Coping strategies in candidates of kidney biopsy: A qualitative content analysis study

Abstract

BACKGROUND:

Kidney biopsy is the gold standard in the diagnosis and management of many kidney diseases. Due to the physical and mental burden of disease diagnosis on a person’s life and the impact of adaptation strategies on the physical and mental well-being of people, it is important to evaluate adaptation strategies in these patients. This qualitative study aimed to investigate the coping strategies of candidates for kidney biopsy in Iran.

MATERIALS AND METHODS:

A qualitative study was conducted to investigate the experiences of kidney biopsy candidates as to their kidney disease and methods of dealing with anxiety. Twenty-two semistructured interviews were conducted with men and women in the internal kidney department in Namazi Hospital in Shiraz. The participants were selected using a purposive sampling technique. All interviews were recorded and transcribed verbatim in Persian and analyzed using content analysis. MAXQDA software version 10 was used to facilitate data analysis.

RESULTS:

The codes were classified into 3 categories and 21 subcategories. The categories included coping methods, coping methods with a focus on emotional release, and less effective or ineffective coping methods.

CONCLUSION:

Results showed that biopsy was a more traumatic experience for patients and the use of coping strategies during the kidney biopsy was beneficial for them; therefore, it is very important to create and implement appropriate interventions for kidney biopsy candidates patients. Because patients with good mental health use more problem-oriented coping methods, the authors suggest teaching efficient coping methods to ensure the mental health of patients waiting for kidney biopsy.

Introduction

Kidney diseases are among chronic disorders that affect most aspects of the patient’s life and personality.[1] Kidney biopsy is the gold standard for the diagnosis and management of many kidney diseases.[2] Since chronic diseases can cause mental pressure, understanding of the disease and social support increases the ability of a person to deal with these conditions adaptively and efficiently.[3] In general, health-related behaviors and treatment adherence can be influenced by cognitive representations and perceptions that patients have about their illness. This dynamic process changes patient’s coping patterns, seeking treatment and care.[4] Many researchers have tried to explain and describe the psychological processes of why some people get through the disease better than others. These mental processes are often referred to as coping and adaptation.[5] In their study, Dumaradzka and Fajkoska concluded that negative emotion regulation strategies had a positive relationship with anxiety and depression.[6] The experience of depression, anxiety, and inflexibility can be caused by problems in the patients’ sense of worth and self-esteem.[7,8,9] The results of the studies have shown that psychological training can improve the patient’s self-esteem in adapting to the problem, so that modification of thinking and restoration of communication can be effective in achieving the existing adaptation.[10,11] The strategy that patients adopt to deal with such a situation affects their performance and also influences the way they are managed and adhere to treatment.[12] Coping strategies refer to the methods that people use as a tool to manage and deal with stressful events and factors.[13] In general, coping strategies can be divided into efficient (useful) and ineffective coping strategies. Effective coping strategies maintain people’s mental health in critical situations; on the other hand, negative coping strategies can lead to psychologically destructive consequences.[14,15] Given the physical and mental burden of the disease diagnosis on a person’s life and the impact of adaptation strategies on the physical and mental well-being of people, it is important to evaluate adaptation strategies in these patients.[16,17] What affects people’s mental health and social functioning is not stress itself, but the use of ineffective coping strategies and lack of control over emotions.[18] Therefore, education makes people get to know themselves more, know their strengths and weaknesses, achieve a certain level of self-knowledge, and take action to correct their weaknesses and boost their strengths. As a result, the person accepts the facts of his physical condition better and reconciles with them more correctly; this increases adaptation and reduces mental pressure.[19] Adaptation strategy training provides a person with the possibility of developing the necessary abilities to act according to his criteria and achieve desirable outcomes in a special situation. In addition, it increases a person’s knowledge and strengthens their positive beliefs.[20] Meanwhile, according to research studies, the type of adaptation methods used by people in critical situations will play an important role in mitigating or intensifying the effects of psychological distress experienced by people.[21] Given that there is still no agreement on the categorization of adaptation strategies and no acceptable method of evaluation exists, there is no consensus on which adaptation strategies are effective; also, due to the difference in diseases and the different way people look at psychological experiences and challenges, it seems that this research should deal with a qualitative approach through the recognition of their experiences and the support and awareness of patients from the experiences of others and the management of this issue in kidney biopsy patients. Kidney disease is one of the chronic diseases that, if left untreated, may lead to long-term disability or even death and kidney biopsy makes it possible to diagnose the cause of kidney disease, prognosis, or treatment of kidney disease. Today, how humans react to problems and problems in life has been widely studied, and the expansion of topics related to stress, illness, and health has led to the emergence of concepts such as adaptation and coping strategies. In this study, researchers hope to know if adaptation mechanisms provide a way to plan, implement, and evaluate actions that facilitate adaptation.

Material and Methods

Study design and setting

The statistical population consisted of individuals with kidney protein excretion, increased blood creatinine, lupus, and glomerulonephritis, who were referred to the internal kidney department located in Nemazi Hospital in Shiraz, as the only source of referral for these patients in Fars province; for accurate diagnosis of the cause of kidney disease, kidney biopsy is performed for them as the gold standard.

Study participants and sampling

Patients were usually admitted to the ward one day before the biopsy, and this allowed the researchers to interview the participants. Therefore, the studied samples were selected from candidates for kidney biopsy according to the inclusion criteria. Inclusion criteria were the participants’ willingness to participate in the research and the ability to share their experiences related to this diagnosis. The exclusion criteria were the unwillingness of the individuals to continue participating in the research.

Data collection tool and technique

Different methods can be used to obtain qualitative research data. One of the most popular methods of data collection is an individual interview with open questions. This type of interview is a formal interview in qualitative research, which is considered an unstructured conversation which is accompanied by word-for-word transcription and audio recording, and is more self-directed than being limited to inflexible questions. Open interviews (unstructured) give participants the opportunity to fully describe and define their experiences.[22,23,24,25]

In this research, at first, a purpose-based sampling method was used, and according to the purpose of the study, patients who were willing to share their experiences regarding their kidney disease and methods of dealing with anxiety caused by this disease were selected as the main contributors; also, since the most important type of purpose-based sampling in qualitative research is sampling with maximum diversity,[26,27] an attempt was made in this study to select the patients who have different views on the subject and also have different backgrounds.

In this study, the data collection method used was a semistructured interview. In this way, the interviews started with a general question and then with the continuation of the interview; more specific questions were asked based on the results of the initial interviews and the main themes in the direction of the research goals.[28,29]

The information of this research was obtained through interviews. Therefore, according to the literature and research objectives, a semistructured interview guide was compiled and used in the form of questions. Questions were asked to the participants and they were asked to explain about it. If necessary, other questions were asked based on the participants’ statements.

In this way, the interview started by establishing intimate communication and explaining the purpose of the research to the participants, and questions were asked based on the semistructured interview guide in Table 1.

Table 1.

Semistructured interview guide

Number		Questions
Q1		Could you talk about your previous experiences in facing the possibility of kidney disease?
Q2		Could you talk about your previous experiences in facing the possibility of a kidney biopsy?
Q3		Do you have any fears of a kidney disease? Explain in this respect.
Q4		Do you have any fears of a kidney biopsy? Explain in this respect.
Q5		What do you think about the consequences of kidney disease?
Q6		What do you think about the results of your kidney biopsy?
Q7		What do you think about the complications of kidney disease?
Q8		What do you think about the complications of kidney biopsy?
Q9		How would you feel if they told you: “You have failed from the disease”?
Q10		What do you think about the consequences of dying from kidney disease?
Q11		How would you feel if you were told: “The result of your kidney biopsy is positive”?
Q12		Has your kidney disease affected your daily life, job, and activities? Explain in this respect.
Q13		Do you talk to others about your kidney disease? Explain in this respect.
Q14		Do you talk to others about having your kidney biopsy? Explain in this respect.
Q15		What do you do so that the result of your kidney biopsy is not negative? Explain in this respect.

We gradually focused on specific issues. If necessary, we asked probing questions such as “Can you explain more?” or “can you give an example?” to collect deeper information. As the interview process continued, the researcher summarized the participant’s words from time to time in order to show his attention to the participant and encourage him to express more topics. Also, the form and order of the questions were somewhat different with the progress of the research and at different stages, and the researcher was flexible in responding to different answers of the participants. At the end of each interview, the interviewer asked the participants to talk about other important issues that were not mentioned during the interview. The participants were informed about the possible duration of the interview in advance. The time and place of the interview were determined after completing the consent form and agreement between the interviewer and the client regarding the time of the interview. During the interview, to increase the accuracy of data collection, with the consent of the participants, we used audio recording and note taking. The interviews were conducted in the presence of researchers. At the end, after thanking the participants, they talked about the possibility of conducting further interviews. After each interview, the researchers reviewed the interview like an external observer, identified the weak and strong points of the interview, and reviewed the issues that should be considered in the next interviews with other participants. The comfort of the participants and the existence of a quiet and secluded place for conducting the interviews were considered.

In this study, sampling continued until the data saturation level was reached, i.e., until the obtained classes had no changes and the characteristics of each class were completely determined; with the entry of the new data into the research, there was no change in the classes and their characteristics.

Taking notes in the field was another method of data collection in this research. When field notes were taken, the researcher must record what they heard, saw, thought, or experienced.[30,31] In addition to interviews and field notes, researchers also recorded their ideas as reminders. Reminders are separate ideas from the data that emphasize connections between the codes and their attributes or subclasses to make them clear to the analyst. These theoretical ideas emerge during coding, data collection, and analysis. Reminders are an important tool for correcting and maintaining ideas that play a role in the theory formation process when comparing case to case or concept to concept.[32,33,34] The reminders helped the researchers to continue the study process, guide the interviews, perform theoretical sampling, and further reflect on the stated topics.

In this study, data collection and analysis were done simultaneously. To analyze the data, at first, we recorded each interview; after listening several times, we typed them word by word and then entered them into the Max Q10 software. After each interview was entered into the software, each interview was read word for word, and then each text was broken into meaning units. Then, the units of meaning that had similar meanings were placed in the same category. Finally, based on the content and similarities, the main classes were formed using subclasses. In order to improve the accuracy and strength of the findings, Lincoln and Guba criteria were used.[35,36]

Ethical consideration

The research was approved by the University Ethics Committee. Research code: (1401-133) and ethical approval code: (IR.LARUMS.REC.1402.011).

Results

Twenty-two patients with a mean age of 44.22 ± 11.93 participated in this study. The demographic characteristics of the participants are summarized in Table 2. According to Table 3, the codes were classified into three categories: coping methods which focused on problem solving, coping methods which focused on releasing emotions, and less effective or ineffective coping methods.

Table 2.

Demographic characteristics of the participants

Variable		Number		Percentage
Age
30>		2		9.1
30–40		7		31.8
41–50		7		31.8
50<		6		27.3
Gender
Male		13		59.1
Female		9		40.9
Job
Housewife     Employee     Self-employee     Unemployed     Retired		7 8 3 1 3		31.8 36.4 13.6 4.5 13.6
Level of Education
Illiterate		1		4.5
Elementary school		3		13.6
Middle school		2		9.1
High school		4		18.2
Diploma		4		18.2
Academic		8		36.4

Table 3.

Categories and subcategories

Categories		Subcategories
Coping methods which focused on problem solving		Facing the problem directly, Use of information sources, Increase self-efficacy, Working through difficult emotions, Consulting with expert people, Trust the physician, Getting help from other patients, Use of support persons
Coping methods which focused on releasing emotions		Discharge of emotions, Praying, trusting in God and making a vow, Humor
Less effective and ineffective coping methods		Denial, Postponing, Distractions, Addiction, Surrender to the problem, Escape from trouble, Surrender to fate, Taking sedatives, Social withdrawal, Wishful thinking

1. Coping methods which focused on problem solving

   Some of the participants tried to solve the problem with individual efforts to change the situation and directly confront the problem. This category included eight subcategories of facing the problem directly, using information sources, increasing self-efficacy, working through difficult emotions, consulting with expert people, trusting the physician, getting help from other patients, and using support persons.

   1. Facing the problem directly

      One of the participants said: “I am a fighter in life. Problems that are not just work or family; illness is also a problem, and you should seek to solve the problem. Even now, kidney sampling is a solution to the problem.” (a 68-year-old man)

   2. Using information sources

      When some people were informed that their kidneys should be sampled, they tried to master the situation by collecting information about kidney sampling. One of the participants said: “I was scared when the physician said that I should take a sample of my kidney, but I tried to get information by asking different people like physicians or reading on different sites to understand the reason for doing it and how it is done.” (a 44-year-old women)

   3. Increasing self-efficacy

      Some people try to increase their ability to deal with problems when faced with problems. One of the participants said: “I believe in my abilities. I agree that kidney sampling is necessary. Sampling is part of the diagnosis and treatment process….” (a 28-year-old man)

   4. Working through difficult emotions

      Some participants tried to control their emotions in challenging situations. One of the participants said: “When the physician said that I should take a kidney sample, at first I was afraid…. but I tried to manage this situation and I made a contract with myself to have correct and effective thoughts to be neither a pure pessimist nor a pure optimist, but a realistic hopeful man.” (a 54-year-old women)

   5. Consulting with expert people

      Consultation with kidney disease specialists was one of the effective methods that the participants used to cope with the new conditions. One of the participants said: “When my physician said that I should do a kidney biopsy, I said that something must have happened as he says. I consulted several kidney specialists, and they were of the opinion that sampling is necessary for me.” (a 34-year-old women)

   6. Trusting the physician

      Trusting the doctor also made the participants better able to cope with the stress of kidney biopsy. One of the participants said: “My physician is famous, and he is also a university professor. I believe and trust him. He must have had a reason for saying that kidney sampling is necessary through getting help from other patients.” (45-year-old, man)

   7. Getting help from other patients

      Some participants tried to make decisions by talking to patients who had similar problems. Therefore, the words of the patients with similar problems were also effective in encouraging the participants to perform a kidney biopsy. One of the participants said: “I asked for help and advice from several people who are kidney patients both for choosing a doctor and for nutrition and activity. I also got their guidance for sampling, and it was really useful.” (a 37-year-old man)

   8. Using support persons

      The presence of family and relatives and their support were the other strategies used by the participants to control the situation. One of the participants said: “My sister is a nurse and she really helps me. She gives me information about medicines and nutrition. She even follows me when taking a sample of my kidney.” (a 37-year-old man)

2. Coping methods which focused on releasing emotions

   Some participants tried to control and improve the unpleasant feelings caused by stressful conditions without solving the problem in order to alleviate the psychological stress caused by performing a kidney biopsy. Although these coping methods do not solve the problem, they can reduce the psychological pressure caused by the problem.

   1. Discharge of emotions

      Some participants tried to reduce the stress of undergoing a kidney biopsy by talking to friends or traveling. One of the participants said: “I have this kidney problem for a long time, but when it comes to kidney sampling, I get a lot of stress and I try to get rid of this stress by talking to my friends or traveling.” (a 44-year-old man)

   2. Praying, trusting in God, and making a vow

      Some participants tried to reduce their stress with the help of religious beliefs and worship. One of the participants said: “I believe in God. I seek help from God and say zikr regularly. Even now, the rosary is following me and I say zikr; then, I pray for the healing of myself and all the sick people (a 61-year-old women)”. Another participant added: “I vowed that if my kidney sampling does not show any problems, I will sacrifice a sheep and give its meat to poor people.” (a 68-year-old man)

   3. Humor

      Another method that helped the participants cope with the stressful situation of kidney biopsy was the use of a humor technique. One of the participants mentioned: “Life itself is hard and it gets harder when you get sick. You should not give up; I myself can reduce these difficulties by entertaining myself and joking and laughing. For example, we have a joke group with my friends on WhatsApp. I was reading jokes before sampling.” (a 37-year-old man)

3. Less effective and ineffective coping methods

   Some participants also used ineffective coping methods when faced with kidney biopsy, which are discussed below.

   1. Denial

      Some participants denied their problem. One of the participants said: “I have no problem. These symptoms I have are nothing special; other people have problems like me, but they live comfortably. I want to take a sample now; I’m sure I don’t have a problem.” (a 57-year-old woman)

   2. Postponing

      Some participants tried to reduce their stress by postponing the follow-up of their problem. One of the participants said: “I have had the kidney problem for a long time. I visited several physicians. Their opinion was that I should do a biopsy. During this time, I waited until my kidney problem was solved or it was not necessary to do a biopsy.” (a 42-year-old man)

   3. Distractions

      Some participants tried to reduce their stress through distraction from their problems. One of the participants said: “I am sad that I have kidney problem. The physician said that sampling is necessary for me. I am a shopkeeper, but I also engaged myself in sports and studying in order to forget the discomfort and not have the stress of taking a kidney sample.” (a 44-year-old man)

   4. Addiction

      Unfortunately, some participants tried to control their stress by using tobacco and drugs. One of the participants said: “I smoke cigarrets, but since I got sick a few years ago, my stress increased and some people said that opium was good for my illness, so I started using opium. A few weeks ago, my physician said that I should take a sample of my kidneys. Now my stress has increased and the consumption of opium has also increased.” (a 37-year-old man)

   5. Surrender to the problem

      Some participants also surrendered to the situation and did not actually take effective actions to reduce stress. One of the participants said: “I came to believe that there is nothing I can do and that my efforts are useless. I accept whatever has happened and whatever my physician says.” (24-year-old, woman)

   6. Escape from trouble

      Some participants were also escaping from their problem due to fear. One of the participants said: “I have been suffering from kidney problems for several years, and I am more or less looking for medical treatment. Physicians said several times that I should do a kidney biopsy, but because I was afraid, I didn’t do it as far as I could. But it seems I have no choice, and I have to take a sample.” (a 34-year-old women)

   7. Surrender to fate

      Some participants also surrendered to fate. One of the participants said: “I strongly believe in fate. It is in my destiny to have kidney disease, and now I must take a sample from my kidney. There is no choice; I have to accept it, whether it’s good or bad.” (a 46-year-old man)

   8. Taking sedatives

      Some participants used quick methods to reduce stress, such as taking sedatives. One of the participants said: “I don’t know why I was so anxious when I found out I had to take a sample. I cannot control it. No matter what I do, I can’t calm down. I started taking sedatives. I took pills last night and today and I am confused.” (a 54-year-old women)

   9. Social withdrawal

      Some participants were also socially isolated after hearing the news of kidney biopsy. One of the participants said: “Ever since I had a kidney problem, I became discouraged with life. When the doctor said that I should do a kidney biopsy, my condition worsened and I was alone for a long time and was not in the mood for anyone. I came alone now to take samples.” (33-year-old, man)

   10. Wishful thinking

       Wishful thinking for the absence of problems was another method that participants used to cope with the stress of kidney biopsy. One of the participants said: “I hope that no problem will be found in my kidney sampling and that I will recover quickly. I always believed that a person should wish and hope for the fulfillment of his wishes.” (a 45-year-old woman)

Discussion

Kidney biopsy is considered the gold standard for diagnosis of kidney disease.[37] Although it is a common diagnostic method,[38] we have little information about patients’ experiences. This knowledge can help understand the patient’s perspective and develop patient care before, during, and after kidney biopsy, ensuring targeted and relevant information. Therefore, this study was conducted with the aim of gaining knowledge about the experiences of kidney biopsy candidates; to achieve this goal, we used the content analysis method to get the depth of the participants’ experiences and their coping strategies. Our study addressed aspects of sampling that are typically overlooked in quantitative studies, including the emotional response and reasons for anxiety that patients feel throughout the process, and coping strategies. The findings of the study showed that the coping methods focused on problem solving and releasing emotions, and less effective or ineffective coping methods were adaptation strategies in kidney biopsy candidates.

In the cognitive theory of psychological stress and coping proposed by Lazarus and Folkman,[39] coping strategies are both active and avoidance strategies. Active coping strategies are behavioral or psychological responses that change the nature of the stressor or way of thinking about it, while avoidant coping strategies cause people to engage in activities or mental states that prevent them from directly dealing with stressful events. In general, active coping strategies are thought to be better ways to deal with stressful situations.[40] According to the results of the present study, one of the most important strategies was focusing on solving the problem. Johnson[41] showed that patients undergoing dialysis who use avoidant evasive, comforting, and fateful coping activities rate themselves less efficient in disease management. The results of the mentioned study are consistent with those of the present study, so that in the present study, kidney biopsy candidates used strategies such as escaping from problems and surrendering to fate, which are inefficient coping strategies. Accordingly, these coping activities can be associated with low coping efficiency in disease management; also, studies that examined the choice of coping activities in patients with chronic renal failure showed that patients undergoing dialysis used problem-focused coping activities more than emotion-focused coping activities.[40] This study showed that the activities used by patients to face the situation were often problem-oriented, active, and avoidant coping strategies. For example, patients tried to control their stress by using tobacco and drugs as an avoidance strategy. The reasons for using the avoidant coping strategy may be uncertainty about how to manage problems or a feeling of inadequacy to deal with them in a problem-solving way. If the person is actually able to do something about the situation but uses avoidant coping, the problem is not solved and the stress experienced may increase.[42]

In the present study, some patients also used coping strategies with problem-oriented social support (kidney disease specialists, talking to patients with similar problems, relatives, and family); for example, they asked their family to provide information about medications and nutrition and accompany them during kidney sampling because they knew that they did not have the necessary strength or energy. The role of social support in adaptation to chronic illness is unclear, assuming that the use of social support coping strategies can improve patient outcomes after exposure to stressors and may disregard the perceived costs to the individual.[40] The subcategories of “trusting the doctor” and “relying on family and friends” mentioned by the patients are consistent with the results of Subramanian et al. (2017).[43] Our results show that these patients want to take better care of themselves and they have to trust others to cope with the problem. This may indicate that these patients respond to opportunities to improve self-reliance if they receive more structured and systematic support from health care providers and social services to address their lifestyle and quality of life needs which will result in better patient-centered health outcomes. Therefore, psychosocial interventions which allow the patients to talk about their concerns and emotional problems may be very useful in preparation for kidney biopsy. Finally, the search for social support endorsed by patients also highlights the role played by the health care system. Health workers should act as a source of social support for patients with fragile social networks. Communication with the health care team is important for better compliance and satisfactory adherence to treatment. In addition, increasing social and family support should be a goal for an individual’s preparation for kidney biopsy, especially if this patient has a fragile social network.[44] In Pekkola’s study, the need for social support by women during the breast biopsy experience was observed, which is consistent with the results of the present study. In fact, the stress experienced by women before biopsy is more affected by the reduction of social support, and several studies have shown the positive effect of social support among women with breast cancer. There are different social support groups for them,[45] so, according to the importance given to social support, the lack of social support of kidney biopsy candidates should be evaluated and alternative options should be considered.

The results of the present study showed that the patients used information gathering as a coping strategy focused on solving the problem in order to master the conditions. Our findings about the patients’ need for information are consistent with those of Demir et al. (2019). They found a significant need for information in patients undergoing excisional breast biopsy.[46] Also, some studies show that many men have little or no information about prostate biopsies and may search for information through the Internet; however, they are unlikely to find accurate and up-to-date information on how this procedure is performed in particular hospitals. Therefore, urologists must provide an accurate and realistic picture of what might happen.[47]

Increasing self-efficacy was another coping strategy which focused on solving the problem of kidney biopsy candidates; some people try to increase their ability to deal with problems when faced with problems. Bandura (2004) believed that adequacy, competence, and ability to cope with life are levels of self-efficacy needed for adaptation; therefore, individuals who feel highly efficient can cope with the situation more effectively and often work at a high level because they expect to overcome the obstacles.[48]

According to the results of the present study, one of the most important strategies for adaptation was focusing on releasing emotions. Some participants tried to reduce their stress with the help of religious beliefs and worship. According to the main coping strategies adopted by the participants in the present study, this preference to deal with religiosity and problem-oriented coping may be related to the nature of kidney disease treatment, as it requires specific measures by the patient to prevent symptom; also, defects in health may explain the use of problem-focused coping which is related to participation in medical consultations, limitations in food, medical diet, and activity restrictions. Although these behaviors certainly help to maintain health, they may not be sufficient to ensure the patient’s well-being and survival. Therefore, the need for religious coping may be the only way to cope. In addition, religion is a strong cultural characteristic in Iran which may explain the preference for religious coping. The fact that religion plays the main role highlights the need for specific interventions that may analyze the functioning of this strategy as a protection against depression or anxiety, as a way of coping with the fear of success and/or uncontrollability.[44] The results of Salvador et al.’s[49] study showed that one of the parents’ strategies in caring children with chronic diseases was faith in God. The results of the above studies are consistent with those of our study, so that it shows that in the process of dealing with chronic disease, religious beliefs pave the way for many patients and create a sense of hope, motivation, positive thinking, and emotional support in patients. These findings emphasize that health workers should consider the spiritual needs and religious beliefs of patients to provide comprehensive care.

The results of the present study showed that some participants tried to reduce stress before kidney biopsy by talking with friends or traveling; the desire to talk more with others may indicate increased anxiety, while in Mardani et al.’s (2023)[50] study, participants often did not express their concern about cancer recurrence to protect their family; this is not consistent with the results of our study. It seems that hiding concerns among cancer survivors in the Iranian population is also deeply influenced by the cultural context. Men have the most important role in the family in Iran, they are considered as the main support and provider of financial needs, and it is expected that they will remain strong even at times of illness.

According to the results of the present study, one of the most important strategies for adapting was less effective and ineffective coping methods such as denial. In Subramanian et al.’s[43] (2017) study, patients mainly used emotion-focused coping strategies (denial and avoidance) which were often combined with problem-oriented strategies; this is consistent with the results of the present study. Therefore, a deep understanding of the context of these coping strategies has been obtained among patients with kidney disease by using a qualitative approach which can lead to the evaluation of the effectiveness of specific coping strategies in dealing with stressful factors and outcomes of interest in this patient population. Some participants tried to reduce their stress by distractions from their problems such as sports and studying to forget the discomfort. Mardani et al.[50] (2023) reported that distraction was a useful coping strategy in anxious patients who were to be operated, which is consistent with the results of the present study.

In our study, the patients used distraction techniques such as exercise and study, Teo’s study (2022) has shown that exercise improves psychosocial well-being as well as physical and functional capacity in patients with chronic renal failure.[40] Therefore, informing patients about physical exercise as a potential activity to deal with mental/physical fatigue decreases functional capacity, and stress may be a way to improve long-term coping effectiveness.

Some participants used quick methods such as taking sedatives to reduce stress; the results of Aust et al.[51] (2016) showed that most patients did not expect antianxiety to be the first line of defense. Therefore, other supported coping efforts should be prioritized, and antianxiety drugs should be prescribed for patients with more anxiety.

The diversity of coping techniques and the complexity of their interactions which was observed in this study show many opportunities for the healthcare system to support individuals in developing effective coping skills and better managing the significant impact of kidney diseases on the patient’s life and well-being. This understanding helps healthcare providers to adopt coping supports to the individual’s current needs. This may include facilitating access or customizing training in problem-solving strategies that can be helpful for patients experiencing negative symptoms.

Limitations

This study was conducted in a single center according to a local guideline. Therefore, we expect that a study in another context may show other findings. In our study, males predominated. This may be a reflection of our patient population. Efforts were made by the research team to search for female candidates for kidney biopsy. However, we ultimately could not achieve equal samples due to the study period limitations. It should be noted that no potential participant, male or female, refused to participate in this study. This shows that women were equally willing and interested in participating in this study. Although no major differences were observed in the frequency and type of coping strategies used by men and women in our study, the literature in nonsurgical patients suggests that there may be gender differences in coping approaches. For example, women may use more verbal strategies, while men may use more distraction strategies.

Conclusion

The present study provides information about coping strategies used in kidney biopsy candidate patients to cope with fatigue, reduced functional capacity, and situational stress. Coping strategies used by patients were both emotion-focused and problem-focused, which is evident in their decision to delay or ask for help. It seems that biopsy is a more traumatic experience for patients. Finally, the use of coping strategies during the kidney biopsy experience was beneficial for patients. These results are applicable to nurses who care for patients before, during, and after kidney biopsy. There is a relationship between coping and mental health, so it is very important to create and implement appropriate interventions for patients with kidney biopsy candidates. Therefore, strategies such as prioritizing the issue of mental health in the country’s public policies, along with using the opinions of religious experts to increase people’s awareness of religious-spiritual coping strategies through mass media, establishment of interdepartmental and interlevel referral systems, and mental health support centers, providing and empowering specialized and efficient human resources, should be on the agenda of policy makers and managers in the field of mental health in Iran. We suggest that the researchers should prepare relevant training programs for them, so it enables the family members and the care team to play an active role in supporting kidney biopsy candidates. Referrals to therapists who can help the patients to find appropriate coping tools may also be an option. In addition, connecting with the experiences of patients who are in a similar situation can lead to the creation of a mutual community of patients who have positive coping skills to deal with the many challenges of living with chronic kidney disease and diagnostic procedures such as kidney biopsy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.