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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1342-1349
Effectiveness of prehemodialysis preparatory program on improving coping among chronic kidney disease patients


1 M. S. Ramaiah Institute of Nursing Education and Research, Bengaluru, Karnataka, India
2 Department of Surgical Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India

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Date of Submission13-Oct-2017
Date of Decision06-Dec-2017
Date of Acceptance07-Dec-2017
Date of Web Publication27-Dec-2018
 

   Abstract 

Diagnosis of chronic kidney disease (CKD) and initiation of dialysis treatment is reported to be stressful for patients. It is essential that patients use effective coping strategies to deal with these stressors, since ineffective coping could have several adverse effects on various treatment-related as well as personal aspects of life, thereby lowering the quality of life in these patients. The study used a quasi-experimental design. The study population comprised 100 adult patients with Stage 3 and Stage 4 CKD whose glomerular filtration rate was deteriorating and required to undergo hemodialysis (HD) treatment. Carver’s Brief Cope Scale was used to assess coping strategies used. The study was carried out in a tertiary care hospital in Bengaluru, India. Patients in the intervention group received pre-HD preparatory program and those in the control group received standard care. Postassessment for coping strategies used was carried out two weeks after the delivery of intervention. Highly significant statistical differences were observed in the use of certain adaptive coping strategies among the experimental group as compared to the control group after implementation of pre-HD preparatory program. These adaptive coping strategies included self-distraction (P = 0.011), active coping (P = 0.000), planning (P = 0.026), acceptance (P = 0.001), and religion (P = 0.005). The intervention was not found to be significant in reducing use of maladaptive coping strategies (P = 0.095). In India, 61%–66% of patients who present to nephrologists are already in end-stage renal disease. These patients hardly receive any organized education that would prepare them to understand their disease and enable them to manage it to the best of their abilities. An ongoing patient education and counseling program led by trained nurse educator will help patients cope effectively with the diagnosis of CKD and its treatment.

How to cite this article:
Jadhav ST, Lee P, D’souza CV. Effectiveness of prehemodialysis preparatory program on improving coping among chronic kidney disease patients. Saudi J Kidney Dis Transpl 2018;29:1342-9

How to cite this URL:
Jadhav ST, Lee P, D’souza CV. Effectiveness of prehemodialysis preparatory program on improving coping among chronic kidney disease patients. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Mar 21];29:1342-9. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1342/248295

   Introduction Top


The diagnosis of chronic kidney disease (CKD) and initiation of dialysis treatment is reported to be stressful for patients.[1],[2],[3],[4],[5] It is essential that patients use effective coping strategies to deal with these stressors, since ineffective coping could have several adverse effects on various treatment-related as well as personal aspects of life, thereby lowering the quality of life in these patients.[6] Adaptive coping can produce desirable outcomes, such as employment and successful functioning within the family.[7] Emotion-oriented coping has been found to be negatively associated with employment among patients receiving maintenance hemodialysis (HD).[8] Maladaptive coping can result in marital and family dysfunction, loss of one’s role and identity, as well as resulting in an increase in depression and anxiety among these patients.[9] Decreased sense of well-being is found to be associated with considerable functional disabilities and high level of anxiety among predialysis uremic patients.[6] The use of avoidance coping is associated with increase in depression.[10] Patients who use denial as a defense mechanism to cope with stress of disease and treatment have high levels of noncompliance to treatment.[9] The present study assesses effectiveness of pre-HD preparatory program on coping strategies used by Stage 3 and Stage 4 CKD patients.


   Hypothesis Top


Chronic kidney disease patients receiving pre-hemodialysis preparatory program use adaptive coping strategies than those who receive standard care.

Hypothesis was tested at P <0.05 level of significance.


   Materials and Methods Top


Design and setting

The study used a quasi-experimental design (nonequivalent control group pre-and posttest design). The study population comprised Stage 3 and Stage 4 CKD patients who had selected HD as a treatment option. The group included 100 adult patients (20–60 years), with CKD whose glomerular filtration rate was deteriorating and required to undergo HD treatment. Patients diagnosed with associated psychological and psychiatric disorders were excluded from the study. The sample size was computed based on power analysis, keeping the power of study at 80% (P <0.05 two-tailed). The study was carried out at a tertiary care hospital in Bengaluru, India.

Intervention

The intervention consisted of a pre-HD preparatory program, which was prepared by researcher based on the findings of qualitative study. Transactional model of stress and coping which is based on psychological stress theory of Lazarus was used as guiding framework to develop the intervention. The program consisted of three sessions, namely “CKD and its conservative management,” “understanding HD as treatment option,” and “coping with disease and HD treatment.” A nurse with post-graduate qualification was trained to deliver the pre-HD preparatory program in local language (Kannada). The researcher herself delivered the sessions to patients who spoke English language. Intervention implementation fidelity was ensured by having a nephrologist observe both the interventionist implement the intervention and rate them on predesigned criteria.

Instrument

The Carver’ s Brief Cope Scale was used to assess the coping strategies used. This scale comprises 14 scales, each of which assesses the degree to which a respondent utilizes a specific coping strategy. These scales include (1) active coping, (2) planning, (3) positive reframing, (4) acceptance, (5) humor, (6) religion, (7) using emotional support, (8) using instrumental support, (9) self-distraction, (10) denial, (11) venting, (12) substance use, (13) behavioral disengagement, and (14) self-blame. The scale requires only a basic reading level and is used as self-report tool that can be completed in 10 min. The scale was translated to local language (Kannada), and reliability for translated version was computed using Cronbach α (English version α = 0.91; Kannada version α = 0.91).

Permission to conduct study was obtained from hospital authorities. Ethical clearance was obtained from hospital ethics committee. Hospital units were randomly assigned as experimental and control units at the beginning of the study. Patients who met inclusion criteria were recruited for the study using consecutive sampling technique. Informed consent was obtained from all the participants. Patients admitted in the experimental group received pre-HD preparatory program and those in the control group received standard care. This helped in avoiding contamination of the control group. Preassessment of coping strategies used was carried out for patients in both groups by administering Carver’s Brief Cope Scale by two nurses with basic Bachelor of Science in nursing qualification, who were trained to administer the tool. The pre-HD preparatory program was delivered individually to each participant in three sessions each lasting for 30–45 min on three consecutive days. PowerPoint presentation with simple pictures and illustrations was used as a teaching aid. Patients were encouraged to discuss specific issues encountered by them during the sessions. Patients were given an information booklet at the end of the program.

Postassessment of coping strategies used was carried out for patients in both the groups after two-week period. A consort table depicting enrollment, allocation, and follow-up of the patients during the study is presented in [Figure 1].
Figure 1: Consort table depicting enrollment, allocation, and follow-up of the patients.

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The Statistical Package for the Social Sciences Software (SPSS) program version 20.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis.


   Results Top


Majority of the participants from both the groups (68% in experimental and 70% in control group) were male. Mean age of the participants was 50.08 years in the experimental and 45.26 years in the control group. Most participants had stopped working due to their illness (16% in experimental and 24% in control group). Majority of the participants (34% in experimental and 36% in control group) had preexisting diabetes mellitus and hypertension. The mean annual income was Indian Rupees 200,000 (2 lakhs) for participants in both the groups. More than half of the participants from both the groups did not have medical insurance (54% in experimental and 66% in control group). Participants in both the groups were similar with regard to their sociodemographic variables except for their age (0.049), education (P = 0.036), and annual income (P = 0.015).

Factor analysis was carried out to identify predominant coping strategies used by participants. Two main factors as adaptive coping and maladaptive coping strategies were identified. Adaptive coping strategies included self-distraction, active coping, use of emotional support, use of instrumental support, positive reframing, planning, acceptance, religion, and venting. Maladaptive coping strategies included denial, substance abuse, behavioral disengagement, and humor.

Participants in the experimental and control groups did not differ significantly with regard to the use of adaptive (P = 0.912) and mal-adaptive coping (P = 0.812) before implementation of pre-HD preparatory program. After implementation of the pre-HD preparatory program, highly significant improvement with moderate-to-large effect size was observed in patients receiving pre-HD preparatory program with relation to use of adaptive coping strategies (P = 0.001) as compared to those receiving standard care [Table 1].
Table 1: Comparison of the mean pre- and posttest scores of experimental and control group participants for adaptive coping and maladaptive coping (n =50+50).

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After controlling for confounding socio-demographic variables [age (P = 0.049), education (P = 0.036), and annual income (P = 0.015)], the intervention was found to be significantly effective in improving use of adaptive coping strategies (P = 0.006). The intervention was not found to be significant in reducing use of maladaptive coping strategies (P = 0.095) [Table 2]. Highly significant statistical differences were observed in the use of certain adaptive coping strategies in the experimental group as compared to control group after implementation of pre-HD preparatory program. These adaptive coping strategies included self-distraction (P = 0.011), active coping (P = 0.000), planning (P = 0.026), acceptance (P = 0.001), and religion (P = 0.005) [Table 3]. The use of adaptive coping strategies was found to have significant but weak positive correlation with age (r = 0.245, P = 0.05).
Table 2: Main effect of intervention on adaptive coping and maladaptive coping after controlling for age, education, and annual income (n =50+50).

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Table 3: Comparison between mean pre- and posttest scores of experimental and control group participants for subscales of adaptive coping (n = 50+50).

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   Discussion Top


Majority of the patients in this study predominantly used adaptive coping strategies as compared to maladaptive strategies. Several studies report that HD patients use task-oriented/problem-oriented coping strategies more often than emotion-oriented coping strategies.[3],[5],[11],[12] Task-oriented coping is a means of confronting and dealing with stressful situations using purposeful task-oriented efforts aimed at problem solving, cognitively restructuring the problem, or attempting to alter the situation.[8] Most of the adaptive coping strategies adopted by patients in this study (active coping, use of instrumental support, positive reframing, planning, and acceptance) are task-oriented coping strategies. Hence, findings of this study are in agreement with the existing body of knowledge in this area.

The pre-HD preparatory program was effective in enhancing use of certain adaptive coping strategies. The program seemed to help patients to positively reappraise their life goals and encouraged them to take control over their own lives by actively participating in decision-making in all aspects of their lives. The patients felt that this program motivated them to take charge of their lives and gave them an insight that leading a near normal life is possible. It is also important to note that the pre-HD preparatory program was also significantly effective in reducing use of substance abuse, a maladaptive coping strategy (P = 0.016). This probably is a result of acceptance of disease and its treatment and positive re-appraisal of the life situation.


   Conclusion Top


In India, 61%–66% of patients who present to nephrologists are already in end-stage renal disease. These patients do not receive any organized education that would prepare them to understand their disease and enable them to manage it to the best of their abilities.[13] An ongoing patient education and counseling program led by trained nurse educator will help patients cope effectively with the diagnosis of CKD and its treatment.

Conflict of interest: None declared

 
   References Top

1.
Harwood L, Wilson B, Locking-Cusolito H, Sontrop J, Spittal J. Stressors and coping in individuals with chronic kidney disease. Nephrol Nurs J 2009;36:265-76, 301.  Back to cited text no. 1
    
2.
Kline SA, Burton HJ, De-Nour AK, Bolley H. Patient’s self assessment of stressors and adjustment to home hemodialysis and capd. Perit Dial Int 1985;5:36-9.  Back to cited text no. 2
    
3.
Gurklis JA, Menke EM. Identification of stressors and use of coping methods in chronic hemodialysis patients. Nurs Res 1988;37:236-9, 248.  Back to cited text no. 3
    
4.
Yeh SC, Chou HC. Coping strategies and stressors in patients with hemodialysis. Psychosom Med 2007;69:182-90.  Back to cited text no. 4
    
5.
Baldree KS, Murphy SP, Powers MJ. Stress identification and coping patterns in patients on hemodialysis. Nurs Res 1982;31:107-12.  Back to cited text no. 5
    
6.
Klang B, Björvell H, Clyne N. Quality of life in predialytic uremic patients. Qual Life Res 1996;5:109-16.  Back to cited text no. 6
    
7.
Quinan P. Control and coping for individuals with end stage renal disease on hemodialysis: A position paper. CANNT J 2007;17:77-84.  Back to cited text no. 7
    
8.
Takaki J, Yano E. The relationship between coping with stress and employment in patients receiving maintenance hemodialysis. J Occup Health 2006;48:276-83.  Back to cited text no. 8
    
9.
Yanagida EH, Streltzer J, Siemsen A. Denial in dialysis patients: Relationship to compliance and other variables. Psychosom Med 1981 ;43: 271-80.  Back to cited text no. 9
    
10.
Welch JL, Austin JK. Stressors, coping and depression in haemodialysis patients. J Adv Nurs 2001;33:200-7.  Back to cited text no. 10
    
11.
Lok P. Stressors, coping mechanisms and quality of life among dialysis patients in australia. J Adv Nurs 1996;23:873-81.  Back to cited text no. 11
    
12.
Cormier-Daigle M, Stewart M. Support and coping of male hemodialysis-dependent patients. Int J Nurs Stud 1997;34:420-30.  Back to cited text no. 12
    
13.
Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK. Factors affecting the use of peritoneal dialysis among the ESRD population in India: A single-center study. Perit Dial Int 2004;24:538-41.  Back to cited text no. 13
    

Top
Correspondence Address:
Dr. Sonali Tarachand Jadhav
M. S. Ramaiah Institute of Nursing Education and Research, MSRIT Post, MSR Nagara, Bengaluru -560 054, Karnataka
India
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DOI: 10.4103/1319-2442.248295

PMID: 30588965

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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