Reshmaaa

CHAPTER 1
INTRODUCTION
Background of the problem
Need and significance of the study
Statement of the problem
Objectives
Operational definitions
Assumptions
Hypotheses
Conceptual/theoretical framework
CHAPTER I
INTRODUCTION
It is health that real wealth and not pieces of gold and silver.1
Health is a state of perfect harmony between all the organs and systems of the body.
Good health is more than being free from disease, good hygiene and the access to
medical and social care also important. According to world Health Organization
(WHO) health is a state of complete physical, mental and social well being not merely
the absence of disease or infirmity.2 Thus health is a positive concept emphasising
social and personal resources as well as physical capabilities. Perception about health
is varies according to individuals previous experience, expectation of life, age and
socio cultural factors.
A disease is an abnormal condition that affects the body of an organism. An
impairment of the normal state of the living animal or plant body or one of its parts
that interrupts or modifies the performance of the vital functions.3The kidneys are the
most important excretory organs within the human body. The word excretion means
the removal of metabolic waste substances from the body. This "metabolic waste" is
the large number of chemical reactions that occur in the cells, tissues and organs. Of
these substances, some of the by-products and end-products of metabolism are toxic
and have to be removed from the body, before they will poison the body tissues.
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) is the
progressive, irreversible deterioration in renal function in which the body's ability to
maintain metabolic, fluid and electrolyte balance resulting in uraemia or azotemia.
Chronic kidney disease is the condition causes reduced kidney function over a period
of time. Chronic kidney disease is present when glomerular filtration rate remains
2
below 60 ml per minute for more than 3 months or when urine albumin-creatinine
ratio is over 30 mg of albumin for each gram of creatinine (30 mg/g).4-6
End Stage Renal Disease is a chronic illness which inevitably reduces the
lifespan of the patients. The Continuous Ambulatory Peritoneal Dialysis [CAPD],
Hemodialysis (HD) and Renal Transplantation treatment modalities are not curative,
instead they offer symptom relief, extend life expectancy and are intended to improve
the quality of life.6
Hemodialysis plays an important role in maintaining renal function. It filters
circulating blood through a semi permeable membrane in an apparatus to remove
waste products in case of kidney failure and it attempts in replacing kidney function.
Hemodialysis can be an outpatient or inpatient therapy. Routine haemodialysis is
conducted in a dialysis outpatient facility, either a purpose built room in a hospital or
a dedicated, stand alone clinic. Less frequently haemodialysis is done at home.7
However, it has been argued that a number of restrictions and modifications
accompany this treatment, which have a detrimental impact on the quality of patients
life and affects individuals physical and psychological wellbeing. Much evidence
exists to suggest that stress is a significant factor in haemodialysis, since the latter
results in a marked change in the quality of patients life.
Relaxation is one of the most useful non pharmacological techniques, which
reduce stress through impact on mental and physical conditions. Among relaxation
methods Bensons relaxation method (1970) is one of the easiest to learn and
administer. The relaxation response is a physical state of deep rest that changes in the
physical and emotional response to stress and opposite of response may help people to
counteract the toxic effects of chronic stress by slowing breathing rate, relaxing
muscles and reducing blood pressure. Bensons relaxation technique is a simple
3
version of Transcendental Meditation .This will reduce the stress and reversal of some
physiologic changes associated with chronic stress.8 The majority of people report
feelings of relaxation and freedom from stress during the elicitation of the relaxation
response and during the rest of the day as well. Through this study hemodialysis
patients get a relief from stress and help to improve their quality of life.
Background of study
Kidney is the principal organ of urinary system. Adequate functioning of
kidney is essential to maintenance of healthy body. The kidneys are highly vascular
organ and receive 20% to 25% of the resting cardiac output. The patients with renal
failure face a lot of challenges especially from the aspect of health status, life style as
well as their roles in life. End stage renal disease occurs when the kidneys are no
longer able to clean and filter waste and fluids from the blood circulation as they
normally do. When this occurs, it would endanger the patients life. According the
Global Burden of Disease Study, chronic kidney disease was ranked 18th in the list of
causes of death Worldwide in 2010.9
Chronic kidney disease (CKD) is a worldwide public health problem, both for
the number of patients and cost of treatment involved. Globally, CKD is the 12th
cause of death and the 17th cause of disability respectively. The prevalence of ESRD
and patients on RRT has increased over last two decades.10According to National
Kidney Foundation ESRD is defined as the point where kidney function is at 10% of
normal.11
Every year one lakhs new cases of ESRD have been detected and the demand
for dialysis is around 9 lakhs per year.12The prevalence of chronic kidney disease in
adults over 30 to rise 27% by 2030.
4
The world wide incidence of renal failure is about 140 per million population
and more than one million people are on dialysis. Health statistics shown that
incidence of ESRD has increased for almost 80% per year for the past 5 years, with
more than 300,000 patients being treated in the United States. The valid treatment
option for renal failure patients are hemodialysis, peritoneal dialysis and renal
transplantation.13
Over 1 million people worldwide are alive on dialysis or with a functional
graft. During hemodilysis procedure patients may suffer lots of pressure and
tension.The dialysis depends onmachine for survival conflicts with the independence
neededto maintain a normal life. A number of stress and copingmechanism factors
operate in patients on maintenancehemodialysis.14
Stress is one of the biggest health issues in the hemodialysis patients.Chronic renal
failure is threatened withmany potential losses and changes in lifestyle.
Haemodialysis patients use various strategies to cope up with the stressors related to
their disease and the procedures used in its treatment.15In recent days the use of
complementary and alternative medicines has increased in conventional health care
settings. Fear of medications side effects and desire for symptom relief are possible
reasons for the increasing use of complementary alternative medicine by patients.
With consumer interest in complementary, nurses have increasingly incorporated
these modalities into their practice. 16
The exact burden of chronic kidney disease in India still undefined. A
community based study conducted in New Delhi in the year 2005, regarding
prevalence of chronic renal failure among adults, shows that prevalence of CRF in
adult population was 7852/million.16
5
A descriptive cross sectional study was conducted at Mumbai (2014) to
assess the level of stress and coping among 30hemodialysis patients were selected
conveniently by using Stress and Adaptation Questionnaire revealed that about 97%
of dialysis patients had severe stress.17
A randomized control trial was conducted at India (2013) to explore the
efficacy of Bensons relaxation technique on stress, anxiety and depression among 80
hemodialysis patients were selected by simplerandom method using Depression
Anxiety Stress Scale indicated that there were significant difference between stress
and anxiety after intervention and instructing Bensons relaxation technique is helped
to reduce stress and anxiety level of hemodialysis patients.18
Need and significance of the study
Stress is a state of disequilibrium that occurs when there is a disharmony
between demands occurring within an individuals internal or external environment
and his/ her ability to cope with that demands.19 It is one of the biggest health issues
in the society today. Over a half of the million people will have their physical or
mental health damaged as a result of renal failure.
Chronic kidney disease can occur at any age but becomes more common with
increasing age and is more common in women. Currently 35000 people are treated
with dialysis with stress it is estimated that this number will increase > 50000 by the
year 2020, in Europe the number of dialysis patient with stress is also increasing
annually. The mortality rate in dialysis patient is very high with a mean death rate of
22% per year due to stress. This rate mainly influenced by age, with a yearly mortality
of 4% in patients younger than 20years rising to 35% in patient older than 65 years.20
A descriptive correlational study was conducted at Ireland (2005) to measure
the overall quality of life among 97 hemodialysis patients were selected purposively
6
by using Health survey questionnaire revealed that dialysis patients had severe stress
and which negatively affect quality of life.21
Most of the studies investigating the stressors faced by haemodialysis patients
have found them to be both physiological and psychological stressors. The most
common physiological stressors for these clients are limitation of fluid, limitation of
food, fatigue, and sleep disturbance. The most common psychological stressors have
been reported to include role disturbance, employment status, social support, stress,
anxiety and depression.
The high prevalence of stress in dialysis patients is very crucial. Appropriate
diagnosis and treatment of this condition is certainly important. Among the various
measures Bensons relaxation technique has been gaining popularity as a simple and
easy administrative mode of alternative therapy not only for stress but also anxiety,
depression, pain and insomnia.
From the review of literature, the researcher understood that Bensons
relaxation technique can be administered effectively for hemodialysis patients
especially with high stress. Hence the researcher got interested in assessing stress
among hemodialysis patients and determine the effectiveness of Bensons relaxation
technique in reducing the stress among hemodialysis patients.
Statement of the problem
A study to assess the effectiveness of Bensons relaxation technique on stress among
hemodialysis patients in a selected hospital at Alappuzha district.
Objectives of the study
1. To assess the pretest and post test level of stress among hemodialysis patients.
2. To find out the effectiveness of Bensons relaxation technique on stress among
hemodialysis patients.
7
3. To find out the association with pretest level of stress and selected
sociodemographic variables.
Operational definitions
Effectiveness : In this study, effectiveness refers to the extent to which the
Hemodialysis patients have achieved a significant reduction in the post test level of
stress after practicing Bensons relaxation technique for 10 minutes once daily for a
period of 24 days and is measured by using Cohen Perceived Stress Scale.
Bensons relaxation technique: In this study, Bensons relaxation technique refers to a type of
breathing exercise performed in sitting position with closed eyes and relaxing the
body from toes to top and then taking a deep breath through nose and exhale from
mouth by saying one word or number for 10 minutes once daily for three days in a
week under the supervision of the researcher and all other days by themselves for a
period of 24 days.
Stress: In this study, stress refers to a mental distress associated with physical,
psychological, emotional alteration experienced by hemodialysis patients which is
measured by using Cohen Perceived Stress Scale.
Hemodialysis patients: In this study, Hemodialysis patients refer to chronic renal
failure patients having stress score 14 and above undergoing hemodialysis regularly
atleast thrice in a week minimum for a period of 1 month in a selected hospital at
Alappuzha district.
Hospital: In this study, hospital refers to a place where hemodialysis treatment
provided regularly for chronic renal failure at Alappuzha district
Assumptions
The study assumes that:
8
Bensons relaxation technique may be effective in reducing stress among
Hemodialysis patient.
Hemodialysis patients can effectively practice Bensons relaxation technique in
order to reduce stress.
Hypothesis
H01 There will be no significant difference in pretest and post test level of stress
among hemodialysis patients after practicing Bensons relaxation technique.
H1There will be a significant difference in pre test and post test level of stress
among hemodialysis patientsafter practicing Bensons relaxation technique.
H02There will be no significant association with pre test level of stress and
selected sociodemographic variable.
H2There will be a significant association with pre test level of stress and selected
sociodemographic variable.
Conceptual/theoretical frame work
The framework is an abstract, logical structure of meaning such as portion
oftheory which guides the development of the study and enables the researcher to link
the findings to nursing body of knowledge. The study framework is called the
conceptual framework or theoretical framework in a study.22 The present study is
aimed to assess the effectiveness of Bensons relaxation technique on stress among
hemodialysis patients in a selected hospital at Alappuzha district. The conceptual
frame work of the present study is based on Imogene King Goal Attainment theory.
The theory is based on assumption that humans are open system who
continuously interacts with their environment. The theory is focus on interpersonal
system reflects King's belief that the practice of nursing is differentiated for in that of
other health profession by what nurses do with and for individual. The major elements
9
of the theory of Goal Attainment are seen "in the interpersonal systems in which two
people, who are usually strangers, come together in a health care organization to help
and be helped to maintain a state of health that permits functioning in roles.
The theory concepts focus on the methods to help nurses in the nurse-patient
relationship. King used a "systems" approach in the development of her dynamic
interacting systems framework and in her subsequent Goal-Attainment Theory. She
developed a general systems framework and a theory of goal attainment where the
framework refers to the three interacting systems - individual or personal, group or
interpersonal, and society or social, while the theory of goal attainment pertains to the
importance of interaction, perception, communication, transaction, self, role, stress,
growth and development, time, and personal space. King emphasizes that both the
nurse and the client bring important knowledge and information to the relationship
and that they work together to achieve goals.23
The concepts of the theory are perception, judgment, action, interaction and
transaction. These concepts are interrelated to in every nursing situation. These terms
are defined as concepts in conceptual framework.
Perception
It is each persons representation of reality.24 The elements of perception are
imparting of energy from the environment and organizing it by information,
transforming energy, processing information, storing information in the form of overt
behaviour. In this study, investigator perceives Bensons relaxation technique helps in
reducing stress among hemodialysis patients.
Judgement
Individuals come together for a purpose and perceive each other. Each makes
a judgement and takes mental action to decide and act.24 In this study, judgement of
10
researcher is that Bensons relaxation technique will be effective for reducing stress
among hemodialysis patients and judgement of hemodialysis patients are Bensons
relaxation technique will help to reduce stress.
Action
Refers to the activity to achieve the goal what the individual perceives.24 In
this study it is mutual goal setting to reduce the stress among hemodialysis patients by
practicing Bensons relaxation technique. Investigator administering Cohen perceived
stress scale to analyze the stress and patients are motivated to answer the questions in
the scale.
Reaction
Action results in reactions. In this study, reaction of the researcher is to find
out the pre test score of stress and deciding to practice Bensons relaxation technique
for reducing stress among hemodialysis patients.
Interaction
Interaction refers to goals what individuals perceive. In this study, interaction
regards with the investigator to administer Bensons relaxation technique for
hemodialysis patients who have stress assessed by Cohen Perceived Stress Scale..
Transaction
It is a process of interaction in which human being communicate with the
environment to achieve goals that are valued and directs human behaviour.24In this
study, transaction is the assessment of post test score among hemodialysis patients in
Rating Scale on stress shows the stress is reduced or not.
Positive outcome
Significant reduction in the level of stress as measured by Cohen Perceived
Stress Scale.
11
Negative outcome
No reduction in the level of stress.
The diagrammatic representation of the theory based on Imogene.M.Kings
Goal Attainment theory shown in figure. 1
The succeeding chapter deals with review of literature.
12
ACTION INTERACTION TRANSACTION
REACTION
PERCEPTION
Investigator assumes that Pretest assessment Researcher assess
Find out the effect
Conducting
R Bensons relaxation technique of stress of the stress among of stress after
E may effective in reducing practice session of
S stress of hemodialysis patients hemodialysis hemodialysis practicing
Bensons relaxation
E
patients using patientsand decided Bensons
A technique to make
R Cohen Perceived to teach and relaxation
changes on stress
C JUDGEMENT demonstrate
Stress Scale. technique among
H Bensons relaxation among
E technique will be effective Bensons relaxation hemodialysis
hemodialysis
R for reducing stress among technique to the
patients.
Hemodialysis patients. patients.
group .
ACTION
P PERCEPTION Actively participate

A Hemodialysis patient feel that
in practice Bensons POSITIVE
T researcher will help them to
relaxation technique OUTCOME
I practice Bensons relaxation
technique which may help to and in the pretest NEGATIVE
E Stress is reduced
reduce the stress. OUTCOME
N
inhemodialysis
T Stress is not
patients
JUDGEMENT reduced
Bensons relaxation technique

will help to reduce stress.
Feed back*
Figure 1: Conceptual framework of the study based on Imogene .M.Kings Goal Attainment theory.*not included in the study
13
CHAPTER 2
REVIEW OF LITERATURE
Section I : Studies related to Stress among hemodialysis patients.
Section II : Studies related to effectiveness of Bensons relaxation technique on
stress among hemodialysis patients
Summary
14
CHAPTER 2
REVIEW OF LITERATURE
Review of literature is a body of text that aims to review the critical points
ofknowledge on a particular topic of research. Review of literature is defined
asselection of available documents, both published and unpublished on the topic
ofresearch interest, which contain information, ideas data and evidence written from a
particular stand point to fulfil certain aims or express certain views on the nature
oftopic and how it is to be investigated and the effective evaluation of these
documents in relation to the research being proposed.22
The researcher has organized the related literature under the following
headings after reviewing various research studies and non research literature.
Section I : Studies related to Stress among hemodialysis patients.
Section II: Studies related to effectiveness of Bensons relaxation technique on stress
among hemodialysis patients
Section I: Studies related to Stress among hemodialysis patients
A descriptive analytical study was conducted at Iran (2015) to evaluate coping
strategies to stress among 70 hemodialysis and peritoneal dialysis patients were
selected by simple random method using Jelowice Coping Scale and Customorized
Stress Questionnaire showed that hemodialysis patients used coping methods more
frequently than peritoneal dialysis patients and majority of patient used emotion
oriented coping strategies to deal with stress factors.25
A descriptive cross sectional study was conducted at Mumbai (2014) to assess
the level of stress and coping among 30hemodialysis patients were selected
conveniently by using Stress and Adaptation Questionnaire revealed that about 97%
patients undergoing hemodialysis had severe stress26
15
A cross-sectional survey was conducted at Scotland (2014) to
assess patientshealth status and impact of haemodialysis treatment on quality of life
and well-being among 60 hemodialysis patients were selected by non probability
sampling method using General Well-being Questionnaire for Stress showed that the
hemodialysis patients had severe stress and anxiety .27
A cross sectional study was conducted at Chennai (2013) to assess the stress
and coping among 50 hemodialysis and peritoneal dialysis patients were selected
purposively by using Modified Jelowice, Murphy and Power Structured Questionnaire
and Stress Scale indicated that overall mean stress score in chronic hemodialysis
patients was higher (78.3%) than in peritoneal dialysis patients (43.3%) p<0.01.28
A descriptive study was conducted at Iran (2013) to determine stressful
factors, coping mechanism and quality of life among 113 hemodialysis patients were
selected by census method using Hemodialysis Stressor Scale and Jelowice Coping
Scale indicated that hemodialysis patients had severe stress.29
A descriptive comparative survey was conducted at United Arab Emirates
(2013) to assess the quality of life among 161 dialysis patients and 350 participants
from community were selected conveniently by using Quality of life Index Dialysis
Version Tool and SF-36 questionnaire indicated that the overall quality of life for
dialysis patients was rated lower with the community sample (58.92 vs 75.02,
p<0.0001).30
A descriptive cohort study was conducted at Brazil (2011) to verify the
association between quality of life and morbidity and mortality among 40
hemodialysis patients were selected by using Medical outcome study 36 item short
form health survey questionnaire indicated that there is a close relationship between
quality of life with morbidity and mortality.31
16
A descriptive study was conducted at Hong Kong (2011) to determine the
stressors and coping methods among 50 hemodialysis patients were selected using
Baldree Haemodialysis Stressor Scale (HSS) and Jalowiec Coping Scale (JCS)
revealed that limitation of fluid was the most frequently identified stressor and most
common coping methods are accepted the situation .32
A cross sectional study was conducted at Northern Iran (2011) to evaluate the
physiological and psychological stressors among 80 hemodialysis patients were
selected by survey method using demographic information record sheet and Baldree
Hemodialysis Stress Scale revealed that hemodialysis patients have significant
physical and psychosocial problems and stress level was high in women who were
married, younger belonged to low educational level.33
A descriptive study was conducted at Iran (2011) to investigate coping styles
among 96 hemodialysis by using Hemodialysis Questionnaire revealed that
hemodialysis patients use emotion focused coping style. The study suggested that
educational programme on application of problem focused coping styles helped to
decreases the pressure of diseases and promote mental health, quality of life and
efficiency.34
A descriptive correlation study was conducted at Pakistan (2008) to assess the
relationship between quality of life and stress among 100 hemodialysis patients were
selected conveniently by using SF-36 and Depression Anxiety Stress Scale showed
that increased depression, anxiety, and stress could reduce the quality of life of
hemodialysis patients.35
A descriptive correlational study was conducted at Ireland (2005) to measure the
overall quality of life among 97 hemodialysis patients were selected purposively by
17
using Short Form Health survey questionnaire revealed that End stage renal disease
and its treatments negatively affect quality of life.36
A study was conducted at Istabul (2005) to determine relationship among
treatment related stressors and coping strategies among 224 chronic hemodialysis
patients were selected by non probability sampling technique using Hemodialysis
Stressor Scale and Carver Coping Scale indicated that most frequently frequent
stressors reported were limitation of vacation (80.4%), followed by fatigue (79.9%) .37
A descriptive correlational study was conducted at (2004) to investigate
stressors and coping among 60 hemodialysis patients were selected using Baldree
Hemodialysis Stressor Scale and Jalowiec Coping Scale indicated that length of time
of hemodialysis may be affects the participants appraisal of stressors and few coping
strategies found less helpful.38
A cross sectional study was conducted at Japan (2008) to examine the
relationships among coping, co morbidity and stress among 2642 hemodialysis
patients from 27 nursing centres were selected by interview method using
Hemodialysis Stressor Scale and Jalowiec Coping Scale indicated that hemodialysis
patients with comorbidities were found to have higher level of stress.39
A descriptive study was conducted at Chennai (2003) to assess the stress and
coping among 60 hemodialysis patients were selected conveniently by using Stress
and Coping Questionnaire showed that 65% had mild stress, 20% had moderate stress
and 63.3 % never had any coping where as 36.7 % had some coping. The study
concluded that there was a negative correlation between level of stress and coping
among hemodialysis patients.40
A comparative study was conducted at Iran (1999) to evaluate the factors
associated with treatment related stressors among 86 haemodialysis patients were
18
selected at two points in time, three months apart by using the Haemodialysis Stressor
Scale revealed that greatest stressors were fluid limitations and patients new to
dialysis with more education had relatively more stressor.41
A descriptive study was conducted at Portugal (1999).to evaluate the factors
associated with treatment related stressors among 75 haemodialysis patients aged 18-
65 years were selected at two points in time, three months apart by using the
Haemodialysis Stressor Scale revealed that hemodialysis patients had high level of
stress and psychological stressors are problematic than physiological ones.42
A survey was conducted at Australia (1996) to determine the
significant stressors and coping methods which are related to quality of life among 64
dialysis patients were selected by survey method by using Stress and Coping
Questionnaire revealed that limitation of physical activity was the most troublesome
stressor and length of time on the dialysis programme was not significantly related to
coping behavior.43
A descriptive study was conducted at Greece (1994) to investigate stress
among chronic hemodialysis patients selected based on Literature Review from
international data base showed that stressors had particular importance among
hemodialysis patients and these affect their physiologic as well as psychological well-
being.44
A study was conducted at Japan (1993) to assess stress and coping patterns
among 35 hemodialysis patients were selected purposively by using Hemodialysis
Stressor Scale revealed that psychosocial stressors have an impact equal to that of
physiological stressors and fluid restriction was ranked as the highest psychosocial
stressor and the top physiological stressors were muscle cramps and fatigue.45
19
An exploratory study was conducted at Columbus (1988) to assess the stress
and use of coping methods among 68 chronic hemodialysis patients were selected by
non probability sampling method using Hemodialysis Stressor Scale and Jalowiec
Coping Scale indicated that physiological stressors were more troublesome than
psychosocial stressorsp< 0.0001 and no significant relationships between stressor and
coping scores.46
Section II: Studies related to effectiveness of Bensons relaxation technique on
stress among hemodialysis patients.
A clinical trial was conducted at Imam (2016) to determine the effect of
Bensons Relaxation on depression, anxiety and stress among 70 hemodialysis patients
were selected randomly by using Depression Anxiety Stress -21 (DAS)
Questionnaires showed that there is a significant difference between stress and
anxiety in experimental and control groups in all intervals after intervention and no
significant difference between mean score of depression. The study concluded that
utilizing Bensons relaxation technique helped to reduce stress and anxiety among
dialysis patients.47
An experimental study was conducted at Iran (2014) to investigate the effects
of Bensons relaxation technique on quality of life among 60 hemodialysis patients
were selected conveniently by using Disease-specific Questionnaire indicated that
mean scores of general and total quality of life were significantly higher than the
corresponding pre test readings and Bensons relaxation technique had a positive
effects on quality of life among patients receiving hemodialysis.48
A randomized control study was conducted at Iran (2014) to assess theefficacy
of Bensons relaxation training on stress, anxiety, and depression among 80
hemodialysis patients were selected by using Depression Anxiety Stress Scaleshowed
20
that there were significant differences between stress and anxiety levels in case group
before and after intervention (P <0.001)The study concluded that instructing Bensons
relaxation technique is helped to reduce stress and anxiety level of hemodialysis
patients.49
A randomized control trial was conducted at India (2013) to explore the efficacy
of Bensons relaxation technique on stress, anxiety and depression among 80
hemodialysis patients were selected by simplerandom method using Depression
Anxiety Stress Scale indicated that there were significant difference between stress
and anxiety level in case group before and after intervention and instructing Bensons
relaxation technique is accompanied by reducing stress and anxiety level of
hemodialysis patients.18
A randomized control study was conducted at Shiraz University of Medical
Sciences (2012) to evaluatethe effect of Bensons relaxation technique on pain and
quality of life among 86 haemodialysis patients were selected randomly by using
Ferrans and Powers Quality of Life Index-dialysis version Questionnaire indicated
that Bensons relaxation technique help to relieve the intensity of pain and improve the
quality of life of haemodialysis patients.50
A randomized study was conducted at Australia ( 2008) to determine the effect
of Bensons relaxation technique to reduce stress and improve the responses among 40
hemodialysis patients were selected purposively by Baldree Hemodialysis Stresss
Scale revealed that 85% of the selected samples response of relaxation technique is
more effective in reduction of stress.51
A randomised study was conducted at Bahrain (2003) to determine the
efficacy of Bensons relaxation technique on reduction of stress and improving quality
of life among 59 hemodialysis patients were selected using Hemodialysis Stressor
21
Scale and Quality Life Scales showed that Bensons relaxation technique significantly
decreases the state of stress and improved generic quality of life in the experimental
group (p<0 and improved the psychological health and quality of life.52
An experimental study was conducted at India (1996) to assess the effect of
Benson relaxation technique on reduction of stress among 33 dialysis clients between
the ages of 44 and 50 years were selected purposively by using Perceived Stress Scale
showed that daily practice of the Benson relaxation technique lead to a significant
reduction in the concurrent psychological symptoms like stress.53
Summary
Review of literature is an extensive systematic solution of potential source of
pre work, fact and finding of the chosen problem. This chapter described a brief
account of various studies conducted by different investigators and few citations from
the books and journals which are found to be relevant to the study.
The next chapter deals with the methodology of the study.
22
CHAPTER 3
METHODOLOGY
Research approach
Research design
Variables
Schematic representation of the study
Setting of the study
Population
Sample and sampling technique
Inclusion criteria
Exclusion criteria
Tool/Instruments
Development of the tool
Description of the tool
Content validity
Reliability of the tool
Translation of tool
Pilot study
Data collection process
Plan for data analysis
23
CHAPTER 3
METHODOLOGY
Methodology is the systematic, theoretical analysis of the methods applied to a
field of study.23 Research methodology is the way in which research problems are
solved scientifically. It is a science of studying how research is conducted
scientifically.54
This chapter deals with methodology adopted for the study. It includes
research approach, design, variables, and schematic representation of the study,
setting of the study, population, sample and sampling technique, sampling criteria,
development and selection of the tool, description of the tool, content validity, and
reliability of the tool, pilot study, data collection process and plan for data analysis.
Research approach
Research approaches are plans and the procedures for research. It involves
thedescription of the plan to investigate the phenomenon under study in
Qualitative,Quantitative or a combination of the two methods.54Quantitative research
approachwas used in this study.
Research design
Research design is defined as the blue print to conduct a research study.
Research design basically provides an outline of how the research will be carried out
and the methods that will be used.54 It is a systematic plan of what is to be done, how
it will be done and how the data will be analyzed.
The research design adopted for the study was pre experimental one group
pretest post test design.
24
Table 1: Schematic representation of research design
Group Pretest Intervention Post test
Experimental group O1 X O2
Key: -
O1: Pretest for assessing the level of stress among hemodialysis patients.
X: Bensons relaxation technique
O2: Posttest for assessing the effectiveness of Bensons relaxation technique.
Variables
Variables are qualities, properties or characteristics of the person, things
orsituation that can change or vary. Variables are concepts at different level
ofabstraction that are concisely defined to promote their measurement and
manipulationwithin the study.54
The following variables can be identified in the present study.
Sociodemographic variables
Sociodemographic variables are the characteristics and attributes of the study
subjects. A Sociodemographic variable helps to understand sample characteristics and
to determine if samples are representative of the population of interest.54
The sociodemographic variables in this study were collected in two sections.
First section was demographic variables which includes age, gender, religion,
education, type of family, marital status, occupation, place of residence, family
income, percentage of income spent for treatment, money expended so far for
treatment, financial support, medical insurance, co morbidities, family history of
25
chronic kidney disease, duration of dialysis treatment, total number of dialysis done,
average loss of working days per week, performance of daily activity, level of
physical activity, most commonly faced problem before dialysis, most commonly
faced problem during dialysis, most commonly faced problem after dialysis. Second
section was clinical variables which include post dialysis weight, temperature, pulse,
respiration, systolic blood pressure, diastolic blood pressure, blood urea nitrogen,
serum creatinine, and serum sodium and serum potassium
Dependent variable
Dependent variable is the variable that is affected by the independent variable.
It is the variable in a research design that is free to change over a range of
intervention. The dependent variable is the outcome or response due to the effect of
the independent variable, which researcher wants to predict or explain.54
In the study, stress of hemodialysis patients was the dependent variable.
Independent variable
An independent variable is a stimulus or activity that is manipulated or varied
by the researcher to create the effect on the independent variable.22 It is the treatment
or experimental activity that is manipulated or varied by the researcher to cause an
effect on the dependent variable.54
Bensons relaxation technique was the independent variable in the present
study. The Bensons relaxation technique is a type of breathing exercise which
performed in sitting position with closed eyes and relaxing the body from toes to top
and then taking a deep breath through nose and exhale from mouth by saying one
word or number for 10 minutes once daily for three days in a week under the
supervision of the researcher and all other days by themselves for a period of 24 days.
26
Purpose Setting
Study design Population
To assess the Hemodialysis unit of
Pre-experimental 35 hemodialysis
effectiveness of a selected hospital
one group pretest- patients
Bensons relaxation
posttest design
technique on stress
among hemodialysis
patients
Pretest
Assess the pre Tools and technique Sampling technique
test stress score Non probability purposive
1. Socio demographic proforma
Demonstrating sampling
2. Cohen Perceived Stress Scale
Bensons
relaxation Sample size: 35
technique hemodialysis patients
Intervention with stress score 14 and
above
Administering Bensons
relaxation technique 10
minutes daily for a Posttest
period of 24 days Statistical analysis
Assessing post test
level of stress by Descriptive: Frequency, percentage,
using Cohen mean and standard deviation
Presentation and
Perceived Stress Inferential: Pairedt test and chi-square
Scale communication of
test
research
Figure 2: Schematic representation of the study design
27
Setting of the study
Settings are the most specific places where data collection occurs. It could be
natural, partially controls or highly controlled.54
The present study was conducted at Hemodialysis unit of Century Hospital,
Mulakkuzha, Kerala. It is a 300 bedded multispecialty hospital with all modern
facilities. The nephrology department of hospital consists of a well equipped
hemodialysis unit. Six beds are available in the dialysis unit. Average number of
hemodialysis was about 16-18 per day.
Population
A population is the entire aggregation of cases in which researcher is interested.54
In the present study, the populations comprised of hemodialysis patients in the
age group of 20 to 80 years with stress score 14 and above which is measured by
Cohen using Perceived Stress Scale in a selected hospital at Alappuzha district.
Sample and sampling technique
Sample refers to a subset of a population selected to participate in a research
study.22
In this study, the sample consists of 35 hemodialysis patients, who fulfilled
both the inclusion and exclusion criteria were selected from Century Hospital at
Alappuzha district.
Sampling technique is a process of selecting subjects who are representative of
the population being studied.52
In order to select the sample from the population, investigator adopted non-
probability purposive sampling technique. In nonprobability purposive sampling
technique the researcher believes that some subjects are fit for research compared to
other individuals.
28
The researcher purposefully selected the hemodialysis patients from Century
hospital at Alappuzha district.
Inclusion criteria
The criteria that specify the characteristics of the subjects in the population are
referred to as the inclusion criteria.22
Hemodialysis patients who are:
willing to participate in the study.
male or female.
in the age group of 20 to 80 years.
available during the time of data collection.
able to comprehend the instructions.
having stress score 14 and above.
perform hemodialysis at least thrice in a week
Exclusion criteria
The criteria that specify the characteristics that a study population does not
possess are referred to as exclusion criteria.22
Hemodialysis patients who are:-
not willing to participate in the study.
having any debilitating illness which restricts to practice Bensons relaxation
technique.
presently doing other exercises.
having altered sensory perception.
Tool / Instruments
A research instrument is a device used to measure the concepts of interest in a
research project that uses to collect data.54

29
The data were collected using the following tool which was prepared by the
researcher.
Tool 1 : Sociodemographic proforma
Section A : Demographic variables
Technique : Structured interview schedule
Section B : Clinical Variables
Technique : Bio physiological method
Tool 2 : Cohen Perceived Stress Scale
Technique : Self-administered Structured 5 point rating scale
Development of the tool
Data collection tools are the procedures or instruments used by the researcher
to observe or measure the key variables in the research problem.22
The tool used in this study consisted of sociodemographic proforma of
hemodialysis patients and Cohen Perceived Stress Scale. An intense search of related
literature and extensive consultation with the experts was done for selection of the
tool and thus the tool was finalized.
The following methods were used for the selection of the tool
Review of literature (Journal articles, websites, Text books)
Personal consultation with guide, research co-ordinator, subject experts and
from Paediatrics medicine.
Discussion with colleagues
The following steps were carried out in the selecting the tool
1. Preparation of content
2. Development of criterion checklist
3. Content validation of the tool

30
4. Pretesting the tool
5. Ensuring reliability
6. Selection of final tool
Description of the tool
Tool 1: Socio-demographic proforma
The socio demographic variables are sub divided in to two sections.
Section A: Demographic variables
In present research study demographic variables included 23 items such as
age, gender, religion, education, type of family, marital status, occupation, place of
residence, family income, percentage of income spent for treatment, money expended
so far for treatment, financial support, medical insurance, co morbidities, family
history of chronic kidney disease, duration of dialysis treatment, total number of
dialysis done, average loss of working days per week, performance of daily activity,
level of physical activity, most commonly faced problem before dialysis, most
commonly faced problem during dialysis, most commonly faced problem after
dialysis
Technique: Structured Interview Schedule.
Section B: clinical variables
It included 10 items such as post dialysis weight, temperature, pulse,
respiration, systolic blood pressure, diastolic blood pressure, blood urea nitrogen,
serum creatinine, and serum sodium and serum potassium.
The purpose was to determine distribution of samples according to
demographic proforma and to find the association with the variables. The technique
for administering the tool was structured interview schedule.
Technique : Bio physiological method
31
Tool 2: Cohen Perceived Stress Scale
Cohen Perceived Stress Scale is a standardized 5 point rating scale which was
originally developed by Cohen. The stress scale comprises of 10 items. Each item had
five alternatives varying from the response No Stress to Severe Stress. Each
response carries a score of 0, 1, 2, 3 and 4 respectively.
Technique: Self - administered structured 5 point rating scale
Table 2: Interpretation of stress scores
Sl No Score Level of Stress
1 0 No stress
2 1-13 Mild stress
3 14-27 Moderate stress
4 28-40 Severe stress
Content validity
Content validity is the degree to which the items in an instrument adequately
represent the universe of content for concept being measured.23
In order to assess the content validity of the tools, the prepared tool along with
the problem statement, objectives, hypothesis, operational definitions, criteria rating
scale and research methodology are submitted to 10 experts. The experts were from
the field of Medical Surgical Nursing, Psychiatrist, Psychologist and Therapist.
Theexperts were requested to judge the items for accuracy, relevance and
appropriateness of the items for further modifications.
32
Translation of the tool
The language experts translated the tool in to Malayalam. The tool was given
to the English expert, to translate back to English to establish the language validity of
the tool. There was 100% agreement with the translation of sociodemographic
proforma and Cohen Perceived Stress Scale.
Reliability of the tool
Reliability of an instrument is the degree of consistency with which it
measures the attribute it is supposed to be measuring.54
The tool was administered to 10 hemodialysis patients in Josco multi
speciality hospital for establishing the reliability of the instrument. The reliability of
modified tool was calculated and the value was found to be 0.72 by Cronbachs alpha
which indicated that the instrument was reliable.
Pilot study
Pilot study is defined as a smaller version or trial run done in preparation for a
major study.22
Pilot study was conducted at Josco Multi-specialityHospital, Alappuzha
district in order to check the feasibility and practicability of the tool. The investigator
obtained written permission from the concerned authorities prior to the study. The
period of study was one week from 25-10-2016 to 31-10-2016. The samples were 10
hemodialysis patients were selected by non-probability purposive sampling technique.
Informed consent was taken from the study subjects and purpose of the study was
explained and confidentiality was assured. Each sample took 10 minutes to answer the
questions. Bensons relaxation technique was administered to the participants 3
samples per day 10 minutes daily from 12 pm to 12.10 pm for 7 days. Next day
33
posttest was conducted using Cohen perceived stress scale. Data were analyzed using
descriptive and inferential statistics.
After conducting the pilot study, it was found that the study was feasible, the
subjects were cooperative and the data collection instruments were relevant. So the
investigator planned to carry out the data collection for the main study on the same
way as the pilot study was conducted.
Data Collection Process
Data collection process is the gathering of the information to address research
problem.54
Step 1
For conducting main study, prior permission was obtained from the Medical
superintendent and Nursing superintendent in Century Hospital at Alappuzha district.
The data collection period from 03/12/2016 to 31/12/2016. There were 35
hemodialysis patients at Century Hospital. The investigator familiarized her with
subjects and explained the purpose of the study to them and confidentiality was
assured to all subjects. An informed consent was taken from the study subjects. Thirty
five subjects were purposively selected from the population as per the inclusion
criteria.
Step 2
Bensons relaxation techniquewas administered for hemodialysis patients 10
minute daily and alternative days under supervision by the researcher for a period of
24 days.
Step 3
Post test was conducted after 24 days of intervention. The tool was collected
and recorded systematically.
34
Plan for data analysis
Analysis is the systematic organization and synthesis of research data and the
testing of the research hypothesis using that data.22
After the data collection, data were organized, tabulated, summarized and
analyzed by using descriptive statistics and inferential statistics based on the
objectives and hypothesis of the study. Master data sheet was prepared by the
investigator to analyze the data.
Descriptive statistics
1. Frequency and percentage distribution were used to describe the socio
demographic variables.
2. Mean, percentage and standard deviation were used to analyze the pretest and
posttest level of stress.
Inferential statistics
1. Pairedttest was used to compare the pretest and posttest level of stress scores.
2. Chi-square test was used to find out the association between the selected
sociodemographic variables and pre test level of stress scores.
Summary
This chapter dealt with the research approach, research design, variables,
schematic representation of the study, population, sample and sampling technique,
inclusion criteria and exclusion criteria, tool/instruments, development/selection of
the tool, content validity and reliability of the tool, pilot study, data collection process
and plan for data analysis.
The next chapter deals with the analysis and interpretation of the study.
35
CHAPTER 4
ANALYSIS AND INTERPRETATION
Section I : Description of subjects according to the socio demographic
variables.
A : Distribution of subjects according to demographic variables.
B : Distribution of subjects according to clinical variables.
Section II: Assessment of pretest levelof stress among hemodialysis
patients in a selected hospital at Alappuzha district.
SectionIII: Assessment of posttest level of stress among hemodialysis
patientsin a selected hospital at Alappuzha district.
Section IV : Analysis of the effectiveness of Bensons relaxation technique
on stress among hemodialysis patients in a selected hospital at
Alappuzha district.
Section V : Association between the pre test level of stress and selected
socio demographic variables.
36
CHAPTER 4
ANALYSIS AND INTERPRETATION
Statistical analysis enable researchers to summarize, organize, evaluate,
interpret and communicate numeric information. The purpose of data analysis is to
translate the information collected during the course of research project into an
interpretable form so that proposed relation of research problem could be tested.54
This chapter deals with analysis and interpretation of data obtained from 35
hemodialysis patients in a selected hospital at Alappuzha District. Quantitative
approach was used in the present study. The data were processed and analyzed on the
basis of the objectives and hypotheses formulated for the present study.
Objectives of the study
1. To assess the pretest and post test level of stress among hemodialysis patients.
3. To find out the association with pretest level of stress and selected socio-
Organization of the study findings
Data are organized and presented under the following headings
variables.
Section II: Assessment of pretest level of stress among hemodialysis
37
SectionIII: Assessment of posttest level of stress among hemodialysis
Section IV : Analysis of the effectiveness of Bensons relaxation technique
Alappuzha district.
Section V : Association between the pre test level of stress and selected
socio demographic variables
Section I: Description of subjects according to the socio demographic variables.
This section includes the description of sociodemographic variables of
hemodialysis patients. Sociodemographic variables of the subjects are categorized
into two sections: Demographic variables and Clinical variables.
A: Distribution of subjects according to demographic variables
The socio demographic variables of the subjects are described in terms of age,
gender, religion, education, type of family, marital status, occupation, place of
history of kidney disease, duration of dialysis treatment, total number of dialysis
done, average loss of working days per week, performance of daily activity, level of
physical activity, most commonly faced problem before dialysis, most commonly
faced problem during dialysis, most commonly faced problem after dialysis. The
technique was structured interview and data were analyzed using descriptive statistics
and are summarized in terms of percentage.
38
60
51.4%
50
40 34.3%
20-40
Percentage
30 40-60
60-80
20 14.3%
10
0
20-40 40-60 60-80
Figure 3: Cylindrical diagram showing percentage distribution of samples based
on age in years. (n=35 )
Figure 3 illustrates that more than half (51.4%) of the samples were in the age
group of 60-80 years, more than one third(34.3%) of the samples were in the age
group of 40-60 years and more than one tenth (14.3%) of the samples were in the age
group of 20-40 years.
39
68.6%
70
60
50
40 31.4%
percentage
Male
30 Female
20
10
0
Male Female
Gender
Figure 4: Cone diagram showing percentage distribution of samples based on
sex. (n=35)
It is evident from figure 4 that more than two third(68.6%) of the samples
were males and less than one third (31.4%) of the samples were females.
40
60 54.3%
50 45.7%
40
Percentage
Hindu
30
Christian
Muslim
20
10 0%
0
Hindu Christian Muslim
Religion
Figure 5: Pyramidal diagram showing percentage distribution of samples based
on Religion. (n=35)
Figure 5 depicts that more than half (54.3%) of the samples were Hindu and
less than half (45.7%) of the samples were Christians whereas no subjects were from
Muslim.
41
42.8%
45
40
35 28.6%
30
Percentage
25 Up to high school
17.1%
20
Higher scondary
15 8.6%
10 Diploma
2.9%
5 Graduation
0 Post greaduation and above
Education
on education. (n=35)
Figure 6 illustrates that less than half (42.8%) of the samples educated up to
high school, more than one fourth (28.6%) of the samples had higher secondary
education, less than one fifth (17.1%) of the samples had diploma education, less than
one tenth (8.6%) of the samples had graduation and remaining very few samples
(2.9%) had education of post graduation and above.
42
100%
100
90
80
70
Percentage
60
50 Nuclear family
Joint famliy
40
30
20 0%
10
0
Nuclear family Joint famliy
Type of family
on type of family. (n=35)
Data presented in figure 7 depicts that all (100%) of the samples belonged to
nuclear family and none of them belonged to joint family.
43
70 65.71%
60
50
Percentage
40
30 Married
20%
20 14.29% Unmarried
Divorced/separated
10 0%
Widow/Widower
0
Marital status
marital status. (n=35)
Figure 8 shows that less than two third(65.71%) of the samples were married,
one fifth (20%) of the samples were unmarried, less than one fifth (14.29%) of the
samples were widow/widower and none of them were divorced/separated.
44
35
30 28.6%
25 22.9%
percentage
20%
20
17.1%
15
Daily wager
11.4%
Self employed
10
Unemployed
Private employed
5
Government employed
Occupation
Figure 9: Bar diagram showing percentage distribution of samples based on
occupation. (n=35)
Figure 9 illustrates more than one fourth (28.6%) of the samples were
government employed, less than one fourth (22.9%) of the samples were private
employed, one fifth(20%) of the samples were self employed, less than one fifth
(17.1%) of the samples were unemployed and more than one tenth(11.4%) of the
samples were daily wager.
45
80 74.3%
70
60
50
Percentage
Panchayat
40
Muncipality
Corporation
30 20%
20
5.7%
10
0
Panchayat Muncipality Corporation
Place of residence
on place of residence (n=35)
Figure 10 shows that less than three fourth (74.3%) of the samples were
residing in Panchayat, one fifth (20%) of the samples were in Corporation and few
(5.7%) of the sampleswere in municipality.
46
60
51.4%
50
40 34.3%
30
Rs 10000
Percentage
Rs 10001-20000
20 11.5% Rs 20001-30000
Rs 30001
10
2.8%
Family income per month
family income per month. (n=35)
Figure 11 illustrates that more than half (51.4%) of the samples hadmonthly
family income of Rs 10001 - 20000, more than one third (34.3%) of the samples
hadfamily income of Rs 10000 , more than one tenth (11.5%) of the samples had
monthly family income of Rs 20001 to 30000 and very few(2.8%) of the samples
had family incomeof Rs 30001.
47
80%
80
70
60
< 25%
50 25-50 %
50-75 %
Percentage
40 75-100%
30
20%
20
0% 0%
10
0
< 25% 25-50 % 50-75 % 75-100%
Percentage of income spent for treatment
Figure 12: Cylindrical diagram showing percentage distribution of samples
based on percentage of income spent for treatment. (n=35)
Figure 12 illustrates that majority (80%) of the samples were spent 25-50
percentage of their family income for treatment , one fifth (20%) of the samples were
spent 50-75 percentage of their family income and none of them were spent less than
25% and 75 to 100% of their family income for treatment.
48
40 37.1%
35
30
25.7%
25 22.9%
Percentage
20
14.3% Rs 10000
15 Rs 10001-50000
Rs 50001-100000
10
Rs 100001
5
Money expended so far for treatment
on money expended so far for treatment . (n=35)
Figure 13 shows that more than one third (37.1%)of samplesexpended Rs
50001 to 100000 for treatment, more than one fourth(25.7%) of samples expended Rs
10001 to 50000 for treatment, less than one fourth (22.9%) of samples expended Rs
100001 for treatment and more than one tenth (14.3%) of samplesexpended Rs
10000 for treatment.
49
11.4%
14.3% 31.4% Own savings
Assistance from family
Pension
Assistance from others
42.9%
Financial support
Figure 14: Pie diagram showing percentage distribution of samples based on
financial support. (n=35)
Figure 14 illustrates that less than half (42.9%)of samples were financially
supported by assistance from family, less than one third (31.4%) of the samples were
financially supported with own savings, more than one tenth (14.3%) of the samples
were financially supported by pension and less than one tenth (11.4%) of the samples
were financially supported by assistance from others.
50
70
62.9%
ESI
60
Arogya insurance
50
Others
40 None
Percentage
30
20%
20 17.1%
10 0%
0
ESI Arogya Others None
insurance
Medical insurance
medical insurance. (n=35)
Findings from Figure 15 evidenced that more than half (62.9%) of the samples
had no any medical insurance, one fifth(20%) of the sampleshad Arogya insurance,
less than one fifth (17.1%) of the samples had ESI and none of them had other
medical insurance
51
50 45.7
45
40
Diabetes melitus
35
Percentage
30 22.9%
Hypertension
25 20%
20 11.4% Diabetes and hypertension
15
Diabetes and others
10 0%
0%
5
Hypertension and others
0
Hypertension, diabetes and
others
Co-morbidities
Figure 16: Bar diagram showing percentage distribution of samples based on co-
morbidities. (n=35)
Figure 16 depicts that less than half (45.7%) of samples had diabetes and
hypertension, less than one fourth (22.9%) of the samples had hypertension, diabetes
and others, one fifth (20%) of the samples had only hypertension and more than one
tenth (11.4%) of the samples had hypertension and others.
52
100%
100
90
80
70
percentage
60
Yes
50
No
40 Don't know
30
20
0% 0%
10
0
Yes No Don't know
Family history of chronic kidney disease
based on family history of chronic kidney disease. (n=35)
Figure 17 shows that all the samples (100%) had no family history of chronic
kidney disease.
53
8.6%
22.9% < 1 year

1-3 year
3-5 year
25.7% 5 year
42.8%
Duration of dialysis treatment
Figure 18: Doughnut diagram showing percentage distribution of samples based
on duration of dialysis treatment. (n=35)
Figure 18 illustrates less than half (42.8%) of the samples were received
dialysis treatment for 1to 3 years, more than one fourth (25.7%) of the samples were
received dialysis treatment for 3 to 5 years, less than one fourth(22.9%) of the
samples were received dialysis treatment less than 1year and less than one tenth
(8.6%) of the samples were received dialysis treatment more than or equal to 5 years.
54
45 42.9%
40
35
28.6%
30
Percentage
25 100
20% 101-200
20 201-300
15 301
8.5%
10
0
100 101-200 201-300 301
Total number of dialysis done
on total number of dialysis done. (n=35)
Figure 19 depicts that less than half(42.9%) of the samples had undergone 101
to 200 dialysis, more than one fourth (28.6%) of the samples had undergone dialysis
between 201 to 300, one fifth (20%) of the sampleshad undergone less than or equal
to100 dialysis and less than one tenth(8.5%) of the samples had undergone greater
than or equal to 301 dialysis.
55
8.6%
14.3%
1-2 days
3-4 days
Unable to go for work
60% 17.1% Unemployed
Average loss of working days per week
average loss of working days per week. (n=35)
Figure 20 illustrates more than half(60%) of the sampleswere unemployed,
less than one fifth (17.1%) of the samples were unable to go for work, less than one
sixth(14.3%) of the samples were loss 3-4 working days per week and less than one
tenth (8.6%) of the samples were loss 1-2 working days per week .
56
77.1%
80
70
60
50
Percentage
40 By self
30 22.9% Assistance from family
Assistance from others
20
10 0%
0
By self Assistance Assistance
from from
family others
Performance of daily activity
performance of daily activity. (n=35)
Figure 21 shows that more than three fourth (77.1%) of the samples were
perform their daily activity by self and less than one fourth(22.9%) of the samples
were perform their daily activity with assistance from family.
57
77.1%
80
70
60
Percentage
50
40
17.1%
30 5.8%
20 Completely dependent
10 Partially dependent
0 Completely independent
Level of physical activity
based on level of physical activity (n=35)
Figure 22 illustrates more than three fourth (77.1%) of the samples were
completely independent to do their physical activity, more than one sixth (17.1%) of
the samples were partially dependent and very few (5.8%) of the samplewere
completely dependent to do their physical activity.
58
60%
60
50
40%
40
Percentage
30
Breathing difficulty
20
0% Edema
0%
10 Anorexia
Vomiting
0
Most commonly faced problem before dialysis
on most commonly faced problem before dialysis. (n=35)
It is evident from Figure 22 that more than half (60%) of the samples were
facing breathing difficulty before dialysis, less than half (40%) of the samples were
facing edema before dialysis and none of them had anorexia and vomiting before
dialysis.
59
20%
2.9%
Muscle cramps
5.7%
Giddiness
Nausea
Head ache
71.%4
Most commonly faced problem during dialysis
most commonly faced problem during dialysis. (n=35)
Figure 23 illustrates more than three fourth (71.4%) of the samples were
facing muscle cramps during dialysis, one fifth (20%) of the samples were facing
head ache, less than one tenth (5.7%) of the samples were facing giddiness and very
few(2.9%) of the samples were facing, nausea during dialysis.
60
80%
80
70
60
Percentage
50
Fatigue
40
17.2% Itching
30 Joint stiffiness
20 2.8% Dizziness
0%
10
0
Fatigue Itching Joint Dizziness
stiffiness
Most commonly faced problem after dialysis
most commonly faced problem after dialysis. (n=35)
Figure 24 shows that majority (80%) of the samples were facing fatigue after
dialysis, less than one fifth (17.2%) of the samples were facing dizziness and very few
(2.8%) of the samples were facing itching after dialysis.
61
Section I (B): Distribution of clinical variables of subjects
42.8%
45
40 34.3%
35
30 22.9%
Percentage
< 50kg
25
50-60 kg
20
60-70 kg
15 70-80 kg
10
0%
5
0
< 50kg 50-60 kg 60-70 kg 70-80 kg
Post dialysis weight
post dialysis weight. (n=35)
Figure 25 depicts that less than half (42.8%) of the samples had post dialysis
weight between 50 to 60 kg, more than one third (34.3%) of the samples had post
dialysis weight less than 50 kg, less than one fourth (22.9%) of the samples had post
dialysis weight between 60 to 70 kg and none of the samples belonged to post dialysis
weight between 70 to 80 kg.
62
100%
100
90
80
70
Percentage
60
50
< 98.6 F
40 <98.6 -99F
30 99F
0% 0%
20
10
0
< 98.6 F <98.6 -99F 99F
Temperature
based on temperature. (n=35)
Figure 26 illustrates that all the samples (100%) had temperature between
98.6F to 99F.
63
80
71.4%
70
60
50
Percentage
< 50 beats/min
40 28.6%
50-70 beats/min
30 70-90 beats/min
90 beats/min
20
0% 0%
10
0
< 50 50-70 70-90 90
beats/min beats/min beats/min beats/min
Pulse
Pulse. (n=35)
Figure 27 shows that less than three fourth (71.4%) of the samples had pulse
between 70 to 90 beats/min, more than one fourth (28.6%) of the samples had pulse
between 50 to 70 beats/min and none of the samples had pulse less than 50 and
greater than or equal to 90 beats/min.
64
54.3%
60
45.7%
50
40
Percentage
30
< 20 breaths/min
20-25 breaths/min
20
25-30 breaths/min
0% 30 breaths/min
10 0%
Respiration
on respiration (n=35)
Figure 28 shows that more than half (54.3%) of the samples had respiration
between 20 to 25 beats/min, less than half (45.7%) of the samples had respiration
between 25 to 30 beats/min and none of the samples had respiration less than 20 and
more than or equal to 30 beats/min.
65
57.1%
60
50
40
Percentage
< 100 mmHg

30 22.9% 100-140 mmHg
20%
140-170 mmHg
20
170 mmHg
10 0%
0
< 100 100-140 140-170 170
mmHg mmHg mmHg mmHg
Systolic blood pressure
systolic blood pressure. (n=35)
Figure 29 illustrates that more than half (57.1%) of the samples had systolic
blood pressure between 140 to 170 mmHg, less than one fourth (22.9%) of the
samples had systolic blood pressure between 100 to140 mmHg, one fifth (20%) of the
samples had systolic blood pressure greater than or equal to 170 mm Hg and none of
the samples had systolic blood pressure less than 100 mmHg.
66
2.8%
< 90 mmHg
90-120 mmHg
120 mmHg
48.6% 48.6%
Diastolic Blood Pressure
Figure 30: Doughnut diagram showing percentage distribution of samples based
on diastolic blood pressure. (n=35)
Figure 30 illustrates that as an equal proportion (48.6%) of samples had
diastolic blood pressure less than 90 mmHg and 90 to120 mm of Hg and very few
(2.8%) of the samples had diastolic blood pressure greater than or equal to 120
mmHg.
67
60
51.4% 48.6%
50
40
Percentage
< 135 mEq/L

30
135-145 mEq/L
20 145 mEq/L
0%
10
0
< 135 mEq/L 135-145 145 mEq/L
mEq/L
Serum sodium
serum sodium. (n=35)
Figure 31 illustrates that more than half (51.4%) of the samples had serum
sodium level less than 135 mEq/L , less than half (48.6%) of the samples had serum
sodium level between 135- 145 mEq/L and none of the samples belonged to serum
sodium greater than or equal to 145 mEq/L
68
44.6%
45
40
31.4%
35
30
Percentage
25 18.3%
<80 mg/dl
20
80-100 mg/dl
15
100-120mg/dl
5.7%
10 120 mg/dl
5
0
Blood urea nitrogen
based on blood urea nitrogen. (n=35)
Figure 32 illustrates that less than half (44.6%) of the samples had blood urea
nitrogen level between 100 to 120 mg/dl, less than one third (31.4%) of the samples
had blood urea nitrogen level between 80 to100 mg/dl, less than one fifth (18.3%) of
the samples had blood urea nitrogen level greater than or equal to 120 mg/dl and very
few(5.7%) of the samples had blood urea nitrogen level less than 80 mg/dl.
69
47.5%
50
45
40
35 30%
Percentage
30
25 < 3 mEq/L
20 15% 3-6 mEq/L
15 6-9 mEq/L
10 7.5%
9 mEq/L
5
0
<3 3-6 6-9 9
mEq/L mEq/L mEq/L mEq/L
Serum potassium
serum potassium. (n=35)
Figure 33 illustrates that less than half (47.5%) of the samples had serum
potassium level between 6 to 9 mEq/L, more than one fourth (30%) of the samples
had serum potassium level greater than or equal to mEq/L, more than one
tenth(15%)of the samples had serum potassium level 3 to 6 mEq/L and less than one
tenth (7.5%) of the samples had serum potassium level less than 3meq/L.
70
40
35.2%
35
28.6% 30.5%
30
25
Percentage
20 < 5.5mg/dl
15 5.5-7.5 mg/dl
5.7% 7.5-10.5 mg/dl
10
10.5mg/dl
5
Serum creatinine
on serum creatinine. (n=35)
Figure 34 illustrates that more than one third (35.2%) of the samples had
serum creatinine level 7.5to 10.5mg/dl, less than one third (30.5%) of the samples had
serum creatinine level greater than or equal to 10.5mg/dl, more than one fourth
(28.6%) of the samples had serum creatinine level between 5.5to 7.5 mg/dland very
few (5.7%) of the samples had serum creatinine level less than 5.5 mg/dl.
71
Section II: Assessment of pre test level of stress among hemodialysis patients in a
selected hospital at Alappuzha district.
60
48.6%
51.4%
50
40
Percentage
30 No stress
Mild stress
20 Moderate stress
Severe stress
10 0%
0%
0
No stress Mild Moderate Severe
stress stress stress
Pretest level of stress
Figure 35: Bar diagram showing distribution of samples based on pre test level
of stress. (n=35)
Figure 35 shows that the percentage distribution of subjects according to the
pre test level of stress, more than half (51.4%) of the samples had moderate level of
stress, less than half (48.6 %) of the sample had severe level of stress and none of the
them had no stress and mild stress.
72
Section III: Assessment of post test level of stress among hemodialysis patients in
a selected hospital at Alappuzha district.
57.1%
60
50
40
Percentage
31.4%
30 No stress
Mild stress
20 Moderate stress
11.5%
Severe stress
10 0%
0
No stress Mild Moderate Severe
stress stress stress
Post test level of stress
Figure 36: Bar diagram showing distribution of samples based on post test level
of stress. (n=35)
Figure 36 shows that the percentage distribution of samples based on post test
level of stress, in which more than half (57.1%) of the samples had moderate stress,
less than one third(31.4%) of the samples had mild stress , more than one tenth
(11.5 %) of the samples had severe stress and none of them had no stress.
73
Section IV: Comparison of pre test and post test level of stress among
57.1%
60
51.4%
48.6%
50
40 31.4%
Percentage
30
Pretest
20 Posttest
11.5%
10
0% 0%
0%
0
No stress Mild stress Moderate Severe
stress stress
Comparison of pretest and posttest level of stress
Figure 37: Bar diagram showing comparison of pre test and post test level of
stress among hemodialysis patients. (n=35)
Figure 37 shows that before practicing Bensons relaxation technique, more
than half (51.4%) of the samples had moderate level of stress and less than half
(48.6 %) of the sample had severe level of stress. Whereas after practicing Bensons
relaxation technique, more than half (57.1%) of the samples had moderate stress, less
than one third (31.4%) of the samples had mild stress and less than on fourth (11.5 %)
of the samples had severe stress.
74
Section V: Analysis of the effectiveness of Bensons relaxation technique on
stress among hemodialysis patients in a selected hospital at Alappuzha district.
This section deals with the analysis of difference between pre test and post test
level of stress and to assess the effectiveness of Bensons relaxation technique among
hemodialysis patients in a selected hospital at Alappuzha district for which pairedt
test was used.
The hypotheses used for this purpose were:
H01: There will be no significant difference in post test level of stress among
hemodialysis patientsafter practicing Bensons relaxation technique.
H1: There will be a significant difference in post test level of stress among
hemodialysis patients after practicing Bensons relaxation technique.
Table 3: Mean, SD, Mean difference and calculated t-value of stress among
hemodialysis patients before and after practicing Bensons relaxation technique.
(n=35)
Test Mean SD Mean Df t p-value

difference
Pretest 24.71 5.42

7.02 34 19.78 P <0.05
Posttest 17.69 5.63
*Significant at p< 0.05 Table value -2.032
Data presented in the table 3 reveals that the mean post test score 17.69 with SD
5.63 was significantly lower than the mean pre test score 24.71 with SD 5.42 with a
mean difference of 7.02. Since the calculatedt value 19.78 which was greater than
the table value (2.032) with degrees of freedom 34 at p< 0.05 level of significance.
75
Hence the null hypothesis (H0) was rejected and research hypothesis (H1) was
accepted. The study concluded that the Bensons relaxation technique is very effective
in reducing stress level of hemodialysis patients.
Section V: Association between the pretest level of stress and selected socio
This section attempts to study the association of the pretest level of stress
among hemodialysis patients and selected socio demographic variables like age,
gender, religion, education, type of family, marital status, occupation, place of
history of chronic kidney disease, duration of dialysis treatment, total number of
dialysis done, average loss of working days per week, performance of daily activity,
level of physical activity, most commonly faced problem before dialysis, most
commonly faced problem during dialysis, most commonly faced problem after
dialysis, post dialysis weight , temperature, pulse, respiration, systolic blood pressure,
diastolic blood pressure, serum sodium, blood urea nitrogen, serum potassium, serum
creatinine.
In order to find the association between pretest level of stress among
haemodialysis patients with selected socio demographic variables, chi-square test was
used and following hypotheses was formulated.
H02: There will be no significant association with pretest level of stress and
H2: There will be a significant association with pretest level of stress and selected
sociodemographic variable
76
Table 4: Association between pretest level of stress and selected socio
demographic Variables. (n=35)
Variables 2 df p value
Inference
Age in years 2.106 2 5.99 NS
Gender .957 1 3.84 NS
Religion 1.391 1 3.84 NS
Education 1.373 4 9.49 NS
Type of family .108 3 7.82 NS
Marital status 1.401 1 3.84 NS
Occupation 2.759 4 9.49 NS
Place of residence 3.157 3 7.82 NS
Family income 2.863 3 7.82 NS
Percentage of income spent for treatment .257 1 3.84 NS
Money expended so far for treatment 3.834 3 7.82 NS
Financial support 1.464 2 5.99 NS
Medical insurance 2.653 2 5.99 NS
Co-morbidities 6.763 3 7.82 NS
Family history of kidney disease .231 3 7.82 NS
Duration of dialysis treatment 3.652 3 7.82 NS
Total number of dialysis done 3.260 3 7.82 NS
Average loss of working days/week 1.601 3 7.82 NS
Performance of daily activity .509 1 3. NS
Most commonly faced problem before .019 NS

3.84
dialysis 1 NS
77
Most commonly faced problem during 2.473
dialysis 5 11.07 NS
Most commonly faced problem after 1.115
dialysis 2 5.99 NS
Clinical variables
Post dialysis weight .372
Temperature .254 2 5.99 NS
Pulse 1.933 1 3.84 NS
Respiration 1.446 1 3.84 NS
Systolic BP .114 1 3.84 NS
Diastolic BP 1.090 2 5.99 NS
Serum sodium .724 2 5.99 NS
Blood urea nitrogen 2.064 1 3.84 NS
Serum potassium 3.728 2 5.99 NS
Serum creatinine 2.417 3 782 NS
2 5.99 NS
NS-not significant at 0.05 levels
Data presented in the table 4 shows that Chi-square was used to determine the
association between the pretest level of stress and selected sociodemographic
variables such as age, gender, religion, education, type of family, marital status,
occupation, place of residence, family income, percentage of income spent for
treatment, money expended so far for treatment, financial support, medical insurance,
co-morbidities, family history of kidney disease, duration of dialysis treatment, total

78
number of dialysis done, average loss of working days per week, performance of daily
activity,level of physical activity, most commonly faced problem before dialysis,
most commonly faced problem during dialysis, most commonly faced problem after
dialysis, post dialysis weight , temperature, pulse, respiration, systolic blood pressure,
diastolic blood pressure, serum sodium, blood urea nitrogen, serum potassium, serum
creatinine.
The calculated Chi-square value was less than the table value at 0.05 level of
significance, hence the null hypothesis (H02) can be accepted and research hypothesis
(H2) can be rejected. So there was no significant association between pretest level of
stress and selected sociodemographic variables.It is concluded that pretest level of
stress is not influenced by sociodemographic variables.
The next chapter deals with the results of the study.
79
CHAPTER5
RESULTS
Objectives
Hypotheses
Results
80
CHAPTER 5
RESULTS
This chapter deals with the findings of the study. The present study was
conducted to determine the effectiveness of Bensons relaxation technique on stress
among hemodialysis patients in a selected hospital at Alappuzha district
Objectives
1. To assess the pretest level of stress among hemodialysis patients.
3. To find out the association with pretest level of stressand selected socio-
Hypotheses
H01 There will be no significant difference in pretest and post test level of stress
among hemodialysis patients after practicing Bensons relaxation technique.
H1There will be a significant difference in pre test and post test level of stress
among hemodialysis patientsafter practicing Bensons relaxation technique.
H02There will be no significant association with pre test level of stress and
81
H3There will be a significant association with pre test level of stress and selected
clinical variable.
Organization of the study findings
Analyzed data was organized under the following heading:
variables.
Section II : Assessment of pre test level of stress among hemodialysis
Section III : Assessment of post test level of stress among hemodialysis
Section IV : Comparison of pre test and post test level of stress among
hemodialysis patients in a selected hospital at Alappuzha
district.
Section V : Analysis of the effectiveness of Bensons relaxation technique
Alappuzha district.
Section VI : Association between the pre test level of stress and selected
socio demographic variables.
Section VII : Association between the pre test level of stress and selected
clinical variables.
82
Results
Section I : Distribution of subjects according to the socio demographic
variables.
The major findings in this section are presented below:
More than half of the samples (51.4%) were in the age group of 60-80 years.
More than two third of the samples (68.6%) were males.
More than half of the samples (54.3%) were Hindu.
Less than half of the samples (42.8%) had up to high school education
All the samples (100%) belonged to nuclear family.
Less than two third of the samples (65.71%) were married.
More than one fourth of the samples (28.6%) were government employed.
Less than three fourth of the samples (74.3%) were place of residence in
Panchayat.
More than half of the samples (51.4%) had monthly family income between
10001 to 20000.
Majority of the samples (80%) were spent 25 to 50 percentage of their income for
treatment.
More than one third of samples (37.1%) expended Rs 50001 to 100000 for
treatment.
Less than half of the samples (42.9%) were financially supported by assistance
from family.
More than half of the samples (62.9%) had no any medical insurance.
Less than half of samples (45.7%) had both diabetes and hypertension.
All the samples (100%) had no family history of chronic kidney disease.
83
Less than half of the samples (42.8%) were received dialysis treatment for 1-3
years.
Less than half of the samples (42.9%) had undergone 101 to 200 dialysis.
More than half of the samples(60%) were unemployed
More than three fourth of the samples (77.1%) were perform their daily activity by
self,
More than three fourth of the samples (77.1%) were completely independent to do
their physical activity
More than half of the samples (60%) were facing breathing difficulty before
dialysis.
Less than three fourth of the samples (71.4%) were facing muscle cramps during
dialysis.
Majority of the samples (80%) were facing fatigue after dialysis.
Less than half of the samples (42.8%) had post dialysis weight between 50-60 kg.
All the samples (100%) had temperature between 98.6F to 99F.
Less than three fourth of the samples (71.4%) had pulse between 70 to 90
beats/min.
More than half of the samples (54.3%) were respiration between 20 to 25
breaths/min.
More than half of the samples (57.1%) had systolic blood pressure between 140 to
170 mm Hg.
As an equal proportion of samples (48.6%) had diastolic blood pressure less than
90 mmHg and 90 to 120 mmHg.
More than half of the samples (51.4%) had serum sodium level less than 135
mEq/L.
84
Less than half of the samples (44.6%) had blood urea nitrogen level between 100
to 120 mg/dl.
Less than half of the samples (47.5%) had serum potassium level between 6 to 9
mEq/L.
More than one third of the samples (35.2%) had serum creatinine level 7.5 to 10.5
mg/dl.
Section II: Assessment of pretest level of stress among hemodialysis patients in a
selected hospital at Alappuzha district.
More than half of the samples (51.4%) had moderate level of stress, less than
half of the sample (48.6 %) had severe level of stress and none of them had no stress
and mild stressbefore administering Bensons relaxation technique with mean score of
24.71.
Section III: Assessment of posttest level of stress among hemodialysis patients in
a selected hospital at Alappuzha district.
More than half of the samples (57.1%) had moderate stress, less than one third
of the samples (31.4%) had mild stress, more than one tenth of the samples (11.5 %)
had severe stress and none of them had no stress after practicing Bensons relaxation
technique with mean score of 17.69.
85
Section V: Analysis of effectiveness of Bensons relaxation technique on stress
among hemodialysis patients in a selected hospital at Alappuzha district.
Pairedt test was used to assess the effectiveness of Bensons relaxation technique
after administering Bensons relaxation technique. The mean post test score 17.69
with SD 5.42 was significantly lower than the mean pretest score 24.71 with SD 5.63
with a mean difference of 7.02. Since the calculated value 19.78 which was greater
than the table value (2.032) with degrees of freedom 34 at p<0.05 levelof significance.
Hence the null hypothesis (H0) was rejected and research hypothesis (H1) was
accepted. The study concluded that the Bensons relaxation technique is very much
useful in reducing stress level of hemodialysis patients.
Section VI: Association between the pre test level of stress and selected socio
Chi-square was used to determine the association between the pretest level of
stress and selected sociodemographic variables such as age, gender, religion,
education, type of family, marital status, occupation, place of residence, family
income, percentage of income spent for treatment, money expended so far for
treatment, financial support, medical insurance, co morbidities, family history of
kidney disease, duration of dialysis treatment, total number of dialysis done, average
loss of working days per week, performance of daily activity, most commonly faced
problem before dialysis, most commonly faced problem during dialysis and most
commonly faced problem after dialysis.
The calculated Chi-square value was less than the table value at p<0.05
level of significance, hence the null hypothesis (H02) can be accepted and research
hypothesis (H2) can be rejected. So there was no significant association between
86
pretest level of stress and selected socio demographic variables. It is concluded that
pretest level of stress is not influenced by socio demographic variables.
Section VII: Association between the pre test level of stress and selected clinical
variables.
Chi-square was used to determine the association between the pretest level of
stress and selected clinical variables such as post dialysis weight, temperature, pulse,
respiration, systolic blood pressure, diastolic blood pressure, serum sodium, blood
urea nitrogen, serum potassium and serum creatinine
The calculated Chi-square value was less than the table value at p<0.05
level of significance, hence the null hypothesis (H03) can be accepted and research
hypothesis (H2) can be rejected. So there was no significant association between
pre test level of stress and selected clinical variables.
The next chapter deals with discussion, summary and conclusion of the study
87
CHAPTER 6
DISCUSSION, SUMMARY AND CONCLUSION
Discussion
Summary
Conclusion
Nursing implications
Limitations
Recommendation
88
CHAPTER 6
DISCUSSION, SUMMARY AND CONCLUSION
This chapter deals with the discussion of the findings, summary and conclusion,
nursing implications, limitations and recommendations of the study. The findings are
discussed in the light of the study objectives.
Discussion
The study intends to find out the effectiveness of Bensons relaxation
technique on stress among hemodialysis patient in a selected hospital at Alappuzha
District. The findings of the study were discussed with reference to the objectives and
with the findings of the other studies.
Objective 1: To assess the pretest and post test level of stress among hemodialysis
patients
The finding of the study revealed that in pretest more than half of the samples
(51.4%) had moderate level of stress, less than half of the sample (48.6 %) had severe
level of stress and none of them had no stress and mild stressand post test level of
stress showed that more than half of the samples (57.1%) had moderate stress, less
than one third of the samples (31.4%) had mild stress, more than one tenth of the
samples (11.5 %) had severe stress and none of them had no stress.
A descriptive cross sectional study was conducted at Mumbai (2014) to assess
the level of stress and coping among 30hemodialysis patients were selected
conveniently by using Stress and Adaptation Questionnaire revealed that dialysis
patients had severe.25
Objective 2: To find out the effectiveness of Bensons relaxation technique on
stress among hemodialysis patients.
89
In the present study, pairedt test was used to compare the effectiveness of
Bensons relaxation technique on stress among hemodialysis patients.
As per the analysis by paired t test test showed that calculated t value 19.78
which was greater than the table value (2.72) with degrees of freedom 34 at 0.01 level
of significance. Hence the null hypothesis (H0) was rejected and research hypothesis
(H1) was accepted. The study concluded that the Bensons relaxation technique is very
effective in reducing stress level of hemodialysis patients.29
An experimental study was conducted at Iran (2014) to investigate the effects
of Bensons relaxation technique on quality of life among 60 hemodialysis patients
were selected conveniently by using Disease-specific Questionnaire indicated that
mean scores of general and total quality of life were significantly higher than the
corresponding pretest readings and Bensons relaxation technique had a positive
effects on quality of life among patients receiving hemodialysis.47
Objective 3: To find out the association with pre test level of stressand selected
socio-demographic variables.
The investigator used chi-square test to find out the association between pre
test level of stress and selected socio demographic variables. The study revealed that
no association of pretest level of stress with selected sociodemographic variables.
Hence null hypothesis was accepted.
90
Summary
The present study focused to assess the effectiveness of Bensons relaxation
technique on stress among hemodialysis patients in a selected hospital at Alappuzha
district. The conceptual frame work accepted for this study was based on Roys
AdaptationTheory. The model helped the investigator to approach the research
problem in a systematic and comprehensive manner.
The research approach used for the study was quantitative research approach.
Research design adopted for the present study was one group pre test post test design.
Dependent variable was the stress among hemodialysis patients in a selected hospital
at Alappuzha district. The setting was Century Hospital, Mulakkuzha. The population
of the study comprised of 40 hemodialysis patients in the age group of 20 to 80 years
with stress score 14 and above which is measured by Cohen using Perceived Stress
Scale in Century hospital. Non probability purposive sampling method was used to
select samples.
The tools used in this study were sociodemographic Performa and Cohen
using Perceived Stress Scale. Tool validity done by the experts. The reliability of the
instrument was calculated by using Cronbachs alpha =0.72.
For conducting the study, the researcher underwent 5 days training programme
in Bensons relaxation technique, from an authorized trainer and got certificate for the
training. Pilot study was done on 10 hemodialysis patients in Josco Multi-speciality
Hospital, Edappon, Pandalam. The main study was conducted in Century Hospital,
Mulakkuzha. Pre test stress score was assessed in the first week by using Cohen
Perceived Stress Scale and taught them about Bensons relaxation technique and how
to perform it. After 25 days post test was done by using the same tool.
91
tool was collected and recorded systematically. The result showed that the
mean posttest score 17.69 with SD 5.63 was significantly lower than the mean pretest
score 24.71 with SD 5.42 with a mean difference of 7.02. Hence null hypothesis was
rejected. So Bensons relaxation technique was very effective in reducing stress level
of hemodialysis patients
Data were analyzed using descriptive and inferential statistics. The results
showed that Bensons relaxation technique was effective in reducing the stress level
among hemodialysis patients.
The major findings of the study were
There was significant difference in the pre test and post test level of stress among
hemodialysis patients after receiving Bensons relaxation technique.
There was no significant association between pre test level of stress and selected
sociodemographic variables.
Conclusion
Renal failure is a serious medical condition affecting the kidneys. When a
person suffers from renal failure, their kidneys are not functioning properly or no
longer work at all. Renal failure can be a progressive disease or a temporary one
depending on the cause and available treatment options. Hemodialysis is the most
frequent treatment method for End stage renal disease. However, it has been argued
that a number of restrictions and modifications accompany this treatment, which have
a detrimental impact on the quality of patients life and affects individuals physical and
psychological wellbeing. By performing the Bensons relaxation technique effect on
the mind & brain and useful in reducing stress, to improve quality of life as well.
Nursing implications
92
The findings of the present study generate some implications to health care
delivery system. It has implications in nursing practice, nursing administration,
nursing education and nursing research. The dissemination of the knowledge takes
place when the research findings are made use of in the following fields.
93
Nursing practice
The nurses working in the dialysis unit are in the best position to understand the
problems of patients.
The main objective should be towards reduction of stress and improving the coping
abilities of patients subjected to hemodialysis .
Nurses in dialysis unit should provide support, information, alternative solution and
assist the patient to utilize better problem solving methods to enhance their quality
of life.
Nurses can incorporate Bensons relaxation technique in their personal practice to
reduce the stress.
Nurses working in the dialysis unit Bensons relaxation technique also can use for
the patients to help them in managing their stress.
Nursing education
Nursing graduates must be equipped to meet the challenges emerging in the health
care services with a focus to enhance the existing situations in a cost effective
manner by promoting preventive services.
The curriculum must give more importance for early detection and prevention life
style disease from early stages of life itself.
The curriculum should incorporate non-pharmacological methods for the care of
the people as a primordial and primary prevention.
Skill oriented curriculum can be prepared for nurses working in nephrology units to
prepare them to care for patient subjected to dialysis.
The students should be encouraged to practice alternative therapies for reducing
stressamong hemodialysis patients.
94
Prepare the students to practice alternative therapies to reduce the stress of
Create awareness in our society about the importance of Bensons relaxation
technique in reducing stress among hemodialysis patients through public health
education progarmmes.
Nursing administration
The nurse leaders must gain knowledge regarding Bensons relaxation technique to
reduce stress among the hospitalized patients.
Nurse administrator should make policies regarding the implementation of
Bensons relaxation technique
The nurse administrators should take initiative to implement Bensons relaxation
technique and other relation therapies in nursing curriculum.
Nursing conference and in-service education programme can be organized on
dialysis.
The nurses can be motivated by the nursing educators and administrators to
conduct research on alternative therapy for dialysis coping strategies and to
implement it in practice by providing monitory and functional support for conduct
research.
Health administrator should make education department aware about the newer
development and studies regarding Bensons relaxation technique.
Nursing research
In India researches on alternative and complimentary therapies are still in its
infancy, even though many of them are empirical and easily tested. The findings of
this study can be a background for future research activities.
95
To make the nursing care evidence based nurse should be interested and motivated
to conduct many research studies on such topic.
More studies can be conducted in this area to determine the effectiveness of
Bensons relaxation technique to decrease the level of stress.
Similar studies can be conducted at different settings.
Limitations
The study was limited to the hemodialysis unit of a single hospital.
Generalization of findings was not possible because of the small sample size.
Long term effect of Bensons relaxation technique was not assessed due to limited
time.
Recommendations
A similar study can be conducted in a large sample for wider generalization.
An experimental study can be conducted with control group.
A comparative study can be conducted between Bensons relaxation technique
and other alternative therapies.
This chapter is followed by references used for the study and the appendices.
96
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Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Disease: 2007.
21. Cristovao F. Stress coping and quality of life among chronic hemodialysis patient.
EDTNA ERCA Journal. Dec 1999, 25(4); 35-8, 44.
22. Sharma K. Nursing Research and Statistics. 1st ed. Haryana: Elsevier Private Ltd;
2011.
23. Kings Goal Attainment Model. 2012: http://currentnursing.com/Kings.html.
24. Burns N, Groove S. Understanding Nursing Research. 2nded. New Delhi: Harcourt
Publishers; 2002.
25. Ronak Ahangar, Kobra Parvan.Coping methods to stress among patients on
hemodialysis and peritoneal dialysis. Year2015, volume 26, issue 2, page 255-26.
26. Supriya Patil Mane, Mahadeo Shinde. To assess the level of stress and coping
stagies among patient undergoing hemodialysis. Journal of Adv nurse. Jan
2011,150.
27. Alshraiefeen A, Mc Creaddie and M Evans JM. International. Journal of Nurs
practitioner.Nov2013,13.Availablefrom:http://www.ncbi.nlm.nih.gov/pubmed/242
19655
28. G Abraham, P Soundarajan, A Amalraj. Level of stress and coping abilities in
patients on chronic hemodialysis and peritoneal dialysis.The indian society of
Nephrology 2013;89-911.
29. Farzan Kheirkhah, Mahboobeh Nasiri. Stressful factors, coping mechanism and
quality in hemodialysis patients. Indian journal of critical care nursing
2013;6(2):119-126.
29. Abdelbasit, Mohamad Abdelhadi Ayoub. Quality of life among dialysis patients in
united Arab emirates, Victoria University of Wellington 2012.
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30. Morsch CM, Goncalves LF and Barros E, Haemodilysis unit, Hospital de clinicas
de Porto Alergre, Ports Alergre, Brazil. Cmfm2@terra.com.br.
31. Mok E, Tam B. Department of Nursing and Health Sciences, The Hong Kong
Polytechnic University, Hug Hom, Kowloon. hsemok@inet.polyu.edu.hk
32. Mohammad Ali Heidari Gorji, Ali Mahdavi, Yadollah Janati, Ehteramossadat
Illayi. Physiological and psychosocial stressors among hemodialysis patients in
educational hospitals of northern Iran.2013,Vol 19, Issue3;Page : 166-169.
33. Logan SM, Pelletier-Hibbert M, Hoolgins M. Extra Mural Program, Atlantic
Health Sciences corporation, Saint John, New Brunswick, Canada.
www.logsu@reg2.health.nb.ca
34. Vida Shafipour. Assessment of the Relationship between quality of life and stress
in the Hemodialysis Patients. Pakistan Journal of Biological Sciences.January
2008, 27; 13:375 379.
35. Cleary J, Drennan J. School on Nursing Dublin City University, Dublin, Ireland.
2005 Sep: 51(6):577-86.
36. Cinar S and Barlas GU. Stressors and Coping Strategies in Hemodialysis Patients.
Pakistan journal of medical science. June 2009; 25: 447-452.
37. Logan SM, Pelletier-Hibbert M, Hoolgins M. Extra Mural Program, Atlantic
Health Sciences corporation, Saint John, New Brunswick, Canada.
www.logsu@reg2.health.nb.ca
38. Cheung YL, Molassiotis A, Chang AM. The effect of Benson relaxation technique
on anxiety and quality of life in haemodialysis patients Psychooncology 2003;
12(3): 254.
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39. TR Udaya Kumar. College of Nursing & Dept of Nephrology, Sri Ramachandra
Medical College & Research Institute (Deemed University), Porur, Chennai.
Indian J Nephrol 2003;13: 89-91.
40. Welch JL and Austin JK. Factors associated with treatment-related stressors in
haemodialysis patients. Journal of American Nephrology Nurses Association.
1999 June 12; 26(3):318-25.]
41. Cristovao.F. Stress coping and quality of life among chronic hemodialysis patient.
EDTNA ERCA Journal. 1999 Dec 12; 25(4):35-8, 44.]
42. Lok P. Stressors, coping mechanisms and quality of life among dialysis patients in
Australia. Journals of Advanced Nursing. 1996 May 23; 23(5): 873-81.
43. Georgia K.Gerogianni1, FotoulaP. Babatsikou. Lecturer of Nursing, laboratory of
community Health Department of Nursing.Technological Educational Institute
(TEI) of Athens, Greece.
44. Aoki K and Muraoka K. Analysis of continuous ambulatory peritoneal dialysis
stressors in CAPD Patients. The Japanese Journal of Nursing.1993 January 20;
26(6): 553-62.
45. Gurklis JA, Menke EM. Identification of stressors and use of coping methods in
chronic hemodialysis patients.Nurse Res. 1988 Jul-Aug;37(4):236-239.
46. Masoumeh Otaghi, Milad Borji, The Effect of Benson's Relaxation on depression,
anxiety and stress in patients undergoing hemodialysis. ISSN No: 2319-5886
International Journal of Medical Research & Health Sciences, 2016, 5, 12:76-83.
47. Feyzi H, Khaledi Paveh B, Hadadian F, Rezaie M, Ahmadi M. Investigating the
effects of Bensons relaxation technique on quality of life among patients
receiving hemodialysis. Iran Journal Critical Care Nurses. 2015;8(1):13-20.
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48. Ali Mahdavi, Mohammed Ali Heidari Gorji. Implementing Bensons Relaxation
training in haemodialysis Patients: Changes in perceived Stress, Anxiety and
depression NAMJ. Med Sci.2013, September, 5(9):536-540.]
49. Rambod M, Sharif F . Evaluation of the effect of Benson's relaxation technique on
pain and quality of life of haemodialysis patients: a randomized controlled trial.
International Journal of Nurses. Jul 2014; 51(7):964-73.
50. Jorm AF, Morgan AJ and Hetrick SE, relaxation for stress, Cochrane database
syst. Rev.2008, Oct 8 ;( 4):CP0071-42.
51. Sanjay kumar, Suresh Chand. Prevalence of chronic renal failure in adult in Delhi,
India. Nephrology dialysis transplantation. Updated on July 30 (Cited on March 8,
2005). Available from; http://ndt.oxfordjournals.org.
52. Irvin JH, Domar AD, et.al, the effects of Benson relaxation on reduction of stress
in patient with dialysis. 1996 ;( 17):202-207.
53. Polit F D, Beck T C. Nursing Research, Principle and methods. 7th ed.
Philaldelphia: Lippincott Williams & Wilkins Publishers; 2004.
54. Green P E, Tull D S. Research methods and technique. 3rd ed. New Delhi: New
age international publishers private limited; 1983.
55. Talbott L A, Principles and practice of Nursing Research. 4th ed. Philadelphia:
Mosby Publishers;1999.
102
APPENDICES
103
APPENDIX A
ETHICAL CLEARANCE COMMITTEE CERTIFICATE
104
105
APPENDIX B
LETTER GRANTING PERMISSION TO CONDUCT PILOT
STUDY
106
107
108
109
APPENDIX C
LETTER GRANTING PERMISSION TO CONDUCT MAIN STUDY
110
111
112
113
APPENDIX D
LETTER REQUESTING FOR CONTENT VALIDITY OFTOOL
From,
Mrs.Reshma.R.S
1st year M.Sc.Nursing
Josco college of nursing
Edappon
To,
Sub: Letter requesting to grant opinion and suggestions of experts for

establishing validity of tool
Respected madam
I Mrs .Reshma.R.S , 1st year M. Sc Nursing student belongs to Medical and Surgical
Nursing department of Josco college of Nursing, Edappon, Pandalam. As a part of partial
fulfillment of M.Sc.Nursing Programme, I would like to do a dissertation on A study to
assess the effectiveness of Bensons relaxation technique on stress among
For which I have prepared a tool for the same.
Herewith I have enclosed,
1. Statement of problem
2. Objectives of the study
3. Hypothesis
4. Operational definition
5. Tool
6. Criteria check list
Hence I request you to kindly examine the tool item wise and give your valuable
opinion and suggestion.
Thanking you , yours sincerely
(Reshma .R.S)
Date:
Place:
114
APPENDIX E
CRITERIA RATING SCALE FORVALIDATIONOF TOOL
Kindly go through the items in the content. There are three response columns
is the scale, namely strongly agree (SA), agree (A), disagree (DA).Place a tick mark
() against the specific columns. If you disagree (DA) to any one of the items, place
your comments in the remark column.
Sl No: Criteria SA A DA Remarks
1 Formulation of objectives
a) Comprehensiveness
b) Realistic
c) Stated in terms of
behavioral outcomes
2 Selection of content
a) Accurate
b) Relevant
c) According to the level
of understanding of
patient
3 Organization of content
a) Logical sequence
b) Continuity of
115
presentation
c) Integration
4 Language
a) Simple and clear
Feasibility of Practicability
5 a) Acceptability to patient
b) Interesting
c) It will be of practical
use for the formal and
informal teaching
6 Teaching Aids
a) Simple and
understandable
b) Appropriate
c) Relevant
d) Easy to follow
e) In sequence
7 Any other suggestion
116
Criteria for validation of research tool
Please tick the column according to your agreement. Please write the modifications
need in remarks column
Sl Tool Items Relevant Relevant Not Remarks

No. but need relevant
to modify
I SOCIO 1
DEMOGRAPHIC
DATA SHEET
2
3
10
11
12
13
14
15
16
17
18
19
117
20
21
22
23
24
II CLINICAL 1
VARIABLES
2
3
4
5
6
7
8
9
10
III PERCEIVED 1
STRESS SCALE
2
10
I have gone through the tools and suggest the above mentioned modifications
Date: Signature and designation
Place
118
APPENDIX F
LIST OF EXPERTS FOR CONTENT VALIDITY
1. Sr. Sajitha
Assoc. Professor
Medical Surgical Nursing
Holy cross college of Nursing, Adoor
2. Mrs.Aneesha
Assoc. Professor
Holy cross college of Nursing, Adoor
3. Mrs. Seethalekhsmi
Assoc. Professor
Mount Zion College Of Nursing, Adoor
4. Mrs. Reshmi Krishnan
Assoc. Professor
Mount Zion College Of Nursing, Adoor
5. Dr. Joseph Vinu
Consultant Nephrologist
Holy cross Hospital, Adoor
6. Dr. Sudheer
Consultant Nephrologist
Josco Multi Speciality Hospital, Pandalam
119
7. Dr. HaiHaran
Physician( General Medicine)
Josco Multi Speciality Hospital, Pandalam
8. Mrs. Sinai Tito
Consultant Psychologist
Lifeline Multi Speciality Hospital, Adoor
9. Fr. Dr. Jacob John
Director
Chaitanya Healing and Training Centre
Kottarakara
10. Mr. Vipin Xavier
Assistant Professor (Bio statistics)
St. Josephs College of Pharmacy
Chertala
120
APPENDIX G
CERTIFICATION FOR CONTENT/TOOL VALIDITY
This is to certify that the tool/content developed by Ms. Reshma.R.S
IIndyear M.Sc nursing, Medical Surgical Nursing Department of Josco College of
Nursing, Edappon, Pandalam, Kerala on the topic A study to assess the
effectiveness of Bensons relaxation technique on stress among hemodialysis
patients in a selected hospital at Alappuzha district is validated by the
undersigned and she can proceed with this tool /content to conduct the research work.
Signature ..
Name .
Designation
Department
Place:
Date:
121
122
123
124
125
126
127
128
129
APPENDIX H
INFORMED CONSENT (ENGLISH)
Study title:
A study to assess the effectiveness of Bensons relaxation technique on
stress among hemodialysis patients in a selected hospital at Alappuzha district.
Investigator:
Mrs. Reshma.R.S
IIndYear M.Sc Nursing student
Josco College of Nursing
Edappon, Pandalam
Dear Participant,
In signing this document, you are giving consent to the investigator
to participate in the research study of 2nd year M.Sc. Nursing course. You will be the
subject of a research study to assess the effectiveness of Bensons relaxation
technique on stress among hemodialysis patients. The study doesnt include any
foreseeable risk or harm to you.
Your participation in this study is voluntary and you are under no obligation
to participate. You have the right to withdraw at any time and your relationship with
the health care authority will not be affected.
The study data will be coded so it will not be linked to your name. Your
identity will not be revealed while the study is being conducted or when the study is
reported or published. All study data will be collected by Mrs.Reshma.R.S, and will
be stored in a secure place and not shared with any other person without your
permission.
I have explained this study to the above subject and I have sought his/her
understanding for the informed consent.
Signature of the investigator
I have been explained and made to understand the need and importance of this study
and I am voluntarily willing to participate in the study.
Signature of the subject
130
APPENDIX I
INFORMED CONSENT (MALAYALAM)

o . . .
o
,
,

..
.

.
.
.
131
APPENDIX J
ATTENDANCE CERTIFICATE
132
APPENDIX K
DATA COLLECTION SCHEDULE FOR THE MAIN STUDY
Name of the student : Reshma R S
Statement of the problem : A study to assess the effectiveness of
Bensons relaxation technique on stress
among hemodialysis patients in a slected
hospital at Alappuzha diastrict.
Research design : Pre experimental one group pretest posttest
design.
Setting : Century Hospital, Mulakkuzha.
Sample size : 35
Sampling technique : Non probability purposive sampling.
Day Date Time Event No: of
sample
Day 1 to 3-12-2016 12-12.15pm and 4- Pretest and socio 7 per
Day 5 to 07-12- 4.15 pm demographic data day
2016
Day 6 to 08-12-2016 12-12.10 pm and 4- Demonstrating and 35
Day 26 to 24-12- 4.10 pm practicing Bensons
2016 relaxation technique
Day 27 25-12-2016 12-12.10 pm and 4- Post test 35
to day to 31-12- 4.10 pm
31 2016
133
APPENDIX L
TRANSLATION CERTIFICATE (ENGLISH)
134
APPENDIX M
TRANSLATION CERTIFICATE (MALAYALAM)
135
APPENDIX N
THERAPY TRAINING CERTIFICATE
136
APPENDIX O
TOOL (ENGLISH)
TOOL 1
SOCIO -DEMOGRAPHIC PROFORMA
Sample No: Date:
Method of Administration: Structured interview schedule.
INSTRUCTIONS: The following section contains questions pertaining to your
personal data. You are requested to kindly read each item and put a tick [] mark in
the box provided against the most appropriate option. The details will be kept
confidential. Kindly answer all the questions.
1. Age in years
1.1 20-40 years
1.2 40-60 years
1.3 60-80 years
2. Gender
2.1 Male
2.2 Female
3. Religion
3.1 Hindu
3.2 Christian
3.3 Muslim
4. Education
4.1 Up to high school
137
4.2 Higher secondary education
4.3 Diploma
4.4 Graduation
4.5 Post graduation and above
5. Type of family
5.1 Nuclear family
5.2 Joint family
6. Marital status
6.1 Married
6.2 Unmarried
6.3 Divorced / Separated
6.4 Widow / Widower
7. Occupation
7.1 Daily wager
7.2 Self employed
7.3 Unemployed
7.4 Private employed
7.5 Government employed
8. Place of residence
8.1 Panchayath
8.2 Municipality
8.3 Corporation
9. Family income per month
9.1 Rs 10000
9.2 Rs 10001- Rs 20000
138
9.3 Rs 20001- Rs 30000
9.4 Rs 30001
10. Percentage of income spent for the treatment
10.1 < 25 % of total family income
10.2 25-50 % of total family income
10.3 50-75 % of total family income
10.4 75- 100 % of total family income
11. Money expended so far for the treatment
11.1 Rs 10000
11.2 Rs 10001- Rs 50000
11.3 Rs 50001- Rs 100000
11.4 Rs 100001
12. Financial support
12.1 Own savings
12.2 Assistance from family
12.3 Pension
12.4 Assistance from others
13. Medical insurance
13.1 ESI
13.2 Arogya insurance
13.3 Others
13.4 None
14. Co-morbidities
14.1 Diabetes melitus
14.2 Hypertension
139
14.3 Diabetes and hypertension
14.4 Diabetes and others
14.5 Hypertension and others
14.6 Hypertension , diabetes and others
15. Family history of chronic kidney disease
15.1 Yes
15.2 No
15.3 Dont know
16. Duration of dialysis treatment
16.1 < 1 year
16.2 1- 3 year
16.3 3-5 year
16.4 5 year
17. Total number of dialysis done
17.1 100
17.2 101 - 200
17.3 201 - 300
17.4 301
18. Average loss of working days / week
18.1 1 2 days
18.2 3 4 days
18.3 Unable to go for work
18.4 Unemployed
19. Performance of daily activity
19.1 By self
140
19.2 Assistance from family
19.3 Assistance from others
20. Level of physical activity
20.1 Completely dependent
20.2 Partially dependent
20.3 Completely independent
21. Most commonly faced problem before dialysis
21.1 Breathing difficulty
21.2 Edema
21.3 Anorexia
21.4 Vomiting
22. Most commonly faced problem during dialysis
22.1 Muscle cramps
22.2 Giddiness
22.3 Nausea
22.4 Head ache
23. Most commonly faced problem after dialysis
23.1 Fatigue
23.2 Itching
23.3 Joint stiffness
23.4 Dizziness
141
SE`CTION B: POST DIALYSIS CLINICAL VARIABLE
1. Post dialysis weight
1.1 < 50 kg
1.2 50 60 kg
1.3 60 70 kg
1.4 70 kg
2. Temperature
2.1 < 98.6 0 F
2.2 98.6 0 F 990 F
2.3 99 0 F
3. Pulse
3.1 < 50 beats/min
3.2 50-70 beats/min
3.3 70-90 beats/min
3.4 90 beats/min
4. Respiration
4.1 < 20 breaths/min
4.2 20 25 breaths/min
4.3 25 30 breaths/min
4.4 30 breaths/min
5. Systolic blood pressure
5.1 < 100 mm of hg
5.2 100 140 mm of hg
5.3 140 170 mm of hg
5.4 170 mm of hg
142
6. Diastolic pressure
6.1 < 90 mm of hg
6.2 90 - 120 mm of hg
6.3 120 mm of hg
7. Serum sodium
7.1 < 135 mg/dl
7.2 135 145 mg/dl
7.3 145 mg/dl
8. Blood urea nitrogen
8.1 <80 mg/dl
8.2 80 100 mg/dl
8.3 100 120 mg/dl
8.4 120 mg/dl
9. Serum potassium
9.1 < 3 meq/L
9.2 3 6 meq/L
9.3 6-9 meq/L
9.4 9 meq/L
10. Serum creatinine
10.1 < 5.5 mg/dl
10.2 5.5- 7.5 mg/dl
10.3 7.5 10.5 mg/dl
10.4 10.5 mg/d
143
TOOL 2
PERCEIVED STRESS SCALE
Sample No: Date:
Method of Administration: Self Administered Structured Questionnaire
Instructions:. Kindly read each questions carefully and put a tick [] mark in the
appropriate option with blue or black ball point pen. Kindly answer all the questions.
Your answers will be kept confidential.
Sl Statement Never Almost Someti Fairly Very

No. Never mes Often often
1. In the last month, how often have

you been upset
because of something that happened
unexpectedly?
you felt that you were unable to
control the important things in your
life?
you felt nervous and stressed?
you felt confident about your ability
to handle your personal problems?
you felt that things were going your
way?
you found that you could not cope
144
with all the things that you had to
do?
you been able to control irritations in
your life?
8. the last month, how often have you
felt that you were on top of things?..
you been angered because of things
that were outside of your control?
you felt difficulties were piling up so
high that you could not overcome
them?
0 = Never
1 = Almost Never
2 = Sometimes
3 = Fairly Often
4 = Very Often
Interpretation of tool
0 -No stress
1-13 - Mild stress
14-27 -Moderate stress
28-40 -Severe stress
145
APPENDIX P
TOOL (MALAYALAM)
: :
1.
1.1 20 40
1.2 40 60
1.3 60 80
2.
2.1
2.2
3.
3.1
3.2
3.3
4.
1..4
4.2
4.3
4.4
4.5
146
5.
5.1
5.2
6.
6.1
6.2
6.3
6.4 /
7.
7.1
7.2
7.3
7.4
7.5
8.
8.1
8.2
8.3
9.
9.1 10000
9.2 20000 10001
9.3 30000 20001
9.4 30001
147
10.
10.1 25
10.2 50 25
10.3 75 50
10.4 100 75
11.
11.1 10000
11.2 50000 10001
11.3 100000 50001
11.4 100001
12.
12.1
12.2
12.3
12.4
13.
13.1 . .
13.2
13.3
13.4
14.
14.1
14.2
148
14.3
14.4
14.5
14.6
15.
15.1
15.2
15.3
16.
16.1
16.2 3 1
16.3 5 3
16.4 5
17.
17.1 100
17.2 200 101
17.3 300 201
17.4 301

18.
18.1 2 1
18.2 4 3
18.3
18.4
149
19.
19.1
19.2
19.3
20.
20.1
20.2
20.3

21.
21.1
21.2
21.3
21.4
22.
22.1
22.2
22.3
22.4
23.

23.1
23.2
23.3
23.4
150
APPENDIX Q
BENSONS RELAXATION TECHNIQUE
The term, Relaxation Response was coined by Dr. Herbert Benson,
professor, author, cardiologist, and founder of Harvards Mind/Body Medical
Institute. The response is defined as your personal ability to encourage your body to
release chemicals and brainsignals that make your muscles and organs slow down and
increase blood flow to the brain. In his book The Relaxation Response, Dr.Benson
describes the scientific benefits of relaxation, explaining that regular practice of the
Relaxation Response can be an effective treatment for a wide range of stress-related
disorders.
Steps to Elicit the Relaxation Response
1. Sit quietly in a comfortable position.
2. Close your eyes.
3. Deeply relax all your muscles, beginning at your feet and progressing up to your
face. Keep them relaxed. [Relax your tongueand thoughts will cease.]
4. Breathe through your nose. Become aware of your breathing. As you breathe out,
say the word "one" silently to yourself. For example, breathe in, and then out, and say
"one", in and out, and repeat "one."Breathe easily and naturally.
5. Continue for 10 to 20 minutes and open your eyes to check the time, but do not use
an alarm. When you finish, sit quietly for several minutes, at first with your eyes
closed and later with your eyes opened. Do not stand up for a few minutes.
6. Do not worry about whether you are successful in achieving a deep level of
relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace.
151
When distracting thoughts occur, try to ignore them by not dwelling upon them and
return to repeating "one."
7. With practice, the response should come with little effort. Practice the technique
once or twice daily, but not within two hours after any meal, since the digestive
processes seem to interfere with the elicitation of the Relaxation Response.
152
APPENDIX R
CERTIFICATE FOR ENGLISH EDITING
153
154
PRRETEST AND POST TEST STRESS SCORE
Pretest stress scores Posttest stress scores
1 36 28
2 24 12
3 32 29
4 26 13
5 28 20
6 25 15
7 27 19
8 31 24
9 29 20
10 28 17
11 33 28
12 18 10
13 29 21
14 16 11
15 14 9
16 30 24
17 15 8
18 25 14
19 28 17
20 29 21
21 22 13
22 30 18
155
23 17 11
24 25 17
25 29 21
26 19 12
27 31 22
28 27 18
29 25 17
30 20 11
31 29 20
32 25 19
33 3 28
34 29 19
35 22 13
156
APPENDIX T
STATISTICAL FORMULA USED IN THE STUDY
1. Reliability
Cronbachs alpha = (k/k-1) (1- sum of item variance / variance of samples)

2. Mean =

1
3. () = 1 ( ( ))f

()2
4.Chi-square, 2 =
157

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CHAPTER 1

Background of the problem

Need and significance of the study

Statement of the problem

the absence of disease or infirmity.2 Thus health is a positive concept emphasising

is varies according to individuals previous experience, expectation of life, age and

socio cultural factors.

A disease is an abnormal condition that affects the body of an organism. An

progressive, irreversible deterioration in renal function in which the body's ability to

maintain metabolic, fluid and electrolyte balance resulting in uraemia or azotemia.

ratio is over 30 mg of albumin for each gram of creatinine (30 mg/g).4-6

lifespan of the patients. The Continuous Ambulatory Peritoneal Dialysis [CAPD],

the quality of life.6

Hemodialysis plays an important role in maintaining renal function. It filters

circulating blood through a semi permeable membrane in an apparatus to remove

Hemodialysis can be an outpatient or inpatient therapy. Routine haemodialysis is

conducted in a dialysis outpatient facility, either a purpose built room in a hospital or

a dedicated, stand alone clinic. Less frequently haemodialysis is done at home.7

However, it has been argued that a number of restrictions and modifications

results in a marked change in the quality of patients life.

Relaxation is one of the most useful non pharmacological techniques, which

muscles and reducing blood pressure. Bensons relaxation technique is a simple

Kidney is the principal organ of urinary system. Adequate functioning of

causes of death Worldwide in 2010.9

adults over 30 to rise 27% by 2030.

Over 1 million people worldwide are alive on dialysis or with a functional

neededto maintain a normal life. A number of stress and copingmechanism factors

operate in patients on maintenancehemodialysis.14

failure is threatened withmany potential losses and changes in lifestyle.

complementary and alternative medicines has increased in conventional health care

reasons for the increasing use of complementary alternative medicine by patients.

With consumer interest in complementary, nurses have increasingly incorporated

these modalities into their practice. 16

The exact burden of chronic kidney disease in India still undefined. A

adult population was 7852/million.16

of dialysis patients had severe stress.17

A randomized control trial was conducted at India (2013) to explore the

efficacy of Bensons relaxation technique on stress, anxiety and depression among 80

hemodialysis patients were selected by simplerandom method using Depression

to reduce stress and anxiety level of hemodialysis patients.18

Need and significance of the study

Stress is a state of disequilibrium that occurs when there is a disharmony

between demands occurring within an individuals internal or external environment

mental health damaged as a result of renal failure.

A descriptive correlational study was conducted at Ireland (2005) to measure

and which negatively affect quality of life.21

Most of the studies investigating the stressors faced by haemodialysis patients

anxiety and depression.

The high prevalence of stress in dialysis patients is very crucial. Appropriate

depression, pain and insomnia.

From the review of literature, the researcher understood that Bensons

relaxation technique can be administered effectively for hemodialysis patients

among hemodialysis patients and determine the effectiveness of Bensons relaxation

technique in reducing the stress among hemodialysis patients.

Statement of the problem

A study to assess the effectiveness of Bensons relaxation technique on stress among

hemodialysis patients in a selected hospital at Alappuzha district.

Objectives of the study

2. To find out the effectiveness of Bensons relaxation technique on stress among

Effectiveness : In this study, effectiveness refers to the extent to which the

period of 24 days and is measured by using Cohen Perceived Stress Scale.

psychological, emotional alteration experienced by hemodialysis patients which is

measured by using Cohen Perceived Stress Scale.