Saudi J Kidney Dis Transpl 2015;26(2):255-262

2015 Saudi Center for Organ Transplantation Saudi Journal

of Kidney Diseases
and Transplantation

Original Article

Coping Methods to Stress Among Patients on Hemodialysis

and Peritoneal Dialysis
Kobra Parvan1, Ronak Ahangar1, Fahimeh Alsadat Hosseini2, Farahnaz Abdollahzadeh1,
Morteza Ghojazadeh3, Madineh Jasemi1
1
Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz, 2Department
of Medical-Surgical Nursing, School of Nursing and Midwifery, Student Research Committee,
Shiraz University of Medical Sciences, Shiraz, 3Department of Physiology, Tabriz University of
Medical Sciences, Tabriz, Iran

ABSTRACT. Dialysis patients need to deal and cope with various aspects of their disease.
Identifying the adaptation methods provides valuable information for planning specific treatment
and medical care delivery and improving the performance of medical teams. The present study
aims to evaluate the coping strategies to stress among patients undergoing hemodialysis (HD) and
peritoneal dialysis (PD) at the Imam Reza Educational-Medical Hospital, Tabriz, West Azarbaijan,
Iran. This descriptive and analytical study was conducted on 70 patients in the year 2012. The
subjects were selected through census method and simple random sampling method. Data were
collected using a customized questionnaire and consisted of demographic information and the
Jalowiec Coping Scale (JCS) through a structured interview. Descriptive and inferential statistics
were used to analyze the data in SPSS (version 13). The mean score of frequency of use of the
coping strategy as sometimes used for the HD patients was 70.94 18.91 and also for PD
patients as seldom used was 58.70 12.66. The mean score of helpfulness of coping strategies
in the HD group was 49.57 19.42 as slightly helpful, whereas in the PD group it was 37.21
14.38 as slightly helpful Furthermore, both groups used the emotion-oriented coping styles
more frequently than the problem-oriented methods. HD patients used coping methods more
frequently than the PD patients. The majority of patients used emotion-oriented coping strategies
to deal with stress factors. Use of educational, counseling and supportive programs to assist in
coping techniques can facilitate the coping process with stress factors in dialysis patients.

Correspondence to: Introduction

Fahimeh Alsadat Hoseini End-stage renal disease (ESRD) is an irrever-

Department of Medical-Surgical Nursing,
School of Nursing and Midwifery,
Student Research Committee, Shiraz
University of Medical Sciences, Shiraz, Iran
E-mail: nurse_meds@sums.ac.ir
sible clinical condition with loss of kidney
function resulting in dependence on renal re-
placement therapy.1,2 There are three types of
renal replacement techniques, including hemo-
dialysis (HD), peritoneal dialysis (PD) and kid-
256
ney transplantation.1
According to a report of the Kidney Patients
and Renal Transplantation Research Center in
Iran, 2007, about 29,000 patients are suffering
from chronic kidney failure in this country;
50% of them are receiving HD, 47.5% are re-
ceiving transplantation and the remaining
2.5% are undergoing PD.3
Each treatment method has some require-
ments, benefits and considerations.4 They help
patients with ESRD; however, they are con-
sidered as a source of stress.5 HD treatment is
highly inflexible and patients, in addition,
need to cope with various aspects of their di-
sease. These patients often have difficulty in
coping with the diseases stress factors.6 Typi-
cal HD stress factors include physical depen-
dence on devices, limitations in physical func-
tion, changes in sexual function and diet, fluid
restriction, taking large doses of drugs for
treatment and loss of appetite and energy.
Psychosocial stress factors include not having
adequate time to perform dialysis, loss of job,
loss of independence, changes in self-percep-
tion and fear of death.6 Like HD, there are some
stress factors for PD also. The complex the-
rapy severely restricts the patients' activities in
ambulatory PD and causes loss of independence,
financial stress, changing roles, changing self-
esteem and breakdown of family life.7
Coping with chronic illness is always a chal-
lenging and threatening process, and health-
care providers need to be aware of these
conditions.8 If coping strategies are used effec-
tively, they can help in improving the per-
formance and well being of individuals. Un-
derstanding the processes that dialysis patients
pass through can help the health-care pro-
viders to efficiently manage their patients.8,9
Studies on the coping strategies are required
because of the following reasons: (a) The con-
flicting findings of the published studies on
this topic,4,10-12 (b) the impact of cultural dif-
ferences in experiencing stress factors in diffe-
rent communities13 and (c) the limitations of
the studies regarding the adaptation strategies,
particularly in patients on PD. The current
study aimed to evaluate the coping strategies
of HD and PD patients.
Parvan K, Ahangar R, Hosseini FA, et al
Materials and Methods
Research design
An analytical, cross-sectional study was per-
formed to evaluate the coping strategies at the
Imam Reza Educational-Medical Hospital
(Tabriz, Iran) among patients undergoing HD
and PD in 2011.
Population and sample
The study patients included those undergoing
HD and PD at the Imam Reza Educational-
Medical Hospital, Tabriz, Iran. Census sam-
pling was applied on HD patients and all
interested patients were included in the study.
Simple random sampling was applied for PD
patients. A total of 70 patients undergoing HD
and 70 other patients on PD were selected by
the simple random sampling method.
Inclusion criteria included age 14 years,
absence of cognitive impairment or psycho-
logical disease such as depression, absence of
acute diseases, physical and mental capability
to answer the questions, on hospital HD for at
least six months and two to three times a week
and PD for at least six months and four times
replacement of the solution per day.
For data collection, a two-part questionnaire
was used; personalsocial characteristics and
the Jalowiec Coping Scale. The first part con-
sisted of six questions regarding the personal
social characteristics of HD and PD patients,
including age, gender, job status, income, ma-
rital status and dialysis duration.
The second part comprised of the Jalowiec
Coping Scale. The 60-item scale (representing
eight coping styles) was applied to determine
the coping strategies of dialysis patients.
The eight coping styles comprised of the fol-
lowing: Confrontive (10 items/strategies); eva-
sive (13 items/strategies); optimistic (nine items/
strategies); fatalistic (four items/strategies);
emotive (five items/strategies); palliative (seven
items/strategies); supportive (five items/strate-
gies) and self-reliant (seven items/strategies).
Confrontive and supportive items were classi-
fied as problem-oriented coping styles. Eva-
sive, optimistic, palliative, emotive, fatalistic and
self-reliant items were attributed to emotion-
Coping methods to stress among HD and PD patients 257

oriented coping styles. In the current study, 37 The validity and reliability of the question-
items were categorized as emotion-oriented naire has been assessed in other studies.
coping styles and 23 as problem-oriented co- Twenty-five nurse researchers familiar with
ping styles. Participants answered each item in the literature about stress and coping methods
two ways: (a) frequency of use and (b) per- approved the Jaloweics Coping Scale.14,15 A
ceived helpfulness. In this regard, the ques- Cronbachs Alfa coefficient of 0.86 for total
tionnaire consisted of two parts, A and B. questionnaire was obtained in the study of
Part A consisted of questions related to fre- Burns.16
quency of use of coping strategies (never, sel- However, the validity and reliability of the
dom, sometimes and often) based on a four- questionnaire has not been studied in the
item scale. The score of each of the response Iranian society. A forwardbackward transla-
was 0 to 3. The scores ranged from 0 to 180. tion method was used to translate the original
In part A of the questionnaire, a total score of English version of this questionnaire to
0 meant never used, 160 meant seldom Persian language. A literature review and stan-
used, 61120 meant sometimes used and dard questionnaire was utilized to assess the
121180 meant often used. The highest validity of the instrument. Also, a total of
score showed the highest rank of coping stra- seven faculty members of nursing and
tegies. Part B was dedicated to the questions midwifery schools of the Tabriz University
on quality of the coping strategies by the pa- Medical Sciences assessed the intelligibility of
tient. The answers included helpful, slightly the instruments content. Revisions were made
helpful, fairly helpful and very helpful. The according to the suggestions received. The
scores were based on a four-item scale. The reliability of the data collection measure was
score of each of the response was 03. The determined using testretest. Ten eligible pa-
scores ranged from 0 to 180. In part B of the tients were interviewed, and, after two weeks,
questionnaire, a total score of 0 meant not the same people were interviewed again. The
helpful, 160 meant slightly helpful, 61 responses were then compared and the corre-
120 meant fairly helpful and 121180 meant lation coefficient was measured. The corre-
very helpful. The highest score showed the lation coefficient of the Jalowiec Coping Scale
highest rank of coping strategies. was 0.81.
Table 1. The demographic characteristics of the study participants.
Peritoneal dialysis Hemodialysis
Variable Group
number (%) number (%)
Age (years) 43.67 14.96 50.71 16.16
Male 29 (41.4) 47 (67.1)
Gender
Female 41 (58.60) 23 (32.9)
Unemployed 8 (11.4) 19 (27.1)
Employed 5 (7.1) -
Self-employed 14 (20) 19 (27.10)
Job
Housewife 36 (51.4) 22 (31.40)
Retired 1 (1.4) 5 (7.1)
Other 6 (8.6) 5 (7.1)
Income less than expenses 30 (60) 34 (64.2)
Income Income = expenses 20 (40) 16 (30.1)
Income more than expenses 0 (0) 3 (5.7)
Single 7 (10) 4 (5.7)
Married 61 (87.1) 65 (92.9)
Marital status
Divorced 0 (0) 1 (1.4)
Widow 2 (2.9) -
Dialysis treatment
23.84 15.35 34.39 21.71
duration (months)
258
The data were collected using a structured
interview by the questionnaire. The researcher
was referred to the HD and PD departments of
the Imam Reza Educational-Medical Hospital,
Tabriz, Iran to interview the patients and ask
them to complete the questionnaires.
Ethical consideration
Approval of the current study was obtained
from the Research Deputy of the Nursing
School of the Medical Sciences of Tabriz
University and the Ethical Committee. Because
the data collection method was based on
interview, patients were explained about the
study details and full confidentiality of the
information was ensured. Also, return of the
completed questionnaire was identified as
giving consent to participate in the study.
The data were analyzed using statistical
package of SPSS (version 13). Descriptive sta-
Table 2. Respective ranking for use and helpfulness of items from the Jalowiec coping scale, based
on highest mean scores in hemodialysis patients (N = 70).
Coping strategies
Rank
Use Mean (SD)
17 - Prayed or put your trust
1 2.97 0.02
in God
12 - Accepted the situation
2 because very little could be 2.19 0.06
done
58 - Hoped that things would
3 1.97 1.09
get better
21 - Waited to see what
4 1.96 0.1
would happen
52 - Preferred to work things
5 1.96 0.92
out yourself
23 - Resigned yourself to the
6 situation because things 1.9 0.08
looked hopeless
18 - Tried to get out of the
7 1.9 0.11
situation
1 - Worried about the
8 1.9 0.12
problem
2 - Hoped that things would
9 1.79 0.11
get better
36 - Tried to distract yourself
10 by doing something that you 1.77 0.11
enjoy
Parvan K, Ahangar R, Hosseini FA, et al
tistics (frequency, percent and mean and stan-
dard deviation) and non-parametric inferential
statistics (KruskalWallis, U-MannWhitney)
and Spearman correlation coefficient were
applied. The significance level was P <0.05.
Results
The demographic characteristics of the pa-
tients who participated in the study are pre-
sented in Table 1. The priority of coping stra-
tegies based on the most frequent use and
helpfulness in patients undergoing HD and PD
are shown in Tables 2 and 3.
The mean score of usage of coping strategies
in the HD group was 70.94 18.91 as some-
times used. The mean score of usage of co-
ping strategies in the PD group was 58.70
12.66 as seldom used.
About the helpfulness of the applied coping
Helpfulness Mean (SD)
17 - Prayed or put your trust in
2.96 0.03
God
36 - Tried to distract yourself
by doing something that you 2.02 0.09
enjoy
3 - Ate or smoked more than
2 0.25
usual
39 - Tried to keep a sense of
1.96 0.09
humor
42 - Talked the problem over
with someone who had been 1.94 0.11
in a similar situation
58 - Hoped that things would
1.86 1.07
get better
49 - Compared yourself with
other people who were in the 1.79 0.19
same situation
34 - Took a drink to make
1.73 0.08
yourself feel better
45 - Learned something new
in order to deal with the 1.71 0.28
problem
32 - Told yourself not to
worry because everything 1.68 0.12
would work out fine
 Coping methods to stress among HD and PD patients 259

Table 3. Respective ranking for use and helpfulness of items from the Jalowiec Coping Scale based
on the highest mean scores in peritoneal patients (N = 70).
Coping strategies
Rank
Use Mean (SD) Helpfulness Mean (SD)
17 - Prayed or put your trust 17 - Prayed or put your trust in
1 2.94 0.03 2.9 0.05
in God God
25 - Tried to change the 3 - Ate or smoked more than
2 1.97 0.04 2 0.2
situation usual
2 - Hoped that things would 52 - Preferred to work things
3 1.96 0.09 1.63 0.48
get better out yourself
52 - Preferred to work things 9 - Expected the worst that
4 1.9 0.74 1.61 0.08
out yourself could happen
18 - Tried to get out o f the 5 - Told yourself that things
5 1.9 0.07 1.6 0.07
situation could be much worse
30 - Tried to keep your life as
14 - Daydreamed about a
6 1.89 0.09 normal as possible and not let 1.51 0.07
better life
the problem interfere
30 - Tried to keep your life as
39 - Tried to keep a sense of
7 normal as possible and not let 1.89 0.04 1.46 0.08
humor
the problem interfere
12 - Accepted the situation
53 - Took medications to
8 because very little could be 1.86 0.08 1.45 0.57
reduce tension
done
49 - Compared yourself with
4 - Thought out different
9 1.7 0.09 other people who were in the 1.43 0.29
ways to handle the situation
same situation
58 - Hoped that things would 21 - Waited to see what would
10 1.64 0.72 1.42 0.07
get better happen

strategies, the mean score of the HD group
was 49.57 19.42 as slightly helpful. The
mean score of the PD group was 37.21
14.38as slightly helpful.
The U-MannWhitney test showed a signi-
ficant difference between the use of coping
strategies and the helpfulness of coping stra-
tegies in the two groups of dialysis patients.
The use and helpfulness of coping strategies in
HD patients were more than in patients under-
going PD (Table 4).
The Spearman correlation test showed a
direct and strong relationship between the use
and helpfulness of the coping methods in both

Table 4. The comparison of the mean score of the use and helpfulness of coping strategies in hemodialysis and
peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.
Coping strategies
The use of coping strategies Helpfulness of coping strategies
Mean SD Mean SD
Group The use of The use of Helpfulness Helpfulness of
problem- emotional- of problem- emotion- Sum of
Sum of scores
oriented oriented oriented oriented scores
method method method method
Hemodialysis 17.46 4.08 53.07 14.11 70.49 1 8.19 13.18 5.29 36.39 14.3 49.57 19.42
Peritoneal
16.93 3.27 41.76 9.39 58.70 12.66 10.09 3.9 24.13 10.48 37.21 14.38
dialysis
U = 1534 U = 1531
Statistical results
P 0.001* P <0.001*
*P 0.05 is considered significant.
260 Parvan K, Ahangar R, Hosseini FA, et al

Table 5. The association between the score and the effect of coping strategies among hemodialysis and
peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.
Coping strategies
The correlation between the use and
The use of coping Helpfulness of
Group helpfulness of coping strategies
strategies coping strategies
Statistical relationship
Mean SD Mean SD
P n rs
Hemodialysis 70.49 18.19 49.57 19.42 0.001* 70 0.87
Peritoneal dialysis 58.70 12.66 37.21 14.38 0.001* 70 0.80
*P 0.05 is considered as significant.

groups (Table 5). There was a weak and nega-
tive correlation between age of the patient and
use of coping strategies in HD patients. The
older the patient, the lower was the use of co-
ping strategies (r = -0.31, P = 0.008). Similar
findings were seen among PD patients as well;
older the patient, lower was the use of coping
strategies (r = -0.23, P = 0.05). There was no
significant association in the other variables.
Discussion
The present study aimed to evaluate the co-
ping strategies in two groups of patients
undergoing HD and PD. Also, the association
between the methods was compared in the two
groups of patients.
Among the 10 most frequently used com-
ponents, the highest coping strategy in both
groups was Prayer and trust in God. Like the
present study, in many previous studies,
Prayer and trust in God has been rated
highly in HD patients.16-18 One of the most
important coping strategies of PD patients in
the study of Zimmer was Prayed or put your
trust in God.1
Generally, in the present study, the religious
aspect, including praying or trust in God, was
the most frequently used and helpful coping
strategy in HD and PD patients; this is largely
related to the prominent position of religious
beliefs in the culture and life of Iranian people.
The mean score of dialysis patients (HD and
PD) regarding the use and helpfulness of
emotion-oriented coping strategies was higher
than problem-oriented coping methods. Based
on the studies performed by many researchers,
it was found that HD and PD patients use the
emotion-oriented styles more often in coping
with the challenges and stresses related to the
disease and treatment.1,19-22 The findings of the
present study are in accordance with the results
of many previous studies. However, the study
performed by Ghaffari et al showed that the
majority of HD patients used problem-oriented
coping strategies to deal with stress factors;12
this finding is inconsistent with the results of
the current study. The reasons for the discre-
pancy between these findings can be the diffe-
rent research methodology used as well as the
different study population.
In this study, patients on HD and PD used
coping methods sometimes and seldom,
respectively, for coping with the existing con-
ditions. Coping methods were slightly helpful
in both groups of patients, and emotion-orien-
ted coping strategies were more frequently
used than problem-oriented coping methods by
both groups of dialysis patients. In earlier
studies,23 problem-oriented styles were more
helpful than emotion-oriented styles in dealing
with stress factors. On the other hand, accor-
ding to Miller, the emotion-oriented coping
mechanism is used when the stress events
cannot be controlled with other methods.24
However, limited use of the problem-oriented
coping strategies by the patients can, at times,
be due to lack of patients knowledge on the
helpfulness of these mechanisms in stress ma-
nagement. Additionally, because the individuals
are not required to learn and apply special skills
to use specific emotion-oriented coping strate-
gies, problem-oriented coping methods are rarely
adapted. Thus, organized planning and training
as well as assessment of problem-oriented
coping strategies in patients are required.
Coping methods to stress among HD and PD patients
There was a significant association between
the use and helpfulness of coping strategies in
both groups. Their use was more beneficial in
the HD patients than in the PD patients.
Previous studies have shown that patients
treated with HD experience significantly
higher stress levels than patients undergoing
PD (P <0.001).25,26 Goker showed that 65.2%
of HD patients had an associated psychiatric
disorder, the most common being depression
and/or anxiety.22,27 Studies have shown that the
level of depression among patients undergoing
HD was higher than in patients undergoing
PD.22,28-30 It could be because PD is less inva-
sive and less restrictive than HD.22
In the current study, there was a strong and
direct association between the use and helpful-
ness of coping strategies in both patent-groups.
Despite the frequent use of emotion-oriented
coping strategies, indeed greater use of coping
strategies (emotion-oriented or problem-orien-
ted coping methods) was found to lead to
higher and helpful coping strategies in both
groups of dialysis patients.
We also found that with an increase in the
age in patients treated with PD or HD, the use
of coping strategies was significantly lower. In
the study performed by Logan et al and Cheng
et al, similar results were obtained in patients
undergoing HD and PD.18,31 It is likely that
with the increase in age, several factors in-
cluding progression of the disease, compli-
cations related to physical and psychological
aspects and developmental stage of the person
and other important factors might play an
important role in the lack of adequate use of
the coping methods.
The present study has several limitations, in-
cluding the large number of questionnaire
items, fatigue and physical and psychological
conditions of patients that might have affected
how the participating patients responded.
Because the current study was conducted on
patients undergoing HD and PD at the Imam
Reza Hospital (Tabriz, Iran), the results cannot
be generalized to other dialysis patients. There-
fore, it is recommended that further studies be
performed on a larger sample size of dialysis
patients.
261
Conclusions
The majority of patients in the current study
used emotion-oriented coping strategies to
deal with the stress factors. Although many of
the emotion-oriented coping strategies were
identified as helpful coping strategies by the
patients, because the problem-oriented coping
strategies are more difficult to respond, these
methods were not adequately applied, which
could be due to lack of knowledge among the
patients. Furthermore, considering the impor-
tance of understanding all aspects of stress
factors and coping strategies, regular psychia-
tric assessment and counseling could facilitate
the coping process of dialysis patients with the
stress factors and lead to improvement in the
quality of life as well as promoting physical
and mental health of these patients.
Conflict of interest: None declared.
Neither this manuscript, nor one with subs-
tantially similar content under my authorship,
has been published or is being considered for
publication elsewhere, and all the data col-
lected during the study is presented in this
manuscript and no data from the study has
been or will be published separately.
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