Abstract
Objective
To study the post-traumatic growth level and influencing factors in patients with maintenance hemodialysis.
Methods
A total of 179 patients receiving maintenance hemodialysis from a third-level grade A hospital in Tianjin, China were investigated using Post-traumatic Growth Inventory (PTGI), Perceived Social Support Scale, and Medical Coping Modes Questionnaire.
Results
The total score for the PTGI was 53.73 ± 16.45. Multiple linear regression analysis showed that social support, coping style, marital status, and family income significantly influenced the post-traumatic growth level in patients undergoing maintenance hemodialysis. These factors explained 41.4% of the variance.
Conclusion
Medical staff should help patients under maintenance hemodialysis to fulfill their potentials by boosting the level of social support and to effectively cope with internal conflicts. In addition, nursing staff should provide relevant psychological health education to patients to improve their post-traumatic growth.
Keywords: Maintenance hemodialysis, Patients, Post-traumatic growth, Root cause analysis
1. Introduction
For decades, researchers have focused on post-traumatic growth to achieve improvement for individuals and groups [1]. In 1996, Tedeschi and Calhoun [2] first proposed the concept of post-traumatic growth. They found that traumatic events, such as major diseases and disasters, bring a negative psychological experience to the affected person. These experiences render the patient unable to apply positive growth changes. Therefore, post-traumatic growth refers to the positive psychological change that is experienced by individuals after confronting traumatic events or situations in their lives. The occurrence of end-stage renal disease (ESRD), a chronic disease that eventually leads to uremia, has increased gradually [3], [4]. As a crucial alternative therapy in ESRD, maintenance hemodialysis is applied to sustain the lives of patients. Long-term hemodialysis is a highly stressful event that brings physiological and social influences to patients with ERSD [5]. Most studies on patients undergoing maintenance hemodialysis have currently focused on negative emotions, such as anxiety and depression; however, research on the positive psychological effect of maintenance hemodialysis is limited. Some scholars have suggested that increased attention should be given to such positive effect, i.e., post-traumatic growth in chronic diseases with long courses and poor prognoses, such as cancer [6]. Existing literature on post-traumatic growth mostly emphasizes cancer [7], [8], acquired immune deficiency syndrome (AIDS) [9], and myocardial infarction [10]. However, few studies were conducted on maintenance hemodialysis. This study investigates the current status of post-traumatic growth in China and explores the related influencing factors. Suggestions are provided for clinical nursing staff in taking appropriate measures to improve the post-traumatic growth level of patients.
2. Methods
2.1. Participants
This study adopted a cross-sectional descriptive design and was conducted from November to December in 2016. Through convenience sampling, 179 patients undergoing maintenance hemodialysis were investigated in a third-level grade A hospital in Tianjin, China. The inclusion criteria for patients are as follows: (1) diagnosed with chronic renal failure, (2) hemodialysis time of more than 3 months, (3) stable condition without mental illness or other serious body diseases, (4) alert consciousness, and (5) informed consent for participation in the survey. Patients who had difficulty in communicating were excluded from the study.
2.2. Instrument
The questionnaire used for data collection consisted of the following four parts: (1)socio-demographic characteristics, (2)Post-traumatic Growth Inventory (PTGI), (3)Perceived Social Support Scale (PSSS),and (4)Medical Coping Modes Questionnaire (MCMQ).
2.2.1. Socio-demographic characteristics
The socio-demographic characteristics of the participants included age, gender, marital status, education level, occupation, family income, living companions (alone or not), family relations, and health-payment types. The clinical information of the participants included dialysis age, frequency of dialysis, primary disease, self-care, acceptance of health education on dialysis from medical staff, and commencement of treatment with medicine.
2.2.2. PGTI
Using PGTI, we assessed the perceived positive changes of participants that resulted from chronic kidney failure [2]. The scale included 21 items that were grouped into five dimensions, i.e., relating to others (7 items), new possibilities (5 items), personal strength (4 items), spiritual change (2 items), and appreciation of life (3 items). Each item was assessed by a six-point Likert scale that ranged from 0 (“no change”) to 5 (“a great deal of change”). High scores reflected great perceived post-traumatic growth. This inventory was translated into Chinese by Wang et al. [11] and was validated with satisfactory reliability and validity. The Cronbach's α of the total inventory and the five dimensions ranged from 0.611 to 0.874. In the present study, the Cronbach's α coefficient of 20 maintenance hemodialysis cases in the pre-experimental stage was 0.852. This value indicated the reliability and validity of this inventory for application to maintenance hemodialysis patients. In this study, the Cronbach's α coefficient was 0.848.
2.2.3. PSSS
The PSSS was developed by Zimet and his friends in 1988 [12]. The Chinese version was eventually introduced and revised by Jiang Qianjin [13]. The revised scale contains three subscales with 12 items, including “support from the friends” (4 items), “support from the family” (4 items), and “support from the significant other” (4 items). Each item was assessed using a seven-point Likert scale ranging from 0 (“strongly disagree”) to 6 (“strongly agree”). The total scores range from 0 to 72, where a high score indicates a high degree of support. In the present study, the Cronbach's α coefficient in the total scale was 0.848. The Cronbach's α coefficients for “support from the friends,” “support from the family,” and “support from the significant other” were 0.898, 0.763, and 0.742, respectively.
2.2.4. MCMQ
H. Feifel [14] developed the MCMQ. The revised MCMQ [15] contained three dimensions, including confrontation (8 items), avoidance (7 items), and acceptance resignation (5 items). These three dimensions can represent the basic behavior of individuals threatened by a disease. Each item in the three dimensions was assessed using a four-point Likert scale. In particular, 8 items entailed reverse scoring. The score of each dimension directly reflects the coping style of patients. A high score indicates a high degree of using such coping strategy. In the present study, the Cronbach's α coefficients for confrontation, avoidance, and acceptance resignation were 0.814, 0.742, and 0.730, respectively.
2.3. Data collection
Data were collected through face-to-face questionnaire survey, which was conducted by researchers in a hospital hemodialysis clinic. The patients were informed of the study purpose beforehand. After acquiring informed consent, the researchers used unified instruction to guide the patients in answering the questionnaires. Any confusion or questions from the patients were addressed by researchers. Our study disseminated 183 questionnaires, and 179 replies were valid, giving a valid response rate of 98%.
2.4. Ethical consideration
Ethical approval was received from the ethics committee of the Tianjin First Center Hospital and the Tianjin University of Traditional Chinese Medicine.
2.5. Statistical analysis
Data were analyzed using SPSS Version 17.0 (Chicago, IL, USA). The statistical methods applied included descriptive statistics, t-test, one-way ANOVA, Pearson or Spearman correlational analysis, and multiple linear regression analysis. Data were presented as means ± standard deviations (SDs), and P < 0.05 was considered statistically significant.
3. Results
3.1. Characteristics of the participants
The questionnaires were answered by 179 participants aged 17–78 years (73.76 ± 8.212). The dialysis age ranged from 3 months to 218 months (45.18 ± 38.70), and the dialysis frequency was 2–4 times per week (2.99 ± 0.20). Additional details on the socio-demographic characteristics of the participants are listed in Table 1.
Table 1.
Demographic and clinical characteristic of the participants.
| Variable | n (%) |
|---|---|
| Gender | |
| Male | 96 (53.6) |
| Female | 83 (46.4) |
| Marital status | |
| Unmarried | 19 (10.6) |
| Married | 147 (82.10) |
| Divorced/Widowed | 13 (7.3) |
| Educational level | |
| Primary school or under | 19 (10.6) |
| Junior middle school | 68 (38.0) |
| Senior middle school | 61 (34.1) |
| Junior college or above | 31 (17.3) |
| Occupation | |
| Stable work | 30 (16.8) |
| Unstable work | 26 (14.5) |
| No work | 49 (27.4) |
| Retirement | 74 (41.3) |
| Family income (RMB/month) | |
| <1000 | 37 (20.7) |
| 1000–2500 | 72 (40.2) |
| 2501–5000 | 44 (24.6) |
| >5000 | 26 (14.5) |
| Living companions | |
| Living with family members | 170 (95.0) |
| Living alone | 9 (5.0) |
| Family relations | |
| Well | 170 (95.0) |
| General | 5 (2.8) |
| Poor | 4 (2.2) |
| Health-payment types | |
| Self-funded | 13 (7.3) |
| Medical insurance | 158 (88.3) |
| Other | 8 (4.5) |
| Primary disease | |
| Chronic glomerulonephritis | 118 (65.9) |
| Nephrotic syndrome | 3 (1.7) |
| Hypertensive nephropathy | 13 (7.3) |
| Diabetic nephropathy | 29 (16.2) |
| Polycystic kidney | 8 (4.5) |
| Other | 8 (4.5) |
| Received health education | |
| Yes | 170 (95.0) |
| No | 9 (5.0) |
| Self-care | |
| Complete self-help | 162 (90.5) |
| Partial self-help | 11 (6.1) |
| Totally dependent on others | 6 (3.4) |
| Treatment type | |
| Medicine | 134 (74.9) |
| Dialysis | 45 (25.1) |
3.2. Level of post-traumatic growth, social support, and coping style among the hemodialysis patients
The overall post-traumatic growth level score was 53.73 ± 16.45. After dividing each dimension score by the corresponding number of items, the mean score of each dimension is calculated and shown in Table 2. The total PSSS and MQMS scores for the three different dimensions are also presented in Table 2.
Table 2.
Scores of post-traumatic growth, social support, and coping styles.
| Item | Dimension | Mean ± SD |
|---|---|---|
| Post-traumatic Growth Inventory | Post-traumatic growth | 53.73 ± 16.45 |
| Personal strength | 3.53 ± 0.84 | |
| Appreciation of life | 2.91 ± 1.03 | |
| Relating to others | 2.79 ± 0.99 | |
| Spiritual change | 2.71 ± 1.48 | |
| New possibilities | 1.16 ± 1.14 | |
| Perceived Social Support Scale | Social support | 66.10 ± 14.05 |
| Medical Coping Modes Questionnaire | Confronting | 20.12 ± 4.94 |
| Avoidance | 13.75 ± 4.54 | |
| Acceptance–resignation | 9.39 ± 3.57 |
3.3. Univariate analysis of the impact on post-traumatic growth among the hemodialysis patients
The socio-demographic characteristics, social support, and coping style with maintenance hemodialysis were considered as independent variables, whereas the total score of post-traumatic growth was regarded as the dependent variable. We used an independent samples t-test, one-way ANOVA, and Spearman correlational analysis to perform a univariate analysis. Results showed that the post-traumatic growth level was not significantly affected by age (r = −0.030, P = 0.685), dialysis age (r = −0.055, P = 0.464), and dialysis frequency (r = 0.005, P = 0.943). By contrast, post-traumatic growth level was significantly changed by marital status, education level, occupation, family income, self-care, social support, and coping style (P < 0.05). These results are shown in Table 3, Table 4.
Table 3.
Comparison of level of post-traumatic growth for different variables.
| Item | Mean ± SD | F/t | P value |
|---|---|---|---|
| Gender | 0.139 | 0.890 | |
| Male | 53.90 ± 13.26 | ||
| Female | 53.54 ± 19.59 | ||
| Marital status | 3.066 | 0.049 | |
| Unmarried | 61.21 ± 13.58 | ||
| Married | 53.33 ± 16.47 | ||
| Divorced/Widowed | 47.31 ± 17.40 | ||
| Educational level | 10.376 | <0.001 | |
| Primary school or under | 36.16 ± 17.39 | ||
| Junior middle school | 55.26 ± 14.56 | ||
| Senior middle school | 54.30 ± 14.65 | ||
| Junior college or above | 60.03 ± 16.73 | ||
| Occupation | 7.173 | <0.001 | |
| Stable work | 59.13 ± 14.92 | ||
| Unstable work | 59.81 ± 15.42 | ||
| No work | 45.47 ± 16.69 | ||
| Retirement | 54.88 ± 15.33 | ||
| Family income (RMB/month) | 13.869 | <0.001 | |
| <1000 | 40.27 ± 14.79 | ||
| 1000–2500 | 57.76 ± 14.85 | ||
| 2501–5000 | 54.16 ± 14.88 | ||
| >5000 | 61.00 ± 15.33 | ||
| Living companions | 1.811 | 0.072 | |
| Living with family numbers | 54.24 ± 16.08 | ||
| Living alone | 44.11 ± 21.34 | ||
| Family relations | 0.258 | 0.773 | |
| Well | 53.94 ± 16.58 | ||
| General | 49.60 ± 16.44 | ||
| Bad | 50.25 ± 13.20 | ||
| Health-payment types | 1.059 | 0.349 | |
| Self-funded | 47.69 ± 17.23 | ||
| Medical insurance | 54.34 ± 16.35 | ||
| Other | 51.50 ± 17.25 | ||
| Primary disease | 0.389 | 0.856 | |
| Chronic glomerulonephritis | 53.68 ± 16.29 | ||
| Nephrotic syndrome | 50.67 ± 17.39 | ||
| Hypertensive nephropathy | 50.31 ± 15.93 | ||
| Diabetic nephropathy | 56.24 ± 14.77 | ||
| Polycystic kidney | 49.75 ± 26.80 | ||
| Other | 56.13 ± 16.09 | ||
| Received health education | 1.769 | 0.079 | |
| Yes | 54.23 ± 16.13 | ||
| No | 44.33 ± 20.54 | ||
| Self-care | 13.601 | <0.001 | |
| Complete self-help | 54.88 ± 15.43 | ||
| Partial self-help | 54.45 ± 18.29 | ||
| Totally dependent on others | 21.50 ± 3.83 | ||
| Treatment type | 0.784 | 0.434 | |
| Medicine | 54.29 ± 16.28 | ||
| Dialysis | 52.07 ± 17.04 |
Table 4.
Analysis of the correlation among post-traumatic growth, social support, and coping style in patients under maintenance hemodialysis.
| Item | r value | P value |
|---|---|---|
| Social support | 0.566 | <0.001 |
| Confronting | 0.555 | <0.001 |
| Avoidance | −0.307 | <0.001 |
| Acceptance–resignation | −0.394 | <0.001 |
3.4. Multiple linear regression analysis of patient post-traumatic growth level
A multiple linear stepwise regression model was used to determine the relationship between patient characteristics and post-traumatic growth level. Statistically significant variables were considered as independent variables, whereas the total score for post-traumatic growth was regarded as the dependent variable. The level of the variable in the equation was an alpha of 0.05, and the elimination level was 0.10. Based on the requirement of independent variable in multiple linear regression analysis, the ordered categorical variables were transformed into numerical data. The detailed method is shown in Table 5. Regression analysis revealed that factors, such as marital status, family income, social support, and confronting strategy, were included in the regression equation and accounted for 41.4% of the variance. The results are listed in Table 6.
Table 5.
Independent variable assignment styles.
| Independent variable | Assignment |
|---|---|
| Marital status | Married (Z1 = 0, Z2 = 0); Unmarried (Z1 = 1, Z2 = 0); Divorced/Widowed (Z1 = 0, Z2 = 1) |
| Educational level | Primary school or under = 1; Junior middle school = 2; Senior middle school = 3; Junior college or above = 4 |
| Occupation | No work/Retirement = 0; Stable work/Unstable work = 1 |
| Family income | <1000 = 1; 1000 to 2500 = 2; 2501 to 5000 = 3; >5000 = 4 |
| Self-care | Totally dependent on others = 1; Partial self-help = 2; Complete self-help = 3 |
| Social support | Input the original value |
| Confronting | Input the original value |
| Avoidance | Input the original value |
| Acceptance–resignation | Input the original value |
Table 6.
Multiple linear regression analysis of post-traumatic growth level.
| Variable | B | SE | b | t | P |
|---|---|---|---|---|---|
| Model 1 constant | −0.176 | 4.976 | – | −0.035 | 0.972 |
| Confronting | 1.169 | 0.232 | 0.351 | 5.044 | <0.001 |
| Social support | 0.337 | 0.081 | 0.287 | 4.180 | <0.001 |
| Marital status | 10.630 | 3.096 | 0.200 | 3.434 | 0.001 |
| Family income | 3.012 | 1.035 | 0.177 | 2.910 | 0.004 |
Note:R2 = 0.427, Adj. R2 = 0.414, F = 32.474, P < 0.001.
4. Discussion
4.1. Post-traumatic growth status in patients undergoing maintenance hemodialysis
The mean post-traumatic growth level score was 53.73 ± 16.45, which indicated the following points. First, in addition to negative emotions, patients undergoing maintenance hemodialysis attained a positive psychological change, such as post-traumatic growth. This result was consistent with Yorulmaz's study [16]. Second, the post-traumatic growth status in patients undergoing maintenance hemodialysis was at the lower–middle level, which urgently requires further improvement. Analysis of the five dimensions of post-traumatic growth showed that the score for personal strength was the highest, whereas that of new possibilities was the lowest. Considering individual differences, the post-traumatic growth levels may have slightly differed for the patients. Clinical staff should guide patients toward positive emotions to promote the latter's physical and mental health and post-traumatic growth.
4.2. Factors influencing post-traumatic growth in patients under maintenance hemodialysis
This study explored that marital status was one of the factors contributing to post-traumatic growth in patients under maintenance hemodialysis. Unmarried patients had higher level of post-traumatic growth than those who were married, divorced and widowed. Unmarred patients were generally young, with less burden of life, less social experience, and higher education level; hence, they had strong confidence to fight against their disease. This finding explains their positive and high post-traumatic growth level. However, due to some differences in subjects, gender, and other demographic characteristics, the result was inconsistent with previous study on breast cancer [17].
In the present work, high family income led to high post-traumatic growth level, which was consistent with Wang and Wu's study [18], [19]. In China, patients with end-stage renal disease (ESRD) must pay expensive bills for dialysis, which must be conducted frequently for up to 2 to 4 times a week. Although the government could reimburse a portion of the medical expenses, the huge dialysis cost still puts a heavy economic burden for a normal family. In this case, patients have difficulty experiencing positive change. Therefore, medical staff should focus on the psychological state of patients who are in poor economic condition and should conduct positive psychological intervention to promote their post-traumatic growth.
Social support is the spiritual and material support patients gain from their social circles by contacting with their family, relatives, and friends. The mean social support score was 66.10 ± 14.05, which revealed that patients with maintenance hemodialysis received middle-level social support. Multiple linear regression analysis showed that social support was an important influencing factor for post-traumatic growth, which is consistent with Hassonohayon's study [20]. Good social support contributes to the physical and mental growth of an individual and improves the living quality of hemodialysis patients [21]. Support, either economic or spiritual, from family, friends, relatives, and others will give patients huge psychological comfort, thereby positively promoting their post-traumatic growth. Medical staff should evaluate the social support system of patients, help them actively seek social resources, and make full use of their social support to promote the level of post-traumatic growth.
Lastly, coping style refers to different strategies that individuals decide to adopt when facing various dreadful life events. Different coping strategies have different effects on disease development. The three main coping styles are confronting, avoidance, and acceptance–resignation. Confronting strategy is positive, whereas the other two strategies are negative [22]. Correlation analysis revealed that post-traumatic growth level was positively related to the confronting coping mode and negatively correlated to the avoidance and acceptance–resignation coping modes. In the present study, multiple linear regression analysis also showed that the confronting coping mode significantly influenced the post-traumatic growth. The confronting coping mode indicates that patients pay close attention to disease, seek help, and support in a positive way [23]. This coping mode relieves anxiety, depression, and other negative emotions and promotes individual growth and physical and mental health development. Medical staff should observe psychological changes in patients and provide them with suitable psychological counseling to introduce a positive approach of coping with disease.
5. Conclusions
The results of multiple regression analysis showed that confronting, social support, marital status, and family income should be entered into the regression equation. The findings indicated the importance of these factors in promoting post-traumatic growth. The status of post-traumatic growth of patients with maintenance hemodialysis was at the lower–middle level, suggesting a large room for improvement. This conclusion on the post-traumatic growth and its relative influencing factors for patients under maintenance hemodialysis provides reasonable and practical psychological intervention measures for medical staff to promote physical and mental health development and improve the post-traumatic growth level of the patients.
6. Study limitation
The major study limitation was that the evaluated factors only accounted for 41.4% of the total number of factors influencing post-traumatic growth. Another limitation was that the cross-sectional design of this study limited the prediction of a causal relationship among variables. Future studies with large sample sizes can focus on exploring other possible underlying factors that can affect the post-traumatic growth level in patients under maintenance hemodialysis.
Conflict of interest
The authors declare no conflict of interest.
Footnotes
Peer review under responsibility of Chinese Nursing Association.
Supplementary data related to this article can be found at https://doi.org/10.1016/j.ijnss.2017.09.008.
Contributor Information
Chuyun Cui, Email: 1213242768@qq.com.
Changde Jin, Email: jcd1886@sina.cn.
Appendix A. Supplementary data
The following is the supplementary data related to this article:
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