Stressors and Coping in Individuals
With Chronic Kidney Disease                                                           ...
Stressors and Coping in Individuals with Chronic Kidney Disease




the design and delivery of services        onset of di...
develop and test an instrument to          period were assessed by the research        et al., 1982; Blake & Courts, 1996;...
Stressors and Coping in Individuals with Chronic Kidney Disease




bility using Flesch-Kincaid grade                     ...
Table 2
    Principal Components Analysis on Stressors Experienced by Patients with Chronic Kidney Disease
               ...
Stressors and Coping in Individuals with Chronic Kidney Disease




being a burden to your family, fre-                   ...
Table 4
              Summary of Coping Strategies Used and Their Effectiveness Among Patients with CKD
                  ...
Stressors and Coping in Individuals with Chronic Kidney Disease




                                                    Ta...
Table 7
          Sequential Multiple Regression of Socio-Demographic, Clinical, and Coping Variables on
                 ...
Stressors and Coping in Individuals with Chronic Kidney Disease




                                   Table 8            ...
problems sleeping as reported by par-       same time, coach patients to use                   apy in Canada in 2003. Otta...
Stressors and Coping in Individuals with Chronic Kidney Disease




     viduals with chronic kidney disease.            u...
Individuals with Chronic Kidney Disease
continued from page 276

Rogers, A.E. (1997). Nursing management of sleep disorder...
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Stressors and Coping in Individuals With Chronic Kidney Disease

  1. 1. Stressors and Coping in Individuals With Chronic Kidney Disease Continuing Nursing Education Lori Harwood Jessica Sontrop Barbara Wilson Joan Spittal Heather Locking-Cusolito n the United States, it is estimated I 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 Objectives 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, MichigANNA Chapter. 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, Canada. 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 Research Grant. 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 the manuscript. 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
  2. 2. 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- Literature Review 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
  3. 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., Conceptual Framework 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 Definitions ( 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
  4. 4. 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- Other* 18.8 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
  5. 5. Table 2 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
  6. 6. 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
  7. 7. Table 4 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 Discussion 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
  8. 8. Stressors and Coping in Individuals with Chronic Kidney Disease Table 6 Correlations Between CKD Stressor Scales and Coping Strategies CKD Stressor Scales Coping Strategies 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
  9. 9. Table 7 Sequential Multiple Regression of Socio-Demographic, Clinical, and Coping Variables on Stressors Among Patients with CKD Stressors 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 0.05 0.04 Nephrologist 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** 2 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
  10. 10. 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 Canada 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. Canada 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
  11. 11. 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 16(1), 31-41. 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), improve patients’ sleep and reduce reported less stress. Stress was posi- 919-925. fatigue (Rogers, 1997). Monitoring tively associated with coping. This Devins, G.M., Mendelssohn, D.C., Barré, hemoglobin levels and treating with study contributes to the authors’ P.E., & Binik, Y.M. (2003). an erythropoietin stimulating agent as understanding of the stressors individ- Predialysis psychoeducational inter- 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 may improve fatigue and RLS. effective. Knowledge gained from this Diseases, 42(4), 693-703. Novak et al. (2006) concluded in study can be applied to education and Eichel, C.J. (1986). 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Journal of strategies used by family members of 18(1), 99-103. Advanced Nursing, 27(2), 312-319. individuals living with end stage renal Kinchen, K.S., Sadler, J., Fink, N., Logan, S.M., Pelletier-Hibbert, M., & disease. Nephrology Nursing Journal, Brookmeyer, R., Klag, M.J., Levey, Hodgins, M. (2006). Stressors and 28(4), 411-417, 419. A.S., et al. (2002). The timing of spe- coping of in-hospital haemodialysis Pereira, B.J., (2000). Optimization of pre- cialist evaluation in chronic kidney patient aged 65 years and over. Journal ESRD care: The key to improved disease and mortality. Annuals of of Advanced Nursing, 56(4), 382-391. dialysis outcomes. Kidney International, Internal Medicine, 137(6), 479-486. 57(1), 351-365. Klang,B., Björvell,H., Berglund, J., continued on page 301 Sundstedt, C., & Clyne, N. (1998). 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
  13. 13. Individuals with Chronic Kidney Disease continued from page 276 Rogers, A.E. (1997). Nursing management of sleep disorders: Part 2 – Behavioral interventions. ANNA Journal, 24(6) 672-675. Roubicek, C., Brunet, P., Huiart, L., Thirion, X., Leonetti, F., Dussol, B. et al., (2000). Timing of nephrology referral: Influence on mortality and morbidity. American Journal of Kidney Diseases, 36(1), 35-41. Sacks, C.R., Peterson, R.A., & Kimmel, P.L. (1990). Perception of illness and depression in chronic renal disease. American Journal of Kidney Diseases, 15(1) 31-39. Schmidt, R.J., Domico, J.R., Sorkin, M.I., & Hobbs, G. (1998). Early referral and its impact on emergent first dialyses, health care costs and outcome. American Journal of Kidney Diseases, 32(2), 278-283. United States Renal Data System (USRDS). (2008). USRDS annu- al data report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Waltz, C.F., Strickland, O.L., & Lenz, E.R., (1991). Measurement in nursing research. Salem, MA: F.A. Davis Company. Welch, J.L., & Austin, J.K. (1999). Factors associated with treat- ment-related stressors in hemodialysis patients. ANNA Journal, 26(3), 318-325. Williams, A.G., Crane, P.B., & Kring, D. (2006). Fatigue in African American women on hemodialysis. Nephrology Nursing Journal, 34(6). 610-617. Yeh, A.J., & Chou, H.C. (2007). Coping strategies and stressors in patient with hemodialysis. Psychomatic Medicine, 69(2), 182-190. 301
  14. 14. ANNJ0906 ANSWER/EVALUATION FORM 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 1.4 Contact Hours Complete the Following: Expires: June 30, 2011 Name: ____________________________________________________________ ANNA Member Price: $15 Regular Price: $25 Address: __________________________________________________________ Posttest Instructions __________________________________________________________________ • Select the best answer and circle the appropriate letter on the answer grid Telephone: ______________________ Email: _____________________________ below. • Complete the evaluation. CNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ No • Send only the answer form to the ANNA National Office; East Holly Payment: Avenue Box 56; Pitman, NJ 08071- ANNA Member: ____ Yes ____ No Member #___________________________ 0056; or fax this form to (856) 589- 7463. Check Enclosed American Express Visa MasterCard • Enclose a check or money order Total Amount Submitted: _________________ payable to ANNA. Fees listed in pay- ment section. Credit Card Number: _______________________________ Exp. Date: _______ • If you receive a passing score of 70% or better, a certificate for the contact Name as it Appears on the Card: ______________________________________ hours will be awarded by ANNA. • Please allow 2-3 weeks for processing. You may submit multiple answer forms in one mailing, however, because of Special Note various processing procedures for Your posttest can be processed in 1 week for an additional rush charge of $5.00. each answer form, you may not receive ■ Yes, I would like this posttest rush processed. I have included an additional fee all of your certificates returned in one of $5.00 for rush processing. mailing. Online submissions through a partnership with HDCN.com are accepted on this posttest at $20 for ANNA members and $30 regular price. CNE certificates will be available immediately upon successful completion of the posttest. Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at www.annanurse.org/journal 1. What would be different in your practice if you applied what you have learned To provide an overview of a valid and reliable instrument from this activity? used to measure stressors of patients with chronic kidney disease, identify those stressors, and determine which ____________________________________________________________ coping strategies were used and effective in the study. ____________________________________________________________ Please note that this continuing nursing education activity does not ____________________________________________________________ contain multiple-choice questions. This posttest substitutes the mul- tiple-choice questions with an open-ended question. Simply answer ____________________________________________________________ the open-ended question(s) directly above the evaluation portion of ____________________________________________________________ the Answer/Evaluation Form and return the form, with payment, to the National Office as usual. Strongly Strongly 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 ________________________________________________________________________________ (Signature) NEPHROLOGY NURSING JOURNAL May-June 2009 Vol. 36, No. 3 277

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