Pergamon PII : SOO20-7489(97)00035-7

hf. J. Nurs. Slud, Vol. 34, No. 6. pp. 420430, 1997 C 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 002&7489/97 $17.00+0.00

Support and coping of male hemodialysis-dependent patients

Monique Cormier-Da&lea* and Miriam Stewartb
Director of Education and Research: Nursing Services, Beausbjour Hospital Corporation, Dr G. L. Dumont Hospital, Moncton, N.B., Canada EIC 223

Regional

Center for Health Promotion Studies, University of Alberta, 5-100 University Extension Center, 8303-l 12 Street, Edmonton, Alberta, Canada T6G 2T4 (Received 14 January 1997;revised 12 May 1997;accepted 11 June 1997) Abstract The purpose of this descriptive-correlational study was to describe coping strategies used by males with chronic renal failure who are dependent on hemodialysis ; to describe their social networks ; to describe the perceived support, conflict, and reciprocity within their interpersonal relationships; and to examine the relationships among the variables support, conflict, reciprocity, social networks, and coping strategies. Social support was conceptualized as a coping resource or source of assistancein coping with the renal illness- or hemodialysis-related stressor. The Ways of Coping questionnaire and the Interpersonal Relationship Inventory were administered to 30 participants while in hospital. Although, both problemfocused and emotion-focused forms of coping were used, participants primarily used problem-focused coping, in particular, seeking social support. Overall, the participants perceived relatively high levels of support and moderate to high levels of reciprocity with members of their social networks. Participants experienced a moderate level of conflict in their interpersonal relationships. Both escape-avoidance and conflict were positively associated with the number of people in the household. Positive reappraisal was negatively associated with the number of close relatives. The small sample size prohibits generalizability of the results. Longitudinal studies with a larger randomly selected sample would yield insights into the long-term psychological outcomes of different coping strategies and into the bi-directional relationship of support from social network and coping in this population. Implications for nurses are discussed.0 1997Elsevier ScienceLtd. All rights reserved. KQYXIY~S: Coping ; hemodialysis ; social support. Support and coping of male hemodialysis-dependent patients Hemodialysis-dependent patients with chronic renal failure (CRF) must cope with severe restrictions such as strict adherence to dialysis and medication regimens, dietary and fluid limitations, and minimal physical activities (Devins et al., 1990). They often experience chronic fatigue, sexual dysfunction, sleep disturbances, altered body image, and uncertainty concerning the future (Bihl et al., 1988). The way an illness is experienced is highly subjective and reflects the meaning attached to it by the ill person and his or her network members (Schiissler, 1992). Ill people have different coping responses and varied coping resources, such as social support (Woods et al., 1989). Most studies of people with CRF have examined coping and social support independently ; few studies have focused on social support in relation to coping with CRF or hemodialysis. Relatively little is known about coping with this specific illness and treatmentstressor and about whether seeking social support is a preferred coping strategy. Although the ameliorative effects of social support in chronic illness have been demonstrated (Kaplan and Toshima, 1990), issues of conflict and reciprocity in the chronically ill peoples interpersonal relationships have been ignored (Dunkel-Schetter and Wortman, 1985). Asking for help from others may become increasingly difficult due to the ill persons inability to reciprocate. Therefore, the purpose of this study was (I) to describe the coping strategies of adult male hemodialysis-dependent patients with CRF in relation to an identified illness- or hemodialysis-related stressor ; (2) to describe their social networks and the perceived support, conflict, and reciprocity within their interpersonal relationships; and (3) to describe the relationships among perceived or enacted support,

*To whom all correspondence should be addressed: Monique Cormier-Daigle, R.N., M.N., Director of Education and Research: Nursing Services,Beauskjour Hospital Corporation, Dr G. L. Dumont Regional Hospital, Moncton, N.B., Canada EIC 223.

420

M. Cormier-Daigle conflict, reciprocity, strategies. Conceptual foundation

and M. Stewart/Male and coping

hemodialysis-dependent

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421

social networks,

Social support was conceptualized as a coping resource or assistance in managing stressful situations ; namely, CRF and hemodialysis-related stressors (Folkman et (II., 1991). Social support, like other coping resources, can moderate negative effects of stressful conditions (Folkman et al., 1991), enhance health outcomes, and foster recovery from illness (Bloom, 1990). Integration in a social network and the ability to elicit resources from that network may enhance health outcomes through direct (main) and indirect (buffering) effects (Dunkel-Schetter and Bennett, 1990 ; Quittner et al., 1990). In this study, social support was defined as social interactions with spouse/partners, family, friends, neighbours, peers, and health care providers that communicate information (that can be used in coping with a personal or environmental situation), practical aid (behaviour that directly helps the person in need), appraisal (transmission of information relevant to self-evaluation and that affirms self-worth), and emotional help (provision of empathy, caring, love and trust) (House et al., 1988). Perceived support is the psychological sense of potentially available support from the social network whereas enacted support is actually delivered and received (Stewart et al., 1994). Inherent in most relationships are both supportive and negative elements (Stewart, 1993). Conflicted support, defined as perceived tension, discord, or stress in relationships within the network (Kirschling et a/., 1990) and miscarried helping may occur in intimate relationships (Eckenrode and Gore, 1990) due to overinvolvement or inadequate involvement of the well intentioned helper (Coyne et al., 1988). or to lack of reciprocity (Rook, 1990). Norms of reciprocity and equity suggest that support should be bi-directional (Gottlieb and Selby, 1989). Reciprocity is perceived as a balance between receipt of reward and returned favours (Tilden and Stewart, 1985). An imbalance in the cost-benefit ratio of relationships due to illness and diminished energy levels can create tension and conflict. The over-benefited feel guilty because of their favoured position and the under-benefited feel angry because of their smaller return (Tilden and Galyen, 1987, p. 12). This dynamic often creates a sense of indebtedness, inhibits support seeking, and ultimately may result in inequitable relationships (Tilden and Weinert, 1987). Coping responses serve two main functions. Problem-focused coping involves efforts to deal with threatening internal or environmental stress. Emotion-focused coping is aimed at controlling the emotional distress of a situation. Both functions may occur simultaneously, interact harmoniously, or interfere with one another (Cohen and Lazarus, 1983). Problem-focused coping tends to predominate in situ-

ations that are appraised as changeable, whereas a preference for emotion-focused coping tends to occur in situations that are not amenable to change (Folkman et al., 1986). Coping responses may be altered behaviourally (action based strategies which confront or modify a stressful event or an undesired emotional state), cognitively (efforts to modify the meaning of the event or emotional reactions) or a combination (Thoits, 1991). Supportive others can alter appraisal of stressors, sustain coping efforts, and influence choice of coping strategies (Stewart et al., 1994). Conversely, coping strategies can influence type and quality of support received, determine whether support is needed, and help to maintain social relationships (Silver et al., 1990). For example, seeking support, a specific coping strategy has been linked to greater receipt of support (Dunkel-Schetter and Skokan, 1990). Literature review Coping with chronic illness Research on coping with chronic illnesses such as circulatory and respiratory disorders, diabetes, cancer, and arthritis (Badger, 1990; Pollock, 1986; Viney and Westbrook, 1984), indicates that both cognitive and affective coping strategies are used. Problem-focused coping, such as control, informationseeking, cognitive restructuring (Felton and Revenson, 1984; Forsythe et al., 1984) and seeking social support (Bombardier et al., 1990) are more likely to favour adaptation. In contrast, emotion-focused coping strategies such as wishful thinking, blaming self, avoidance, and acceptance-resignation seem to be associated with poorer adjustment (Bombardier et al., 1990; Feifel et a/., 1987). Coping strategy preferences may be influenced by illness severity and environmental conditions (Felton and Revenson, 1987). Coping with dialysis Dimond (1980) explored the coping strategies of dialysis-dependent persons and demonstrated that both emotion-focused coping and problem-focused coping were used. Other studies indicate use of problem-focused forms of coping significantly more often than emotion-focused forms of coping (Baldree et al., 1982; Eichel, 1986; Gurklis and Menke, 1988) especially as length of time on dialysis increases (Gurklis and Menke, 1988). Although overall coping behaviours of CRF patients have been examined, relatively little is known about coping with specific hemodialysis- or renal failure-related stressors (e.g. dietary and fluid restrictions, chronic fatigue, sexual dysfunction, etc.) in males. It is noteworthy that the incidence of CRF is higher among males than females (Institut Canadien dInformation sur la Sante, 1995). Investigations of gender differences in coping strategies in the dialysis population are non-existent. Relevant studies of healthy populations demonstrate

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patients

that men use more self-control and less emotional expression than women (Folkman et al., 1987) men use more active cognitive forms of coping while women prefer emotion-focused styles of coping as well as seeking social support (problem-focused). Women tend to use more types of coping strategies than men when confronted with an emotionally distressing situation, while men resort to more active coping strategies (Thoits, 1991). The extent to which chronically ill males seek support, for example, as a coping strategy requires investigation. Social support and chronic illness Studies of chronically ill persons have shown that different types of support have different effects. Emotional support enhances psychological adjustment (Zemore and Shepel, 1989), decreases depression and illness demands, and increases marital satisfaction (Primono et al., 1990). Tangible support, especially financial aid, appears to improve disposition, physical recovery (Funch and Mettlin, 1982) and self-esteem (Dunkel-Schetter, 1984) ; while appraisal support tends to relieve uncertainty and emotional distress (Mishel and Braden, 1987). Informational support may be beneficial when provided by health professionals and harmful when offered by family and friends (Dunkel-Schetter, 1984). Thus different sources of specific types of support need to be considered. Despite recent exploration of the conflictual and reciprocal aspects of social relationships, the costs involved in maintaining supportive ties for the chronically ill are unknown (Kirshling et al., 1990). As negative interactions may exert harmful effects by increasing psychological distress (Schuster et al., 1990) they should be investigated. In healthy populations, women tend to give more emotional support than men, are more socially skilled, and are the prime beneficiaries of support (Roos and Cohen, 1987; Woods et al., 1989). In addition, women benefit from more confidants throughout their life span, have more multi-faceted networks, and are more likely to mobilize their support networks than men (Stewart, 1993). Little is known about mens experiences with social support and if chronically ill males engage in reciprocal exchanges. Social support and dialysis Perceived social support improves psychological well-being of the dialysis patient and the spouse and has been associated with increased participation of the elderly CRF patient in group activities (Burton et al., 1988). Major sources of support for both dialysis patients and their spouses are family members, health professionals, friends, and neighbours (Conley et al., 1981). Studies of in-center hemodialysis patients reveal that family support and a greater availability and involvement of the spouse were significantly associated with higher morale ; family support and the

availability of a confidant were associated with fewer illness exacerbations and difficulties in social functioning (Dimond, 1979). In contrast, Siegal et al. (1987) reported that frequency of contact with friends and relatives increased psychological symptoms suggesting that frequent contacts may be stressful, perhaps due to issues of conflict and reciprocity. Studies of social support in the male dialysis population are non-existent. Summary In summary, the conflicted relationships and reciprocity of supportive exchanges experienced by male hemodialysis-dependent patients have not been described. Furthermore, the relationships between social support (i.e. support, conflict, and reciprocity) and coping and between social network characteristics and the coping strategies used by male hemodialysisdependent patients have not been explored. The extent to which chronically ill men use support-seeking as a coping strategy has not been studied. Finally we do not know if their support or coping varies according to selected demographic characteristics such as age, marital status, and language. Research questions (1) What coping strategies do male hemodialysisdependent patients with CRF use when confronted with an CRF- or hemodialysis-related stressor? (2) What is the level of perceived support, reciprocity of support, and conflict experienced by male hemodialysis-dependent patients with CRF? (3) What are the characteristics of the social networks of male hemodialysis-dependent patients with CRF? (4) What are the relationships among the variables perceived support, conflict, reciprocity, social network characteristics, and coping strategies of male hemodialysis-dependent patients with CRF? (5) Do coping strategies, perceived/available or enacted support, conflict, or reciprocity of male hemodialysis-dependent patients with CRF vary according to age, language, and marital status? Design Due to the paucity of research focused on aspects of interpersonal relationships such as conflict and reciprocal exchanges and on coping strategies such as seeking social support in the male hemodialysis population, a descriptive-correlational design was chosen. This study was conducted in two dialysis centres in a Canadian province. Thirty adult hemodialysis-dependent males with CRF were selected as a non-probability convenience sample out of a total population of approximately 90 in-center hemodialvsis-denendent natients (males/females). The cri, .

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teria for inclusion were: in-center dialysis patients, over 18 years of age, and able to speak, read, and comprehend English or French. Patients who were very ill or illiterate, as determined by the unit manager of the dialysis centers, were excluded from the study. Sample Participants ranged in age from 2482 years (M = 52.7). Seventy-three percent of the sample were married or had a partner. Eighty percent had attended high school or had post-secondary education and 47% were retired. Out of the total sample of participants, 47% had received hemodialysis less than one year, 33% between l-5 years, and 20% over 5 years. Seven of the respondents were French-speaking, the remaining 23 English-speaking. Measures The two instruments used were translated French by a professional translator. WUJT qf Coping questionnaire (WOC) The WOC questionnaire measures the coping strategies used in relation to a specific stressful encounter, which is described prior to completion of the instrument (Folkman and Lazarus, 1985). The 66 items, divided into eight sub-scales, are categorized into problem-focused coping (seeking social support, problem-solving, positive reappraisal, confrontive coping) and emotion-focused coping (distancing, escape-avoidance, accepting responsibility). The final sub-scale, self-controlling, is considered independently since it loads equally in both categories (Dunkel-Schetter et al., 1987). Of the 66 items, only 50 items are analysed as factor analyses of the items by researchers have demonstrated that 16 items do not load significantly on any factor (Folkman and Lazarus, 1988). The items are scored from 0 (does not apply/not used) to 4 (used a great deal). Previous coping studies revealed modest but acceptable evidence of internal consistency with CL coefficients ranging from 0.56-0.85 (Folkman and Lazarus, 1985) and from 0.61-0.79 (Dunkel-Schetter et al., 1987). In this study, the calculated a coefficients were lower, ranging from 0.32 (distancing) to 0.76 (seeking social support), possibly due to differences in health status. The patients in this study were quite ill in comparison to the healthier populations of the studies conducted by the creators of the instrument. Interpersonal Relationship Inventory (IPRI) The IPRI, a 39 item self-report questionnaire, is a multidimensional measure of interpersonal relationships (Tilden, 1989). It measures structure (i.e. social network characteristics, such as sources of support, size of network, household size, and proximity of relainto

tives). Furthermore, it includes three sub-scales of social network function, specifically availability/ enactment of support (13 items), reciprocity (13 items), and conflict (13 items). Repeated administration of the IPRI to various groups yielded evidence of adequate validity and reliability. Adequate convergence was demonstrated with correlations of 0.57 for support and 0.33 for conflict. Reciprocity was excluded due to its high correlation with support (Tilden et al., 1990). Cronbach CIS ranged from 0.870.93 for the support (availability/enactment) subscale, 0.74-0.85 for the reciprocity sub-scale, and 0.8&0.91 for the conflict sub-scale (Tilden et al., 1990). In this study, the calculated CIcoefficients were 0.82 for support (availability/enactment), 0.81 for reciprocity, and 0.73 for conflict. Procedure Prospective participants, who met the study requirements, were recruited by the head nurse of both dialysis units, who then submitted a list of names to the principal investigator. Prior to signing a consent form, participants were told by the principal investigator that the purpose of the study was to explore how personal relationships influence coping with CRF and hemodialysis therapy and that confidentiality was assured. This study was conducted in compliance with the Ethical Review committees of both hospitals and the University guidelines for the protection of human subjects. Data collection occurred 1 h following the initiation of hemodialysis treatment. Although most patients do not feel well at the onset of their treatment due to the accumulation of toxic wastes in the blood, they feel better after the first hour. Cognitive functioning is thought to be impaired when uremic symptoms are greatest (Levy, 1981). Prior to completing the WOC questionnaire, respondents described the most recent stressful situation related to their illness or treatment experienced within the previous month in order to create a situational context enabling respondents to choose coping strategies more accurately. Following the administration of the WOC questionnaire, participants completed the IPRI. Each session lasted between 60 and 90 min. Although 23% of the entire sample were French-speaking, most French-speaking participants preferred answering the questionnaires in English (n = 5). Data analysis Data were analysed by using the Statistical Package for the Social Sciences (SPSS). Psychometric measures, reported in order of use, were computed for the eight coping sub-scales. To enable analysis of the relationship between social support and coping, means and standard deviations were also determined for each item of the seeking social support sub-scale

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Table 1. Psychometric properties of coping strategies (n = 30) Coping scale 1. Seeking social support (P) 2. Self-controlling* 3. Distancing (E) 4. Planful problem-solving (P) 5. Positive reappraisal (P) 6. Accepting responsibility (E) 7. Escape-avoidance (E) 8. Confrontive coping (P) P = problem-focused coping. E = emotion-focused coping. *Not in either factor. Note : Possible range : l&4. No. of items 6 7 6 6 7 4 8 6 Mean 1.44 1.28 1.27 1.17 1.10 0.96 0.93 0.80 SD. 0.74 0.52 0.47 0.62 0.57 0.70 0.52 0.45 Range O-3.0 0.1-2.3 0.7-2.5 0.2-2.3 o-2.4 O-2.5 0.1-2.0 O-2.0

cardiac arrhythmias (n = 1) and diabetic coma (n = 1). Hemodialysis-related stressorsincluded travel Correlation coefficients were computed to determine difficulties (n = 3), time management problems the relationships of the social network variables (n = l), onset of hemodialysis (n = l), fears related to (household size, network size, number of close rela- surgery (n = 4), post-surgical complications (n = l), tives within a 50-mile radius), the coping sub-scales, and fear of a coagulating fistula (n = 1). When conand the interpersonal relationship sub-scales.Due to fronted with an illness- or hemodialysis-related the number of correlational tests being conducted, a stressor,the participants in this study used both probprobability value of 0.01 was selectedto demonstrate lem-focused and emotion-focused forms of coping. statistical significance and to reduce the occurrence of Interestingly problem-focused coping, in particular Type 1 error. In order to determine if the coping seeking social support, was preferred more than strategiesand the IPRI sub-scaleswere related to spec- emotion-focused coping strategies (Table 1). Parific demographic variables such as marital status, age, ticipants responses were compared on the stressor and language, l-tests and ANOVAs were conducted. and coping variables to test for sample homogeneity. No significant differences were found in type of
three sub-scales of the IPRI were also determined. Findings Coping strategies used in stressful situations stressor (illness- or hemodialysis-related) and of coping strategy except for escape-avoidance(t = - 2.07,

of the coping measure.Psychometric measuresfor the

P = 0.05). Participants who chose an illness-related stressor used escape-avoidance as a coping strategy The stressful situations described by the respon- more than participants who chose a hemodialysisdents prior to the administration of the WOC ques- related stressor. The findings elicited by the seeking social support tionnaires were divided into illness-related or hemodialysis-related stressors. Illness-related stressors sub-scale suggest a preference for seeking inforencompassed weakness (n = 3), chronic fatigue mational support (item 8), rather than emotional sup(n = l), sleep disorders (n = l), fluid restrictions port (items 45, 18) although the respondents need to talk to someone about their feelings was also evident (n = l), and illness sequelae including drug-induced

Table 2. Means and standard deviations of items in the coping sub-scale seeking social support Item 8. 31. 45. 22. 18. 42. I talked to someoneto find out more about the situation I talked to someonewho could do something concrete about the problem I talked to someoneabout how I was feeling I got professional help I accepted sympathy and understanding from someone I asked a relative or friend I respectedfor advice Mean 1.7 1.7 1.4 1.3 1.3 1.2 S.D. 1.05 1.21 0.90 1.30 1.05 1.01

M. Cormier-Daigle and M. Stewart/Male hemodialysis-dependent patients

Table 3. Psychometric properties of Interpersonal Scale Perceived available/enacted Reciprocity Conflict Possible range : O-5 support Relationship Inventory Means SD. Median Range

425

No. of items

13 13 13

3.96 3.66 2.56

0.56 0.53 0.56

3.96 3.69 2.54

2.34.9 2.14.6
I .5-3.8

(Table 2). Respondents did not seekprofessional help as often as support from other sources.Asking friends or relatives for advice was the least preferred item in this sub-scale.
Support, conjlict, and reciprocity in interpersonal relationships and social network characteristics

alone. Most of the men indicated that they had an average of 14 relatives living within a 50-mile radius. Some respondents came from large families and lived in small close-knit communities surrounded by their kin.

The participants reported relatively high levels of relationships, and coping strategies, and demographic perceived available or enacted support (M = 3.96, variables SD. = 0.56) and experienced moderate to high levels of reciprocity (M = 3.66, SD. = 0.53). Conflict was Correlations between coping strategies and the present in moderate amounts within their relation- social network structure variables revealed a moderately strong relationship between positive reapships (M = 2.56, SD. = 0.56) (Table 3). In order to identify the number and distribution of praisal and number of close relatives (r = -0.46, network members, participants were asked to list the P = 0.006) and between escape-avoidanceand numpeople who are important to them and state the ber of people in the household (r = 0.40, P = 0.01). relationship of these people to them. Participants The only significant relationship between the function reported an average of 10 people in their social subscalesand social network structure was a positive networks, with a range of 4-24 people. In order of association of conflict and number of people in the priority, the network list comprised family members household (r = 0.42, P = 0.01) (Table 4). Corand/or relatives, friends, health care providers, and relations between the coping strategies and the IPRI spouses or partners. Neighbours, clergy, work or sub-scales yielded only one significant positive school associates, and peers were mentioned relationship between positive reappraisal and reciinfrequently as sources of support. Most participants procity (r = 0.32, P = 0.05) (Table 5). Comparisons were married and shared their living quarters with one between the coping strategies, the IPRI sub-scales, (43%), or more persons (50%). Two respondents lived and the demographic variables of age, language, and

Relationships

among social network,

interpersonal

Table 4. Pearson correlations

analysis--coping

strategies, interpersonal

relationships,

and social network characteristics, No. of close relatives No. of people in social network -0.14

Coping strategies and interpersonal relationships Confrontive coping Distancing Self-controlling Seeking social support Accepting responsibility Escape-avoidance Planful problem-solving Positive reappraisal Social support Reciprocity Conflict

Age 0.13 0.13 -0.11 0.14 -0.22 0.03 0.13 0.27 -0.21 -0.00 -0.11

No. of people in household 0.10 -0.18 0.22 -0.07 0.16 0.40* 0.02 0.01 -0.02 -0.15 0.42*

0.00 -0.23 -0.14

- 0.05 -0.07 -0.21 -0.15 -0.46* 0.10 -0.20 -0.22

-0.14
0.01 0.00 -0.07 0.10 0.06 -0.02 0.23 0.21 0.14

*P < 0.05.

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Table 5. Pearson correlations Sub-scales Confrontive coping Distancing Self-controlling Seeking social support Accepting responsibility Escape-avoidance Planful problem-solving of sub-scales of WOC-questionnaire Support -0.09 0.00 -0.16 0.07 -0.02 -0.23 -0.02 0.04 and IPRI Reciprocity -0.17 0.22 -0.12 0.08 -0.13 -0.38 -0.03 0.32* Conflict 0.25

-0.10
-0.17 0.21 0.17 0.29 -0.03 0.29

Positivereappraisal
*P < 0.05.

marital status failed to determine any significant differences.

Discussion Coping by dialysis patients

These participants overall preference for problemfocused coping strategies, may suggest favourable psychological outcomes as indicated by previous studies (Bombardier et al., 1990; Feifel et al., 1987). However, at present there is no consensus regarding the degree of effectiveness of each coping strategy (Aldwin and Revenson, 1987). The predominance of problem-focused coping is congruent with other studies of dialysis-dependent patients (Baldree et al., 1982; Eichel, 1986; Gurklis and Menke, 1988). Dunkel-Schetter et al. (1987) classified seeking social support to problem-focused coping. Male participants preference for seeking social support to cope is somewhat unexpected in light of an earlier study of healthy males preference for more active, cognitive forms of coping (Defares et al., 1985). Nevertheless, gender variations in coping preferences in the chronically ill population are largely unexplored. Chronically ill individuals who prefer problem-focused coping tend to seek social support more freely than individuals who use emotion-focused coping strategies(Bombardier et al., 1990).Support seeking has been linked to greater provision of support (Dunkel-Schetter and Skokan, 1990). Yet supportseeking behaviours may elicit or discourage needed support depending on coping skills (Barbee et al., 1990; Dunkel-Schetter and Bennett, 1990). A closer examination of support seeking by participants reveals a preference for informational support seeking. A greater understanding of the meaning of the illness and its symptoms may improve health behaviours (Felton and Revenson, 1984). Information-seeking may generate feelings of control ; this underscores the importance of providing this type of support to CRF patients. These findings indicate that friends or relatives are the least preferred source of informational support. Spousesand family are typi-

tally valued for emotional support, while professionals and peers are valued for informational support (Dakof and Taylor, 1990) due to their professional expertise or experiential knowledge of the illness respectively. Well intentioned lay persons, such as family and friends, may offer ill-founded or misleading advice (Dunkel-Schetter, 1984). The second most frequently used coping strategy, self-controlling, implies a reluctance to share emotional feelings with others when confronted with a stressful encounter. Although healthy men appear to use more self-controlling as a coping strategy than women (Folkman et al., 1987), a recent study of elderly arthritic women revealed a preference for use of self-controlling coping strategies(Burke and Flaherty, 1993). This could be the result of coping with the lifelong stresses imposed by chronic illness or the network members expectations that these people be self-controlled and cope without bothering others. In fact, coping portrayals can influence the course of interactions and the nature and quality of support received. Individuals who present themselves as coping well generate positive responses (Silver et al., 1990). Further study of gender differences in coping with chronic illness seemswarranted. The fact that over half of participants who chose an illness-related stressor used escape-avoidanceas a coping strategy is noteworthy. These patients may perceive little control over their illness-related stressor which is chronic and severeand therefore may avoid thinking about it. Emotion-focused types of coping are most often preferred in situations where change is not feasible (Folkman et al., 1986).
Support, reciprocity, and conjlict in relationships of dialysis-dependent males

These men perceived a moderately high level of support. This is noteworthy since chronically ill persons often experience depletion of networks, due to the increasing demands of the illness and its downward trajectory. Illness can involve loss of social context, depleted support resources, and estrangement of the ill person from the social network. The

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ability of providers to sustain support is critical for chronically ill persons (Cohen and Syme, 1985). As network members were not included as participants in this study, we do not know caregivers costs associated with maintaining supportive ties with CRF patients. From the patients perspective, however, their relatively high level of perceived support could indicate a strong sense of belonging in a secure social network (Wineman, 1990). Perceived support has been associated with positive psychological adjustment (McNett, 1987) and life satisfaction (Ducharme and Rowat, 1992). Furthermore, effective coping seems to be influenced more by the perception that support resources are available and can be mobilized when needed, than the actual receipt of support (Gottlieb, 1988). In fact, perception of available support influences the outcome and course of illness (Solomon et al., 1990). The moderately high level of reciprocity reported in this study is unexpected, as chronic illness tends to compromise the ill persons ability to reciprocate. Participants perceived adequate exchanges of resources in their relationships. As almost all participants were married, this may illustrate lifespan reciprocity. Intimates develop a support reserve in long-term relationships which lead them to believe that reciprocity is achieved over time (Antonucci and Jackson, 1990; Clark and Reis, 1988). Reciprocity scores for this sample are lower, however, than Tilden et al.s (1990) healthier sample. Perhaps renal patients experience more difficulty reciprocating, due to chronic fatigue. The moderate amount of conflict within interpersonal relationships yields insights into the nature of unsupportive interactions experienced by some CRF patients. Chronically ill persons may prefer focusing on the positive aspects of their relationships as they may be imprisoned in relationships that fail to meet their needs (Tilden and Weinert, 1987). The increased vulnerability of ill persons and the danger of being perceived as unappreciative towards members of their social network (Kirschling et al., 1990) may limit acknowledgement of negative interactions. Gender differences could also influence perceived conflict. Men tend to eliminate relationships in which they experience hurt, whereas women endure the hurt at the expense of maintaining the relationship (Tilden et al., 1990). The amount of conflict within relationships may increase with illness severity (Dunkel-Schetter, 1984) as the caregivers burden and as the ill persons discomfort and restrictions increase. Furthermore, miscarried helping by spouses can result in counterproductive behaviour by the ill person (Coyne et al., 1988). It is conceivable that the moderate amount of conflict experienced by respondents was related to a phase of stability in the illness trajectory. As the prognosis worsens, the amount of conflict in their relationships might increase. Criticism and conflict can offset support, diminish life satisfaction, and decrease access to helpful information (Brenner et al.,

1989). Research has shown that conflict in conjugal relationships may effect marital satisfaction and life satisfaction (Ducharme and Rowat, 1992). Conflicted support and miscarried support efforts often occur in intimate relationships (Coyne et al., 1988 ; Eckenrode and Gore, 1990) resulting in diminished self-esteem, sense of control, trust, feared lack of support, and uncertainty about interactions (LaGaipa, 1990 ; Fisher et al., 1988).

Relationship of coping with interpersonal relationships and social network characteristics The weak relationship between positive reappraisal and reciprocity could be explained in part by the fact that participants sought social support and reciprocated this support when confronted with an illnessspecific stressor. Supportive others may have suggested alternative ways of handling the problem thereby enabling the patients to reappraise their situation more positively. If beneficial effects experienced following reappraisal were attributed to support from others, feelings of indebtedness may have occurred and reciprocal exchanges may have been initiated. This might partially explain the moderately high level of reciprocity found. Reciprocity has been linked to well-being and life satisfaction (Maton, 1987), and may increase the tendency to reappraise stressful situations positively. Positive reappraisal is a coping response that attracts support from family and friends (Dunkel-Schetter et al., 1987). Escape-avoidance coping and conflict were positively associated with the number of people in the household. As men share their feelings reluctantly and typically only within intimate relationships, a large number of people in the household may inhibit opportunities for intimate disclosure and the maintenance of intimate ties. Gender differences in coping responses to a common stressor have been associated with increased marital conflicts (Gottlieb and Wagner, 1991). Positive reappraisal was inversely related to the number of close relatives. Emotional over-involvement of family members could hinder the ill persons capacity to reappraise the stressful event associated with their illness or treatment positively. Overinvolvement promotes dependency of the ill person and creates resentment and guilt (Coyne et al., 1988). Over-concern and other non-supportive behaviours can be detrimental for self-care (Kaplan and Toshima, 1990). These findings suggest that larger social networks may encourage escape-avoidance, inhibit positive reappraisal, and aggravate conflicted relationships. Many sources of supportive interactions are also sources of problematic interactions (Brenner et al., 1989 ; Rook, 1990). The quality of the relationship is more important than the quantity of network interactions (Glass and Maddox, 1992).

428
Limitations

M. Corrnier-Daigle and M. Stewart/Male hemodialysis-dependent patients and their spouses: Coping, health, and marital adjustment. Archives of Psychiatric Nursing 4,3 19324. Baldree, K. S., Murphy, S. P. and Powers, M. J. (1982) Stressidentification and coping patterns in patients on hemodialysis. Nursing Research 31, 107-I 12. Barbee, A. P., Gully, M. R. and Cunningham, M. R. (1990) Support seeking in personal relationships. Special issue: Predicting, activating and facilitating social support. Journal qf Social and Personal Relationships 7(4), 531-540. Bihl, M. A., Ferrans, C. E. and Powers, M. J. (1988) Comparing stressors and quality of life of dialysis patients. American Nephrology Nurses Association
Journal 15,27T37.

The nature of a descriptive-correlational design precludes firm conclusions. In addition, the small sample size and the non-randomized sampling prohibits generalizability of the results. Eleven respondents chose not to divulge their stressful event due to personal reasons, although they all confirmed that they had selectedan illness or treatment-related situation.
Conclusion

This study provides preliminary evidence that male patients with CRF do not cope with their illness in isolation, but rely on the assistance of supportive others. Longitudinal studies with a larger randomly selectedsamplewould yield insights into the long-term psychological outcomes of different coping strategies such as support seeking and into the bi-directional relationship of support from social network and coping in this population. As escape-avoidancewas used by participants who identified an illness-related stressor, further research is neededin order to determine if such patients require extra support to manage CRF or if this coping strategy is detrimental to the well-being of the person. Given that seeking social support was the preferred coping strategy nurses can focus on teaching social skills and effective strategies for seeking support. When nurses provide informational support to dialysis patients, inclusion of the spouse/partner is desirable as spousescan reinforce health behaviours and reciprocity. Nursing assessmentsshould include an evaluation of the ill persons support network in order to assess inadequate support or conflictual relationif ships exist. In caseswhere overinvolvement prevails, family memberscan be taught to diminish miscarried helping (Coyne et al., 1988).Clearly, nursescan mobilize and enhance the support available to persons with CRF through comprehensive assessmentand appropriate intervention.
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