Indian J Nephrol 2003;13: 89-91 89

ARTICLE

Level of stress and coping abilities in patients on

chronic hemodialysis and peritoneal dialysis
TR Udaya Kumar, A Amalraj, P Soundarajan, G Abraham
College of Nursing & Dept of Nephrology, Sri Ramachandra Medical College &
Research Institute (Deemed University), Porur, Chennai

Abstract
A cross sectional study of 50 patients with end stage renal disease, who were on chronic
peritoneal dialysis (CPD = 25) and chronic hemodialysis (CHD=25), was done for level of
stress and stress coping ability. These patients belonged to different socio-economic
background. A modified structured questionnaire was used (Jelowice, Murphy and Power).
Student t-test was used to compare the mean stress and coping ability between CPD and
CHD patients. The results showed that the overall mean stress score in the CHD patients
was higher (78.3%) than in CPD patients (43.3% p<0.001). Coping ability score for CHD
patients was 51.9% as compared to CPD patients (60.9% p<0.001).
This study suggests that CPD patients have better quality of life when compared to CHD
patients.
Key words: Stress, coping ability, chronic hemodialysis, chronic peritoneal dialysis

Introduction of patients, relatives and staff, which requires a

Stress in human life is often equated with tension,
anxiety, worry and pressure. The social support systems
in contrast to developed countries are not well
established in developing countries like India. Patients
subjected to chronic hemodialysis (CHD) and chronic
peritoneal dialysis (CPD) experience stress of different
nature and their coping ability varies.1 Coping scale
modified by Jelowice, Murphy and Power was adopted
as a standard measure.2 It is an accepted fact that stress
is a part of human life and it can cause either beneficial
or detrimental effects on human beings which can affect
physical, emotional, economical, spiritual and social
aspects3-5.
For the dialysis patient various types of stress includes
abject dependency on the procedure, group of medical
professionals and a medical regimen. Such dependency
places the very independent patient in an uncomfortable
and even untenable situation leading to stress throughout
the course of treatment.
The adequate primary care of patients with renal failure
includes decision about the choice of the modality of
treatment, down to the everyday answering of questions
Address for Correspondence:
Dr G Abraham
Sri Ramachandra Medical College &
Research Institute (DU)
Porur, Chennai - 600 116, India
Email : georgi@eth.net
knowledge of the major psychological stress of the illness
and psychiatric complaints resulting from these stresses
and their treatment. The patient on dialysis is threatened
with many potential losses and changes in the life style.
In the initial stage a patient may need only rest and
dietary restriction but as the disease progresses, the
patient physically may not be able to cope up with his
work and may take medical leave for hospitalization. This
may affect his employment, which indirectly may affect
the whole family especially if the patient is the bread
earner and hence financial situation also gets
jeoparadised 1,4,5. Among the major stresses of dialysis
are the procedure of CHD or CPD, the overall medical
treatment which includes medications and diet, a
procedure and a group of medical professionals. These
physical and psychological stresses can lead to delirium,
depression, anxiety, suicide, uncooperative behaviour,
sexual dysfunction and psychosis.
Materials and methods
The cross sectional study included fifty patients with
end-stage renal disease. Twenty five were on CPD with
the mean age of 60 ± 5yrs (male 19, female 6). Other
twenty five patients were on CHD with the mean age of
57.5 ± 7.5yrs (male 15, female 10). Data was collected
from the patients using a structured questionnaire. The
questionnaire consists of three parts. Part-I demographic
variables of the patients, Part - II stress scale developed
from the literature to suit the socio-economic and family
background of Indian population3.

Copyright © 2003 by The Indian Society of Nephrology

90 Indian Journal of Nephrology Indian J Nephrol 2003;13: 89-91

Stress scale for patients contained 25 items. Each of
these items had 5 responses such as not stressful,
very mild stress, mild stress, moderate stress and
severe stress with the score of 0,1,2,3 & 4 respectively.
The total possible score was 100. The score was
interpreted as percentage of total: not stressful 0%, very
mild stress 1-25%, mild stress 26-50%,moderate stress
51-75%,severe stress76% and above. The overall stress
score represents the sum of physical, psychological and
socio-economic level of stress.
Coping scale contains 15 statements. Each statements
had 3 responses such as never, sometimes and always
with a score of 1,2 and 3 respectively. It includes
affective oriented method and problem oriented
method used by the patients in response to stress. The
total possible score was 45. The score was interpreted
as percentage of total: Never 0-33 %,Sometimes 34-
66%, Always67% and above. The overall coping score
represents the sum of affective oriented method and
problem oriented method.
Part-III coping scale developed by Jelowice, Murphy and
Power was modified to suit the socio-economic and
family background of Indian population3. Coping scale
had two sub-parts. 1. Affective-oriented method 2.
Problem-oriented method. To assess the level of stress
and coping mean and standard deviation was used. To
compare mean stress and coping score between CHD
and CPD patients student t-test was applied.3
Interviews were conducted with the patients by the
authors using the scale and responses given were
entered in appropriate column in front of each statement.
The scale was added up and percentage was calculated
according to the total score obtained.
Most of the patients subjected to chronic hemodialysis
and chronic peritoneal dialysis where undergoing
treatment for about 4-6 months.
Results
The level of stress in CHD and CPD patients is shown
in Table 1. In the CHD patients mean stress score (%)
in “Physical Aspect” was 76.5 ± 4.14. In CPD patients,
mean stress score (%) was 43.17 ± 6.43, which was
less than stress level seen in (P<0.001) CHD patients.
Regarding “Psychological Aspect” the mean score (%)
was 81.09 ± 4.53 in the CHD patients and 46.54 ± 4.69
in CPD patients (p<.001). In the “socio-economic aspect”
of stress CHD patients again had higher score (%) 75.87
± 6.48 as compared to CPD patients (39.0 ± 5.57,

Table 1 : Level of stress in CHD & CPD patients

Aspects of stress Chronic Hemodialysis Chronic Peritoneal dialysis t-value

Mean (%) S.D. Mean (%) S.D.

Physical 76.5 4.14 43.17 6.43 21.70 ***

Psychological 81.09 4.53 46.54 4.69 26.48 ***

Socio-economic 75.87 6.48 39.0 5.57 21.59 ***

Overall stress 78.32 2.82 43.32 3.87 36.53 ***

*** P<0.001 level significance

Table 2 : Level of coping ability in CHD & CPD patients

Coping methods Chronic Hemodialysis Chronic Peritoneal dialysis t-value

Mean (%) S.D. Mean (%) S.D. (P-value)

Problem - oriented method 44.0 3.85 69.87 7.96 14.62 ***

Affective - oriented method‘ 55.87 3.51 55.33 3.73 0.52 NS

Overall coping ability 51.91 3.0 60.18 4.25 7.94 ***

*** P<0.001 level significance

NS - Not Significant

Copyright © 2003 by The Indian Society of Nephrology

Indian J Nephrol 2003;13: 89-91
P<0.001). The higher mean value of overall stress (%)
was 78.32 ± 2.82 among CHD patients when compared
with CPD patients (43.32 ± 3.82, P<0.001).
Patients used two coping methods to overcome stress.
In the CHD patients, score (%) for “Problem-oriented
method” was 44.0 ± 3.85, CPD patients had higher
coping score (%) 69.87 ± 7.92. There was significant
difference among CHD & CPD patients. Regarding
“Affective-oriented method” the mean score for CHD
patients was 55.87 ± 3.51 as compared to CPD (%)
patients (55.3 ± 3.73) which was not statistically different.
CPD patients had a higher overall coping ability as
compared to CHD patients (p<.001).
Discussion
Chronic peritoneal dialysis patients demonstrate a better
perceived health status, a high index of well being and
greater life satisfaction than in center CHD patients.6
Our study is a cross-sectional, which means that the
comparison is made at one point in time and does not
permit comparisons of outcomes over time. This is a
limitation as longitudinal studies would provide more
accurate information. The comparison of stress and
coping ability among CHD and CPD patients in physical,
psychological and socio-economic aspects showed
higher level of stress among the former group compared
with the later group of patients. This has also been
reported by Christensen et al 19957.
An additional factor explaining the better stress outcome
in CPD patients may be the family support and
atmosphere as a result of home therapy compared to
in-centre CHD. The in-centre CHD puts more stress as
References
1. Suzanne CS & Brenda GB. “Text book of medical -
surgical nursing”, 9th edition, 2000,1146-1162.
2. Densise F, Hungler P. “Nursing research - principles and
methods”, 6th edition, 1999,277-305
3. Carol A, Lindeman MM. “Fundamentals of contemporary
nursing”, 1999,903-933.
4. Kozier E, Blais W. “Fundamentals of nursing - concepts,
process and practice”,5th edition,1995, 828-851.
5. Potter and Perry. “Fundamentals of Nursing - concepts,
process and practice”, 5th Edition, 2001,643-667.
6. Wolcott DL, Nisenson AR. Quality of life in chronic
dialysis patients, a critical comparison of CAPD and
CHD. AM J Kidney Dis 1988; 11 :402-412.
7. Christensen AJ et.al. Coping with treatment related
stress: effects on patient adherence in hemodialysis.
Journal of consult clinical psychology 1995, 63(3): 454-
9.
8. Nisenson AR, Prichard SS, Cheng IKP et al. Non medical
factors that impart on ESRD modality seletion. Kidney
Int 1993; 43 (suppl 40): S120-7.
Stress and coping ability in HP and PD 91
the family has to take time off to arrange travel and other
necessary accompaniments including loss of time from
work. Many factors play a role in decision about the
particular modality of therapy to a patient. This situation
is further complicated as patients frequently change their
modality of treatment due to medical or non medical
reasons8,9. The coping strategies in present study, of
CHD patients were less when compared with CPD
patients in the “Problem oriented method” whereas in
“Affective-oriented method” there was no significant
difference in the coping strategy. The comparison of
overall coping abilities between CHD and CPD patients
showed better outcomes among CPD patients who
adopted problem-oriented coping method than affective
oriented method to overcome stress.Patients on chronic
peritoneal dialysis appear to have better coping ability
to overcome stress10 ,11.
Activities of daily living, vocational activities, social
activities, recreational activities may all be adversely
affected by a regular two times or three times per week
hemodialysis schedule unlike chronic peritoneal dialysis
which is a home therapy. Limitations in handling stress
not only adversely affects the quality of life, but also
increases the risk for morbidity and mortality. There are
close links between emotional well being and clinical
outcomes in dialysis patients. Life style modification is
important for stress handling in dialysis patients.
In conclusion although effect of a treatment on patient
survival is important, of equal importance is the effect
of the treatment modality for renal failure on patients
quality of life and that of the family.12,13,14.
9. Portes GA, Lowson L, Buss J, Bias in selecting treatment
for endstage renal disease. Kidney Int 1985; 28 (suppl
17): S34-S37.
10. Cristovao F. Stress, coping and quality of life among
chronic hemodialysis patients, EDTNA ERCA
Journal,1999, 25(4): 35-8.
11. Sjoden, Lindqvist R. Coping strategies and health-related
quality of life among spouses of continuous ambulatory
peritoneal dialysis, hemodialysis and transplant patients.
Journal of Advanced Nursing,2000, 31(6): 1389-408.
12. Potter P, Stewott AL, Carey S. Physical functioning :
Definition, measurement, and expectations. Adv Renal
Replacement therapy 1999; 6 (2): 110-123.
13. Lindqvist.R et.al , Coping strategies and quality of life
among patients on continuous ambulatory peritoneal
dialysis. Journal of advanced nursing 1998, 27(2): 312-
9.
14. Courts NF et.al. Psychosocial adjustment of males on
three types of dialysis. Clinical nursing research,1998,
7(1): 47-63.
Copyright © 2003 by The Indian Society of Nephrology