Copyright 2003 by The Indian Society of Nephrology
Indian J Nephrol 2003;13: 89-91 Address for Correspondence: Dr G Abraham Sri Ramachandra Medical College & Research Institute (DU) Porur, Chennai - 600 116, India Email : georgi@eth.net ARTICLE Level of stress and coping abilities in patients on chronic hemodialysis and peritoneal dialysis TR Udaya Kumar, A Amalraj, P Soundarajan, G Abraham College of Nursing & Dept of Nephrology, Sri Ramachandra Medical College & Research Institute (Deemed University), Porur, Chennai Abstract A cross sectional study of 50 patients with end stage renal disease, who were on chronic peritoneal dialysis (CPD = 25) and chronic hemodialysis (CHD=25), was done for level of stress and stress coping ability. These patients belonged to different socio-economic background. A modified structured questionnaire was used (Jelowice, Murphy and Power). Student t-test was used to compare the mean stress and coping ability between CPD and CHD patients. The results showed that the overall mean stress score in the CHD patients was higher (78.3%) than in CPD patients (43.3% p<0.001). Coping ability score for CHD patients was 51.9% as compared to CPD patients (60.9% p<0.001). This study suggests that CPD patients have better quality of life when compared to CHD patients. Key words: Stress, coping ability, chronic hemodialysis, chronic peritoneal dialysis Introduction Stress in human life is often equated with tension, anxiety, worry and pressure. The social support systems in contrast to developed countries are not well established in developing countries like India. Patients subjected to chronic hemodialysis (CHD) and chronic peritoneal dialysis (CPD) experience stress of different nature and their coping ability varies. 1 Coping scale modified by Jelowice, Murphy and Power was adopted as a standard measure. 2 It is an accepted fact that stress is a part of human life and it can cause either beneficial or detrimental effects on human beings which can affect physical, emotional, economical, spiritual and social aspects 3-5 . For the dialysis patient various types of stress includes abject dependency on the procedure, group of medical professionals and a medical regimen. Such dependency places the very independent patient in an uncomfortable and even untenable situation leading to stress throughout the course of treatment. The adequate primary care of patients with renal failure includes decision about the choice of the modality of treatment, down to the everyday answering of questions of patients, relatives and staff, which requires a knowledge of the major psychological stress of the illness and psychiatric complaints resulting from these stresses and their treatment. The patient on dialysis is threatened with many potential losses and changes in the life style. In the initial stage a patient may need only rest and dietary restriction but as the disease progresses, the patient physically may not be able to cope up with his work and may take medical leave for hospitalization. This may affect his employment, which indirectly may affect the whole family especially if the patient is the bread earner and hence financial situation also gets jeoparadised 1,4,5 . Among the major stresses of dialysis are the procedure of CHD or CPD, the overall medical treatment which includes medications and diet, a procedure and a group of medical professionals. These physical and psychological stresses can lead to delirium, depression, anxiety, suicide, uncooperative behaviour, sexual dysfunction and psychosis. Materials and methods The cross sectional study included fifty patients with end-stage renal disease. Twenty five were on CPD with the mean age of 60 5yrs (male 19, female 6). Other twenty five patients were on CHD with the mean age of 57.5 7.5yrs (male 15, female 10). Data was collected from the patients using a structured questionnaire. The questionnaire consists of three parts. Part-I demographic variables of the patients, Part - II stress scale developed from the literature to suit the socio-economic and family background of Indian population 3 . 9 0 Copyright 2003 by The Indian Society of Nephrology Indian Journal of Nephrology Indian J Nephrol 2003;13: 89-91 Stress scale for patients contained 25 items. Each of these items had 5 responses such as not stressful, very mild stress, mild stress, moderate stress and severe stress with the score of 0,1,2,3 & 4 respectively. The total possible score was 100. The score was interpreted as percentage of total: not stressful 0%, very mild stress 1-25%, mild stress 26-50%,moderate stress 51-75%,severe stress76% and above. The overall stress score represents the sum of physical, psychological and socio-economic level of stress. Coping scale contains 15 statements. Each statements had 3 responses such as never, sometimes and always with a score of 1,2 and 3 respectively. It includes affective oriented method and problem oriented method used by the patients in response to stress. The total possible score was 45. The score was interpreted as percentage of total: Never 0-33 %,Sometimes 34- 66%, Always67% and above. The overall coping score represents the sum of affective oriented method and problem oriented method. Part-III coping scale developed by Jelowice, Murphy and Power was modified to suit the socio-economic and family background of Indian population 3 . Coping scale had two sub-parts. 1. Affective-oriented method 2. Problem-oriented method. To assess the level of stress and coping mean and standard deviation was used. To compare mean stress and coping score between CHD and CPD patients student t-test was applied. 3 Interviews were conducted with the patients by the authors using the scale and responses given were entered in appropriate column in front of each statement. The scale was added up and percentage was calculated according to the total score obtained. Most of the patients subjected to chronic hemodialysis and chronic peritoneal dialysis where undergoing treatment for about 4-6 months. Results The level of stress in CHD and CPD patients is shown in Table 1. In the CHD patients mean stress score (%) in Physical Aspect was 76.5 4.14. In CPD patients, mean stress score (%) was 43.17 6.43, which was less than stress level seen in (P<0.001) CHD patients. Regarding Psychological Aspect the mean score (%) was 81.09 4.53 in the CHD patients and 46.54 4.69 in CPD patients (p<.001). In the socio-economic aspect of stress CHD patients again had higher score (%) 75.87 6.48 as compared to CPD patients (39.0 5.57, Table 1 : Level of stress in CHD & CPD patients Aspects of stress Chronic Hemodialysis Chronic Peritoneal dialysis t-value Mean (%) S.D. Mean (%) S.D. Physical 76.5 4.14 43.17 6.43 21.70 *** Psychological 81.09 4.53 46.54 4.69 26.48 *** Socio-economic 75.87 6.48 39.0 5.57 21.59 *** Overall stress 78.32 2.82 43.32 3.87 36.53 *** *** P<0.001 level significance Table 2 : Level of coping ability in CHD & CPD patients Coping methods Chronic Hemodialysis Chronic Peritoneal dialysis t-value Mean (%) S.D. Mean (%) S.D. (P-value) Problem - oriented method 44.0 3.85 69.87 7.96 14.62 *** Affective - oriented method 55.87 3.51 55.33 3.73 0.52 NS Overall coping ability 51.91 3.0 60.18 4.25 7.94 *** *** P<0.001 level significance NS - Not Significant 9 1 Copyright 2003 by The Indian Society of Nephrology Indian J Nephrol 2003;13: 89-91 P<0.001). The higher mean value of overall stress (%) was 78.32 2.82 among CHD patients when compared with CPD patients (43.32 3.82, P<0.001). Patients used two coping methods to overcome stress. In the CHD patients, score (%) for Problem-oriented method was 44.0 3.85, CPD patients had higher coping score (%) 69.87 7.92. There was significant difference among CHD & CPD patients. Regarding Affective-oriented method the mean score for CHD patients was 55.87 3.51 as compared to CPD (%) patients (55.3 3.73) which was not statistically different. CPD patients had a higher overall coping ability as compared to CHD patients (p<.001). Discussion Chronic peritoneal dialysis patients demonstrate a better perceived health status, a high index of well being and greater life satisfaction than in center CHD patients. 6 Our study is a cross-sectional, which means that the comparison is made at one point in time and does not permit comparisons of outcomes over time. This is a limitation as longitudinal studies would provide more accurate information. The comparison of stress and coping ability among CHD and CPD patients in physical, psychological and socio-economic aspects showed higher level of stress among the former group compared with the later group of patients. This has also been reported by Christensen et al 1995 7 . An additional factor explaining the better stress outcome in CPD patients may be the family support and atmosphere as a result of home therapy compared to in-centre CHD. The in-centre CHD puts more stress as 1. Suzanne CS & Brenda GB. Text book of medical - surgical nursing, 9 th edition, 2000,1146-1162. 2. Densise F, Hungler P. Nursing research - principles and methods, 6 th edition, 1999,277-305 3. Carol A, Lindeman MM. Fundamentals of contemporary nursing, 1999,903-933. 4. Kozier E, Blais W. Fundamentals of nursing - concepts, process and practice,5 th edition,1995, 828-851. 5. Potter and Perry. Fundamentals of Nursing - concepts, process and practice, 5 th Edition, 2001,643-667. 6. Wolcott DL, Nisenson AR. Quality of life in chronic dialysis patients, a critical comparison of CAPD and CHD. AM J Kidney Dis 1988; 11 :402-412. 7. Christensen AJ et.al. Coping with treatment related stress: effects on patient adherence in hemodialysis. Journal of consult clinical psychology 1995, 63(3): 454- 9. 8. Nisenson AR, Prichard SS, Cheng IKP et al. Non medical factors that impart on ESRD modality seletion. Kidney Int 1993; 43 (suppl 40): S120-7. the family has to take time off to arrange travel and other necessary accompaniments including loss of time from work. Many factors play a role in decision about the particular modality of therapy to a patient. This situation is further complicated as patients frequently change their modality of treatment due to medical or non medical reasons 8,9 . The coping strategies in present study, of CHD patients were less when compared with CPD patients in the Problem oriented method whereas in Affective-oriented method there was no significant difference in the coping strategy. The comparison of overall coping abilities between CHD and CPD patients showed better outcomes among CPD patients who adopted problem-oriented coping method than affective oriented method to overcome stress.
Patients on chronic peritoneal dialysis appear to have better coping ability to overcome stress 10 ,11 . Activities of daily living, vocational activities, social activities, recreational activities may all be adversely affected by a regular two times or three times per week hemodialysis schedule unlike chronic peritoneal dialysis which is a home therapy. Limitations in handling stress not only adversely affects the quality of life, but also increases the risk for morbidity and mortality. There are close links between emotional well being and clinical outcomes in dialysis patients. Life style modification is important for stress handling in dialysis patients. In conclusion although effect of a treatment on patient survival is important, of equal importance is the effect of the treatment modality for renal failure on patients quality of life and that of the family. 12,13,14. References 9. Portes GA, Lowson L, Buss J, Bias in selecting treatment for endstage renal disease. Kidney Int 1985; 28 (suppl 17): S34-S37. 10. Cristovao F. Stress, coping and quality of life among chroni c hemodi al ysi s pati ents, EDTNA ERCA Journal,1999, 25(4): 35-8. 11. Sjoden, Lindqvist R. Coping strategies and health-related quality of life among spouses of continuous ambulatory peritoneal dialysis, hemodialysis and transplant patients. Journal of Advanced Nursing,2000, 31(6): 1389-408. 12. Potter P, Stewott AL, Carey S. Physical functioning : Definition, measurement, and expectations. Adv Renal Replacement therapy 1999; 6 (2): 110-123. 13. Lindqvist.R et.al , Coping strategies and quality of life among patients on continuous ambulatory peritoneal dialysis. Journal of advanced nursing 1998, 27(2): 312- 9. 14. Courts NF et.al. Psychosocial adjustment of males on three types of dialysis. Clinical nursing research,1998, 7(1): 47-63. Stress and coping ability in HP and PD