Ways for people on hemodialysis to deal with stressors: a literature review

Abstracts

Foi realizada uma revisão integrativa da literatura com o objetivo de sintetizar a contribuição das pesquisas realizadas sobre os modos de enfrentamento das pessoas em tratamento hemodialítico. Através do levantamento bibliográfico foram identificados 12 artigos que compuseram a amostra do estudo. Os resultados apontam que os modos de enfrentamento focados no problema são mais utilizados e que a depressão se correlacionou positivamente com os modos de enfrentamento focados na emoção para pessoas em tratamento hemodialítico. A identificação dos modos de enfrentamento é informação valiosa para planejar o tratamento individualizado que proporcione controle dos estressores inerentes a doença e ao tratamento hemodialítico, subsidiando melhor adaptação do paciente ao regime terapêutico.

Adaptação psicológica; Diálise renal; Insuficiência renal crônica; Pesquisa

WCN 2007/NURSING MEETING

Ways for people on hemodialysis to deal with stressors: a literature review

Modos de enfrentamento de los estresores de personas en tratamiento hemodialítico: revisión integrativa de la literatura

Daniela Comelis Bertolin^I; Ana Emilia Pace^II; Luciana Kusumota^II; Rita de Cássia Helú Mendonça Ribeiro^III

^IGraduate Student at the Escola de Enfermagem de Ribeirão Preto at Universidade de São Paulo – USP - Ribeirão Preto (SP), Brazil

^IIPhD, Professor at the Escola de Enfermagem de Ribeirão Preto at Universidade de São Paulo – USP - Ribeirão Preto (SP), Brazil

^IIIGraduate Student, Professor at the Faculdade de Medicina de São José do Rio Preto – FAMERP - São José do Rio Preto (SP), Brazil

Corresponding Author

ABSTRACT

An integrative literature review was performed with the purpose to synthesize the contribution brought by research on the ways that people on hemodialysis deal with the treatment. Through a bibliographic review, 12 articles were identified, which composed the study sample. The results point out that problem-focused coping are the most used and that depression was positively correlated with the forms of emotion-focused coping for people on hemodialysis. The identification of the forms of dealing with the treatment is valuable information to plan treatments individually so as to control the stressors inherent to the disease and to hemodialysis, thus supporting the patient toward a better adaptation to the therapeutic regimen.

Keywords: Adaptation, psychological; Renal dialysis; Renal insufficiency, chronic; Research

RESUMEN

Fue realizada una revisión integrativa de la literatura con el objetivo de sintetizar la contribución de las investigaciones llevadas a cabo en relación a los modos de enfrentamiento de las personas en tratamiento hemodialítico. El levantamiento bibliográfico permitió la identificación de 12 artículos que conformaron la muestra del estudio. Los resultados señalaron que los modos de enfrentamiento centrados en el problema son más utilizados y que la depresión se correlacionó positivamente con los modos de enfrentamiento enfocados en la emoción para personas en tratamiento hemodialítico. La identificación de los modos de enfrentamiento constituye información valiosa para planificar el tratamiento individualizado que proporcione control de los estresores inherentes a la enfermedad y al tratamiento hemodialítico, favoreciendo una mejor adaptación del paciente al régimen terapéutico.

Descriptores: Adaptación psicológica; Diálisis renal/psicología; Insuficiencia renal crónica; Investigación

INTRODUCTION

The concept of stress is complex and was introduced in biological sciences in the 1930s by the Austrian physiologist Hans Selye. Stress is a state manifested by a specific syndrome, consisting of unspecific changes produced in a biological system. It can be divided in three phases: alarm (recognizing the stressor), adaptation (repair of the physical damage caused by the stressor), and exhaustion (overload, if maintained in the stressful situation)⁽¹⁾.

Stress has been approached in psychology, emphasizing the stressors, which are situations that require adaptation, and originate out of the organism like a demand of something or someone, internal like self-expectations, or, yet, situations that irritate, scare, excite, confuse, or even those that cause extreme happiness⁽²⁾.

Among the stressors, the chronic health conditions, besides being stressful situation, they are sources of various stressors, including treatment regimen, changes in lifestyle, physical energy, and personal appearance. The stressors are dealt with according to the meaning that they have to those involved, and the health of the people with a chronic disease depends on the result from that coping process⁽³⁾.

In the theory of stress and coping, it is estimated that the latter reduces the effects of the former and contributes with the adaptive process. Coping is defined based on the individual's assessment of the stressor, and this depends on the relation between the individuals and the environment⁽²⁾.

The coping process has two important functions: regulate one's emotional responses to the stressful events, which is emotion-focused coping; and control or change the problem that caused the distress (negative stress), which is problem-focused coping⁽⁴⁾. Ferraz⁽⁵⁾ refers to the effectiveness of the coping patterns affirming that is a threat is resolved, the coping strategy will be used again in similar situations, and this will be the effective coping. If the threatening situation is not effectively managed, the ineffective coping can result in a crisis that, unresolved, can cause a physiological and psychological unbalance⁽⁶⁾.

Patients with chronic renal insufficiency (CRI), which is a chronic non-transmissible disease, experience intense emotional stress, caused by the changes in their lives. Studies addressing stress and the forms of coping used by people on hemodialysis state that the most reported stressors are the restriction of foods and beverages, muscle cramps, uncertainties about the future, interferences at work, changes in the family structure, the fear of staying alone, and sleep disorders⁽⁷⁾.

According to the Brazilian Nephrology Society, there are 64.306 people with CRT on hemodialysis in the country⁽⁸⁾. This high number implies there is a need to identify how these people deal with stress, which could favor their adaption to the disease and treatment. To research the contribution of the studies about the ways that people on hemodialysis cope with stress, the authors chose to use the method of integrative literature review. This strategy is used to identify the existing evidence, basing health care practice on the different specialties⁽⁹⁾.

The integrative review is one of the instruments of the "Evidence-based Practice", which is defined as the care guided by research results, consensus from specialists, or a combination of both. This approach contributes with the decision-making process in health care to people on hemodialysis, considering the types of coping they use⁽¹⁰⁾.

OBJECTIVES

General:

To synthesize the contribution of the studies about the forms of coping used by the people on hemodialysis.

Specific:

- To perform a survey of the scientific publication about the forms of coping used by people on hemodialysis;

- To identify the types of studies, methodological procedures used, and the consistency with the objectives;

- Perform a descriptive analysis of the results of the produced studies.

METHODS

The process of elaborating the integrative review should follow six stages: select the hypotheses or questions for the review; select the studies that will compose the review sample; define the primary research characteristics that compose the review sample; analyze the findings of the articles included in the review; interpret the results; and report the review, providing a critical examination of the findings⁽¹¹⁾.

In this integrative review, the following stages were followed: establishing the hypotheses and review objectives; establishing the inclusion criteria for articles; definition of the information to be extracted from the selected studies; selection of the articles; result analysis; discussion of the findings, and presentation of the review.

The guiding question of this integrative review was: What knowledge has been produced, from the performed studies, about the ways that people on hemodialysis deal with the treatment?

The identification of the study object in national and international publications was performed using online databases.

The study included all the articles about forms of coping in people on hemodialysis available in the national and international literature, from January 1^st 1980 to April 30^th 2007, and indexed in National Library of Medicine (Pubmed) Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Literatura Latino-Americana de Ciências da Saúde (Lilacs).

However, for the appropriate refining of the research, a sample was established, according to the following inclusion criteria:

- Articles in Portuguese, English, or Spanish with abstracts available in the abovementioned databases from January 1^st 1980 to April 30^th 2007;

- Articles indexed by the masch/desc terms: diálise renal/ renal dialysis/ adaptação psicológica/ psychological adaptation/ coping/ hemodialysis;

- Articles that addressed the theme forms of coping associated with the stress in hemodialysis in any ambit, in an adult population (18 years or more);

- Articles that used some methodological criterion.

The strategies used to locate the articles were adapted to each database, according to their access specificities, guided by the question and the inclusion criteria. During the selection, some articles were excluded after reading the abstracts, as they did not fit the proposed inclusion criteria. Other were selected and then excluded after reading the full text, also because they were not in agreement with the previously established criteria. The mesh/decs descriptors used for the search on Pubmed and Lilacs databases were diálise renal; renal dialysis; adaptação psicológica and psychological adaptation. The terms coping and hemodialysis were used for searches on CINAHL, since the mesh/decs descriptors were still in the adaptation stage in this database.

The computerized search was initiated in the Lilacs database. For the term diálise renal, 1327 articles were located; with the terms diálise renal and adaptação psicológica, one article was found and later excluded because it did not address the coping patterns and did not have a methodological criteria.

In Pubmed, 2718 articles were located using the term renal dialysis. When the term psychological adaptation was added, 64 articles were identified; after evaluating the abstracts, it was found that 14 articles met the criteria, and after reading the full texts, eight articles were selected to compose the final sample.

On CINAHL, which has free access, controlled by IP (allowed in universities), through the website www.capes.gov.br, using the term hemodialysis, 369 indexed articles were found. With the terms hemodialysis and coping, eight articles were identified. After evaluating the abstracts, six articles met the criteria, and after reading the full-texts, five were included in the final sample of this review. One article was indexed in the two studied databases. Therefore, the sample consisted of 12 articles extracted from CINAHL and Pubmed.

To collect the data from the articles included in the integrative review, an instrument was created based on the review protocol by Polit, Beck, and Hungler⁽¹²⁾, and the original terms in English citation and interventions were replaced by the Portuguese words procedimentos metodológicos (methodological procedures) and conclusões/considerações finais (conclusions/final considerations). The data collection instrument was subjected to apparent and content validation by three experienced referees, and all their suggestions were complied with. The instrument contains the following data: study title, year, authors, serial of publication, type of analysis used in the study (qualitative, quantitative, or both), study outline, keywords, place where the study was developed, article objectives, studied variables, studied subjects, findings, and the study's conclusion/final considerations.

The data were analyzed, according to its contents, through descriptive statistics and regarding the relation between the data and the object of each study.

After the reading, the articles and instruments were fixated, organized in a folder, and categorized numerically by year of publication.

Data analysis and the synthesis of the articles were done using Chart addressing the following aspects: study title, author, serial, year of publication, objectives, methodology, type of study, outline, variables, place of study, subjects, results, and conclusion.

RESULTS

In the present integrative review, 12 articles met the previously established inclusion criteria and were thus analyzed. Of the selected studies, 30% were produced in the USA, 30% in Japan, 10% in Australia, 10% in England, and 10% in Scandinavia. This shows that developed countries are more concerned with this issue. No studies performed in Brazil, addressing the proposed theme, were found.

Only one of the articles was developed in a hospital. The others were performed in a multicentre fashion, in satellite nephrology units.

Chart 1, below, shows a general view of the analyzed articles.

Among the 12 articles presented, eight were written by nurses and the others by physicians^(7,13-23).

Regarding the type of serial, eight were published in nursing serials, of which one article was published in a nephrology nursing journal, one in a behavior medicine journal, one in a psychosomatic research journal, one in a care sciences journal, and one article was published in an occupational health journal.

The studied population in the selected articles totals 1584 subjects who met the inclusion criteria proposed in the studies. However, not every article specified their inclusion criteria.

Of the articles used in this review, seven were developed after the year 2000, four were published in the 1990s, and one in the 1980s.

Regarding the variables addressed in the studies, ten directly studied the coping parameters of people on hemodialysis, associated to the stress due to treatment. In two studies, the authors did not study coping parameters directly, rather the stressors associated with hemodialysis, the occurrence of anxiety and depression, and measured the subjects' health-related quality of life and adjustment to the diseases.

Regarding the methodology used in the evaluated articles, it is observed that 91.7%, that is, all articles using a quantitative method used preexisting questionnaires to measure the studied variables.

Among the ten articles that studied the variable "coping parameters", nine used preexisting scales for their measurement. Four used the "Jolowiec Coping Scale" by Jolowiec & Powers (1981), three used the "Coping Inventory for Stressful Situations", one used the "Coping Strategy Indicator", and one used the "Ways of Coping" questionnaire. None of these questionnaires is specific for people on hemodialysis.

The "Hemodialysis Stressor Scale" (1982) was used in 50.0% of the studies selected to identify the physiological and psychological stressors associated with hemodialysis.

As to the objectives of the analyzed articles, five aimed to identify the coping parameters associated with the hemodialysis stressors, and seven sought to establish relationships between coping parameters and other studied variables, like depression, anxiety, quality of life, or some particular stressor.

Among the selected articles, six studies had goals with a clear description and attainable through the proposed methodology. In these studies, the results were coherent with the objectives and the methodological procedure used. Among the articles that presented incoherent objectives: the objectives were not totally achieved in one article; another study presented an objective biased by the comparison made to a study performed the year before; in one study, the objectives could not be achieved through the methodology used; and in one of the studies, the objectives were not clearly described.

The results of the analyzed articles showed that, in three papers, the problem-focused coping parameters were mentioned more often. Depression was positively correlated with emotion-focused coping, through the statistical treatment made, in three studies.

The other two studies, which were compared among patients on hemodialysis and those on peritoneal dialysis, better described the emotional health experienced by the patients that are on the second treatment.

The psychosocial stressors were the most frequently mentioned, and although the mean for differences between proportional scores was calculated in the studies and demonstrated that there were no significant differences, it is important to stress that 50.0% of the studies used the Hemodialysis Stressor Scale, and that 23 of the 29 items in the scale were classified as psychosocial stressors. However, the classification between psychosocial and physiological stressors might not be clearly defined.

In one of the studies, the emotion-focused coping parameters demonstrated a positive association with work. People who worked were less depressed that people who did not. Furthermore, working women were less anxious.

In four of the analyzed articles, the authors refer to implication of knowing the coping parameters on the practice of nursing in nephrology, including: following the changes that take place after beginning hemodialysis as a transforming agent of the reality; in performing training sessions and guidance that contribute with a better patient adaptation to the treatment; in directing the patient toward using coping strategies that solve problems, besides developing research on the coping parameters and stress associated with hemodialysis.

DISCUSSION

The great interest that nurses have on the coping process adopted by people on hemodialysis is due to their participation in the process, especially in guiding and looking after the patient regarding problem-focused coping.

Since the early 1990a, the number of patients on dialysis has increased considerably. This fact may have contributed with the attention given to improving the quality of life of people on hemodialysis⁽⁸⁾.

As to the type of research design used by the assessed studies, ten articles are non-experimental, descriptive, prospective; and eleven used quantitative analysis. It is important to develop experimental studies that associate coping parameters with clinical practice, thus, proving the importance of coping in the health-disease process⁽²⁴⁾.

None of the articles used a specific instrument for CRI patients on hemodialysis. Specific instruments should be designed, including in Brazil, to measure the coping parameters of people on hemodialysis due to the specificity of this therapy.

A positive relationship was found between the emotion-focused coping and the occupation of people on hemodialysis. In this regard, the literature describes that people who work have better social support, which is associated with lower morbidity and mortality rates, as it contributes with patient compliance to treatment⁽²⁵⁾.

The knowledge regarding the relationships about the coping parameters used by people on hemodialysis, associated to the identification of the coping parameters used by specific patient groups (ex: adult, elderly, etc) are essential to effectively redirect patients in the coping process.

CONCLUSIONS

Although few articles addressing the proposed theme were found, it is observed that most studies were performed in developed countries and since the 1990s, when the concern about people's health conditions increased. It can be affirmed that population aging and the increase in the survival rate of people with chronic disease with chronic disease, which first occurred in those countries, create the need to think about the chronic characteristic of the disease.

The studied subjects' preference in using the problem-focused coping parameters demonstrated a difficulty that these patients experience to deal with the changes in their feelings, which is evidenced in the studies that affirm there is a positive relationship between emotion-focused coping and depression.

It is considered that the objectives of the present study have been achieved and that the identification of the coping parameters is valuable information when planning individualized treatment for these patients, providing care, capacitating the multidisciplinary team, and, consequently, obtaining a better adequacy of these patients to the treatment.

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Publication Dates

• Publication in this collection
  23 June 2008
• Date of issue
  2008

History

• Accepted
  18 Aug 2007
• Received
  13 June 2007