice and
(1996) Patients on PD Decrease in social life activities Research
Australia Uncertainty concerning future
Mok & Tam n = 50 Fluid limitations
This study provides valuable
(2001) Patients on incenter HD Food limitations information for the renal care team
Hong Kong Pruritis pertaining to stressors experienced by
individuals with CKD. Specifically,
Welch & Austin n = 86 Fluid limitations physical stressors like fatigue, sleep
(1999) Patients on incenter HD Length of dialysis treatments
problems, peripheral neuropathy,
USA Vacation limitations
muscle cramps, restless legs, and
shortness of breath were most often
reported. Those working with
trast to those of the study by Klang and propensity to respond with emotive patients with CKD could include
colleagues (1996), which compared coping styles, which in this study, were questions in their assessments regard-
JCS scores among 25 patients with the least effective. ing these physical symptoms, and if
CKD and 25 patients on hemodialysis present, reassure patients that these
for 3 to 9 months. The hemodialysis Summary of Results problems have been reported by
group used more coping strategies The 34-item CKDSI has been other individuals with CKD. This
(such as confrontational and palliative) shown to be a reliable and valid tool may reduce feelings of frustration and
versus the CKD group, which used to measure stressors experienced by isolation, and improve optimism,
more emotive strategies (such as worry- individuals with CKD. The results which has been shown to be an effec-
ing and getting nervous). Klang et al. from the CKDSI also support previ- tive coping strategy. Strategies to
(1996) attributed this difference to the ous qualitative research (Harwood et assist patients with these symptoms
uncertainty about how the dialysis al., 2005) and provide further should be included in educational
treatment will affect them. In the cur- acknowledgement that stressors per- interventions, which may ultimately
rent study, emotive coping styles were taining to logistics around attending contribute to improved quality of life.
reported as the least used and the least CKD clinic (such as rides and visits) The fifth most frequently ranked
effective. However, in multivariate are important, as well as psychosocial stressor in the current study was “rest-
analyses, those who reported higher and physiological stressors, to individ- less legs.” Although it was not con-
levels of logistical, psychological, and uals with CKD. firmed by the authors if these individ-
physiological stress used more emotive uals were experiencing and diag-
and fatalistic coping strategies. This Limitations nosed with restless legs syndrome
result could be interpreted to mean that (RLS), it was apparent that having
Several limitations must be con- restless legs was stressful for this
as one experiences greater intensity sidered when interpreting the find-
and frequency of stressors, there is a group of individuals. This may be a
ings of this study. First, a conven- contributing factor to the fatigue and
274 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
problems sleeping as reported by par- same time, coach patients to use apy in Canada in 2003. Ottawa,
ticipants. RLS is very prevalent in strategies that keep life as normal for Canada: Author
patients on hemodialysis; however, them as possible. In addition, CKD Canadian Institute for Health Information
there is a lack of information about team members need to consider that (CIHI). (2008). Annual report –
Treatment of end stage organ failure in
the prevalence of RLS in individuals individuals who respond in a more
Canada 1997-2006. Ottawa, Canada:
with early CKD (Novak, Mendelssohn, emotional manner may experience Author.
Shapiro, & Mucsi, 2006). Uremia, more stressors and cope less effective- Churchill, D.N., Blake, P.G., Jindal, K.K.,
neuropathy, anemia, iron deficiency, ly. These individuals may benefit Toffelmire, E.B., & Goldstein, M.B.
and comorbidity are all known to be from a collaborative team approach (1999). Clinical practice guidelines
contributing factors to RLS, and med- with a supportive and educational for initiation of dialysis. Journal of the
ications, caffeine, nicotine, and alco- plan of care that assists them with American Society of Nephrology,
hol may also aggravate symptoms coping and managing their CKD. 10(Suppl. 13), S289-S321.
(Novak et al., 2006). Cockcroft, D.W., & Gault, M.H. (1976).
Nursing assessment and history Prediction of creatinine clearance
Conclusion from serum creatinine. Nephron,
taking should explore if the patient is
having problems with restless legs The CKDSI developed for this Courts, N.F. (2000). Psychosocial adjust-
and possibly RLS, depression, and study is a reliable and valid measure ment of patients on home hemodial-
peripheral neuropathy because any of stressors experienced by patients ysis and their dialysis partners.
or all of these problems can con- with CKD. The 34-item instrument is Clinical Nursing Research, 9(2), 177-190.
tribute to sleep problems and/or grouped into three stressor subscales: Courts, N.F., & Boyette, B.G. (1998).
fatigue. Notifying the nephrologist or logistical, psychological, and physio- Psychosocial adjustment of males of
nurse practitioner for diagnosis and logical. Fatigue, sleep problems, and three types of dialysis. Clinical
treatment is essential. Nephrology peripheral neuropathy were the most Nursing Research, 7(1), 47-63.
nurses have a unique role in assessing frequently reported stressors. Opti- Cohen, S.D., Patel, S.S., Khetpal, P.,
Peterson, R.A., & Kimmel, P.L.
fatigue and coordinating the plan of mism as a coping style was most com-
(2007). Pain, sleep disturbance, and
care (Williams, Crane, & Kring, monly used and was also the most quality of life in patients with chronic
2007). Patient education regarding effective. Older individuals and those kidney disease. Clinical Journal of the
good sleep hygiene may also help who had more kidney dysfunction American Society of Nephrology, 2(5),
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per clinical practice guidelines, as uals with CKD experience and the vention and coping styles influence
well as screening for iron deficiency, coping strategies they believe to be time to dialysis in chronic kidney dis-
ease. American Journal of Kidney
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Predialysis patient education: Effects Nephrology Nursing Journal Editorial Board Statements of Disclosure
on functioning and well-being in
In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclo-
uraemic patients. Journal of Advanced
sure are published with each CNE offering. The statements of disclosure for this offering are published below.
Nursing, 28(1), 36-44.
Klang, B., Björvell,H., & Clyne, N., (1999). Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant for Hoffman-La Roche and Coordinator of
Predialysis education helps patients Clinical Trials for Roche.
choose dialysis modality and increas- Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen,
es disease-specific knowledge. Journal Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the
of Advanced Nursing, 29(4), 869-879. recipient of unrestricted educational grants from OrthoBiotech and Roche.
Klang, B., Björvell,H., & Cronqvist, A. Holly Fadness McFarland, MSN, RN, CNN, disclosed that she is an employee of DaVita, Inc.
(1996). Patients with chronic renal fail-
Karen C. Robbins, MS, RN, CNN, disclosed that she is on the Speakers’ Bureau for Watson Pharma, Inc.
276 NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3
Individuals with Chronic Kidney Disease
continued from page 276
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Stressors and Coping in Individuals with Chronic Kidney Disease
Lori Harwood, MSc, RN; Barbara Wilson, MScN, RN; Heather Locking-Cusolito, MScC, RN; Jessica Sontrop, PhD;
Joan Spittal, MSW, RSW
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the National Office as usual.
Evaluation disagree agree
2. By completing this offering, I was able to meet the stated objectives
a. Define psychological stress. 1 2 3 4 5
b. Discuss two instruments used to measure stress and coping of patients with chronic kidney disease. 1 2 3 4 5
c. Explain effective coping strategies used by patients with chronic kidney disease. 1 2 3 4 5
3. The content was current and relevant. 1 2 3 4 5
4. This was an effective method to learn this content. 1 2 3 4 5
5. Time required to complete reading assignment: _________ minutes.
I verify that I have completed this activity ________________________________________________________________________________
NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 277