Stressors and coping strategies of year-old hemodialysis patients

Collegian (2014) 21, 185 192 Available online at www.sciencedirect.com j ourna l h omepage: www.elsevier.com/l ocate/coll Stressors and coping strategies of 20 45-year-old hemodialysis patients Hsin-Ya Tu, RN, BSN a, Jung-Hua Shao, RN, PhD b, Fang-Ju Wu, RN, BSN c, Su-Hui Chen, RN, PhD d, Yeu-Hui Chuang, RN, PhD, MSN, MS e, a Hemodialysis Center, St. Martin De Porres Hospital, Taiwan b School of Nursing, College of Medicine, Chang Gung University, Taiwan c Department of Nursing, Buddhist Tzu Chi Dalin General Hospital, Taiwan d Department of Nursing, Chang Gung University of Science and Technology, Taiwan e School of Nursing, College of Nursing, Taipei Medical University, Taiwan Received 12 March 2012; received in revised form 29 January 2013; accepted 28 February 2013 KEYWORDS Coping strategies; Early adult; Hemodialysis; Stress; Stressors Summary Objectives: This study attempted to describe stressors, levels of stress, and coping strategies of 20 45-year-old Taiwanese patients undergoing chronic hemodialysis. Methods: A cross-sectional descriptive design was used. A convenience sample of 88 patients with a mean age of 38.55 years was recruited at six dialysis centers in southern Taiwan. Data were collected using the Hemodialysis Stressor Scale and the Jalowiec Coping Scale. Results: The results show that this group of patients had higher levels of stress than those reported in previous studies. The three most frequently reported stressors were limitations of liquids, limitations of food, and fatigue. The two most frequent coping methods were trying to find meaning in the situation and trying out different ways of solving problems to see which works the best. These patients had more physiological stressors than psychosocial stressors and used more problem-oriented coping strategies than affective-oriented ones. Additionally, the longer the patients had received hemodialysis, the lower stress level they had, and patients with jobs, with partners, or with children used significantly more coping strategies than those without jobs, partners, or children. Gender differences were not found in the total stress level or coping strategies of these patients, except that female patients had greater psychosocial stressors than male patients. Corresponding author at: School of Nursing, College of Nursing, Taipei Medical University, 250, Wu-Xing Street, Taipei 110, Taiwan. Tel.: +886 2 27361661x6328; fax: +886 223772842. E-mail addresses: yeuhui@tmu.edu.tw, yeuhui@gmail.com (Y.-H. Chuang). 1322-7696/$ see front matter 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.colegn.2013.02.003

186 H.-Y. Tu et al. Conclusions: The 20 45-year-old hemodialysis patients experienced considerable levels of stress and had a unique ranking order of stressors and coping strategies. These findings will provide healthcare professionals with detailed information to identify priority areas for future intervention development. 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd. Background In Taiwan, the rate of new dialysis cases in 2009 was approximately 347 per million population, and the prevalence rate of end-stage renal disease (ESRD) was 2447 per million people (US Renal Data System, 2011). This prevalence rate was the highest in the world. The numbers of dialysis patients of different ages have grown in recent decades, and older patients ( 65 years) exhibited the greatest increases (Yang, Hwang, & Taiwan Society of Nephrology, 2008). However, 5706 (13.7%) dialysis patients were 20 44 years old in Taiwan in 2005 (Huang & Taiwan Society of Nephrology, 2008). Before requiring renal transplantation, ESRD patients depend upon dialysis, either hemodialysis or peritoneal dialysis, to sustain their lives. Around 90% of patients with ESRD receive hemodialysis which is currently the primary treatment in Taiwan (Bureau of National Health Insurance, 2012). According to previous studies, patients undergoing hemodialysis experience both physiological and psychosocial stressors. Frequently reported physiological stressors include itching and fatigue (Logan, Pelletier-Hibbert, & Hodgins, 2006; Mok & Tam, 2001; Tsay, Lee, & Lee, 2005; Yeh & Chou, 2007). Frequently reported psychosocial stressors include limitations of fluids, limitations of food, sleep disturbances, uncertainties about the future, vacation limitations, activity limitations, decreased social life, limits on time and place of work, length of dialysis treatment, and cost factors (Cinar, Barlas, & Alpar, 2009; Logan et al., 2006; Mok & Tam, 2001; Tsay et al., 2005). Studies also found that patients undergoing hemodialysis experience more physiological stress than psychosocial stress (Lok, 1996; Mok & Tam, 2001). When facing external or internal conflicts or demands, individuals make cognitive and behavioral efforts to confront stressful situations. Several studies demonstrated that patients undergoing hemodialysis experience considerable stress, and they use various strategies to face their stressful situations (Logan et al., 2006; Mok & Tam, 2001; Welch & Austin, 2001; Yeh, Huang, & Chuo, 2008). Their methods of adapting to stress include affective-oriented and problem-oriented coping strategies. Affective-oriented coping strategies involve dealing with the distressing emotions caused by stressful situations, while problem-oriented coping strategies involve handling the stressful situation itself (Jalowiec, Murphy, & Powers, 1984). Previous studies indicated that hemodialysis patients use more problemoriented coping strategies than affective-oriented ones (Mok & Tam, 2001; Welch & Austin, 2001). However, one recent study (Yeh & Chou, 2007) found that Taiwanese hemodialysis patients used more affective-oriented methods than problem-oriented strategies to adapt to their sources of stress. The majority of studies involved dialysis patients of all age groups, resulting in an average participant age of over 50 years, with an age range of 15 95 years (Cinar et al., 2009; Ersoy-Kart & Guldu, 2005; Takaki et al., 2003; Udaya Kumar, Amalraj, Soundarajan, & Abraham, 2003; Welch & Austin, 2001; Yeh et al., 2008). However, one study tried to identify the types of stressors experienced by older hospitalized hemodialysis patients ( 65 years old) (Logan et al., 2006). Unfortunately, few studies have examined the stressors and coping strategies of 20 45-year-old hemodialysis patients. In this age group, developmental tasks focus on developing the ability to share intimacy, establishing a family, finding a job, and making career decisions. They are also major contributors to society. In addition, 20 45-year-old adults are the economic providers for their families, so their financial situations may be at risk after they acquire their illnesses. Accordingly, when they face a long-term chronic illness such as ESRD and need to routinely receive dialysis to survive, their stressors and coping mechanisms may differ from those of individuals in other age groups. Identifying stressors and copying strategies may inform areas for future interventions to support this vulnerable population. Therefore, the purpose of this study was to describe the stressors and levels of stress experienced by 20 45-year-old hemodialysis patients and the coping strategies that they use to deal with stressful situations. Methods Design This was a cross-sectional, descriptive survey study. Sample and data collection A convenience sample was recruited from four dialysis centers in local hospitals and two freestanding dialysis centers in southern Taiwan. The inclusion criteria were as follows: the participants had to (1) be aged between 20 and 45 years old; (2) have received hemodialysis for at least 1 month; (3) have no acute illness during the survey; (4) be alert and oriented to time, place, and person; and (5) be able to understand or read Chinese. Six participating centers provided the name lists of eligible patients. The head nurses of the dialysis centers approached the eligible patients and introduced the researchers to them. Then, the researchers explained the purpose of the study and procedures to them. Questionnaires were given to participants who agreed to participate in the study after signing an informed consent form. The completed questionnaires were placed by patients in a sealed box located beside the door of the dialysis centers. Two research assistants emptied the box at the end of the evening shift every day during the data-collection period. Of 991 ESRD patients in the six dialysis centers, 109 met the inclusion criteria and 105 consented to participate.

Stressors and coping strategies hemodialysis patients 187 Accordingly, 105 questionnaires were distributed, but only 88 were returned, for a response rate of 83.8%. Measurement The questionnaire had three parts, including demographic and characteristic information, the Hemodialysis Stressor Scale (HSS), and the Jalowiec Coping Scale (JCS). The 29-item HSS, developed by Baldree, Murphy, and Powers (1982) and translated into Chinese by Mok and Tam (2001), was used to understand the incidence and severity of physiological and psychosocial stressors experienced by patients undergoing hemodialysis. It consists of two subscales: a 23-item psychosocial subscale and a 6- item physiological subscale. A 4-point Likert scale was used (0 = not at all, 1 = slightly, 2 = moderately, and 3 = a great deal). Summing the rating scores of all items resulted in a total stressor scale score that range between 0 and 87. A higher score indicates a greater degree of stress. The averaged summative score of each item was also computed to examine the intensity of stress for each item of the scale. It was calculated by the summed scores of the specific item divided by the number of the participants in this scale. The range of scores was 0 3, with a higher score indicating a higher intensity of stress. The scale had good internal consistency. Cronbach s alpha was 0.89, and the test-retest reliability correlation was 0.71 (Baldree et al., 1982). In the present study, Cronbach s alpha reliability coefficient was 0.90 for the total scale, 0.89 for the psychosocial subscale, and 0.69 for the physiological subscale. The JCS, developed by Jalowiec and Powers (1981) and translated into Chinese by Mok and Tam (2001), was employed to measure coping methods used to handle stressful situations by hemodialysis patients. It lists 40 coping behaviors (25 affective-oriented and 15 problem-oriented behaviors). A 4-point Likert scale was used (0 = never used, 1 = seldom used, 2 = sometimes used, and 3 = often used) with a range between 0 and 120. A higher score indicates a greater level of coping strategies used. The averaged summative score of each item was also computed to examine the level of use of coping strategies for each item of the scale. This was calculated by the summed scores of the specific item divided by the number of the participants in this scale. The range of scores was 0 3, with a higher score indicating a higher level of coping use. The scale has good content validity and internal reliability. The internal consistency reliability coefficient was shown to be 0.86 (Gurklis & Menke, 1988), and the test-retest reliability of the Chinese instrument was 0.87 (Mok & Tam, 2001). In the present study, respective Cronbach s alpha values of the total scale, the affective-oriented subscale, and the problem-oriented subscale were 0.93, 0.85, and 0.93. Data analysis Data were analyzed using SPSS version 13.0 (SPSS Inc., Chicago, IL). A descriptive analysis was performed for the demographic and characteristic data, the level of stress, and the use of coping strategies by computing the mean (M), standard deviation (SD), and percentage. Differences between nominal variables in the demographic and characteristic data, levels of stress, and coping strategies were calculated using a t-test. Correlation coefficients were examined between continuous variables in the demographic and characteristic data, levels of stress, and coping strategies. Research ethics This study was approved by the research ethics committee of one affiliated university. All participants were informed of the study s purpose and procedures and their rights and provided written informed consent. Anonymity was ensured for all participants. Results Characteristics of participants The convenience sample consisted of 88 patients with an age range of 23 45 years (M = 38.55, SD = 5.55). Among participants, 48 (54.5%) were males and 40 (45.5%) were females. Fifty-five (62.5%) participants had partners (including married ones), and fifty-four (61.4%) had children. Thirty-seven (42%) subjects had completed a college or university education. Taoism (37.5%) and Buddhism (37.4%) were the major religious affiliations. Fifty-nine participants (67%) had jobs. The length of time receiving hemodialysis was 3.41 years (SD = 2.18) (Table 1). Stress and stressors The mean HSS score was 42.2 (SD = 13.84), with a range of 8 73. The average HSS score of each item was 1.46, with a range of 0.60 2.23. The ten most frequently reported stressors among the study participants are listed in Table 2. Limitations of liquids, limitations of food, and fatigue were the top three stressors. The three least frequently reported stressors were a decreased ability to procreate, frequent hospital admissions, and limitations to styles of clothing. Among the study participants, the average physiological stressor score (M = 1.54, SD = 0.522) was greater than the average psychosocial stressor score (M = 1.43, SD = 0.512). Coping strategies The mean coping scale score was 58.43 (SD = 18.58), with a range of 16 87. The average coping scale score of each item was 1.46, with a range of 0.57 1.88. The ten most frequently used coping methods were: trying to find meaning in the situation; trying different ways of solving the problem to see which works the best; setting specific goals to help solve the problem; talking the problem over with someone who has been in the same type of situation; praying/trusting in God; laughing it off/figuring that things could be worse; actively trying to change the situation; thinking through different ways to handle the situation; going to sleep/figuring things will look better in the morning; and accepting the situation as it is (Table 3). The least used coping methods among these patients were: drinking alcoholic

188 H.-Y. Tu et al. Table 1 Characteristics of participants (n = 88). Characteristic Mean SD Number Percentage Age (years) 38.55 5.55 Gender Male 48 54.5 Female 40 45.5 Marital status With a partner 55 62.5 Without a 33 37.5 partner Religious affiliation None 14 15.9 Buddhism 32 36.4 Taoism 36 40.9 Catholic 4 4.5 Non-Catholic 2 2.3 Christian Educational level Primary school 4 4.5 Junior high 26 23.9 Senior high 21 29.5 College (and 37 42.1 above) Working status Yes 59 67 No 29 33 Children Yes 54 61.4 None 34 38.6 Length of hemodialysis (years) 3.41 2.18 beverages; getting mad and cursing/swearing; wanting to be alone; and crying/getting depressed. These hemodialysis patients used more problem-oriented coping methods (M = 1.72, SD = 0.656) than affective-oriented coping methods (M = 1.31, SD = 0.409). Table 2 Rank ordering of the ten most frequently stressors in 20 45-year-old hemodialysis patients (n = 88). Rank Stressor (class) Mean SD 1 Limitations of fluids (PS) 2.23 0.931 2 Limitations of food (PS) 2.11 0.928 2 Fatigue (P) 2.11 0.734 3 Itching (P) 1.88 0.980 3 Sleep disturbances (PS) 1.88 0.980 4 Interference in job (PS) 1.78 0.864 5 Decrease social life (PS) 1.76 0.871 6 Length of treatment (PS) 1.72 0.742 7 Changes in family 1.69 1.032 responsibilities (PS) 8 Limitations on physical activities (PS) 1.65 0.817 Table 3 Rank ordering of the ten most frequently coping strategies in 20 45-year-old hemodialysis patients (n = 88). Rank Coping method (class) Mean SD 1 Try to find meaning in 1.88 0.920 the situation (P) 2 Try out different ways of 1.85 0.977 solving the problem to see which works the best (P) 3 Set specific goals to help 1.83 0.874 solve the problem (P) 3 Talk the problem over 1.83 0.900 with someone who has been in the same type of situation (P) 3 Pray; trust in God (A) 1.83 0.950 4 Laugh it off; figure that 1.80 1.019 things could be worse (A) 5 Actively try to change 1.78 0.850 the situation (P) 5 Think through different 1.78 0.976 ways to handle the situation (P) 6 Go to sleep; figure things 1.76 0.667 will look better in the morning (A) 7 Accept the situation as it is (P) 1.74 0.837 Associations among stresses, coping strategies, and patient characteristics Total stressors (t = 1.133, p = 0.263), physiological stressors (t = 1.879, p = 0.064), and psychosocial stressors (t = 1.772, p = 0.084) did not statistically differ between participants with and without jobs. In addition, patients with children (t = 3.481, p = 0.001) or partners (t = 2.903, p = 0.005) had greater physiological stressors than those who did not. Female patients had more psychosocial stressors than did male patients (t = 2.006, p = 0.049). However, physiological stressors, total stressors, coping strategies, and types (affective-oriented or problem-oriented types) of coping strategies did not differ between genders. Participants with children (t = 2.639, p = 0.01), partners (t = 2.466, p = 0.016), or jobs (t = 3.436, p = 0.001) used more coping methods to handle stressful situations than those who did not (Table 4). Patients who had undergone hemodialysis for a long period of time experienced fewer stressors than those who had undergone a shorter treatment period (r = 0.233, p = 0.029). However, there was no relationship between the coping methods used and the length of hemodialysis (r = 0.054, p = 0.619). Discussion Compared to a previous study conducted by Logan et al. (2006) who used the same HSS rating scale and

Stressors and coping strategies hemodialysis patients 189 Table 4 Differences in patients gender, jobs, partners, and children in terms of total stressors, physiological stressors, psychosocial stressors, coping strategies, affectiveoriented coping strategies, and problem-oriented coping strategies (n = 88). Problem-oriented coping strategies Coping strategies Affective-oriented coping strategies Psychosocial stressors Variable Total stressors Physiological stressors Mean (t-value) Mean (t-value) Mean (t-value) Mean (t-value) Mean (t-value) Mean (t-value) Gender Female 45.2 ( 1.835) 9.5 ( 0.582) 35.7 ( 2.006) * 59.7 ( 0.559) 33.4 ( 0.580) 26.3 ( 0.453) Male 39.7 9.1 30.6 57.4 32.1 25.3 Employment status With a job 40.9 ( 1.133) 9.7 (1.879) 31.2 ( 1.772) 62.9 (3.436) ** 34.4 (2.302) * 28.5 (4.116) *** Without a job 44.9 8.4 36.5 49.3 29.2 20.1 Partners With a partner 44.3 ( 1.835) 9.9 ( 2.903) ** 34.3 ( 1.393) 62.4 ( 2.466) * 34.3 ( 1.905) 27.8 ( 2.809) ** Without a partner 38.8 8.1 30.7 52.3 30.1 22.2 Children With children 44.3 ( 1.777) 10.1 ( 3.481) ** 34.1 ( 1.194) 62.4 ( 2.639) * 34.3 ( 1.842) 28.2 ( 3.232) ** Without children 38.9 7.9 31.1 52.1 30.2 21.9 * p < 0.05. ** p < 0.01. *** p < 0.001. statistical analysis with the present study, the 20 45-yearold hemodialysis patients in this study experienced greater stress than patients aged 65 years and older (M = 0.95, range: 0.23 2.20). In addition, the average HSS score in this study was also higher than the stress level score found in other studies that used the same HSS rating scale to measure stressors of patients undergoing hemodialysis without considering age differences (Chou, Yeh, & Huang, 2005; Mok & Tam, 2001). This finding indicates that 20 45-year-old patients have greater stress levels than older patients or the general population in previous studies. These early-adult patients are fulfilling their social obligations and are the breadwinners in their families. Particularly, occupational, marital, and societal aspects are the highlights of early adults personal lives. Consequently, the progression of the illness and having a machine-dependent life may significantly influence their daily lifestyle and indirectly affect their families. This chronic disease and long-term treatment deeply impact these adult patients and might cause increased stress levels. In this study, 20 45-year-old patients had greater physiological stressors than psychosocial stressors. Mok and Tam (2001) found similar results in a general population of patients in Hong Kong. These patients need strength and energy to work and care for their families, so they may have strong feelings about their physical discomfort and be more aware of physical changes. In addition, during this developmental stage, 20 45-year-old patients are finding partners and sharing intimacy, so their physical appearance and strength may be more important and become bothersome during treatment. Contrarily, one study indicated that the level of physiological stress was similar to the level of psychosocial stress found in hemodialysis patients at the ages of 18 65 (Cristovao, 1999). Limitations on liquids and food were the top two stressors among these patients. This finding is consistent with the findings of Chou (2003) and Mok and Tam (2001), who argued that Chinese people and culture emphasize the importance of food and meals, so patients are strongly impacted by such limitations. Celebrations, social gatherings, business dealings, and romance may all involve food. Even worse, the majority of 20 45-year-old patients had jobs, so they stayed outside of the home for long periods of time during their working hours and frequently dined out for convenience. Restrictions on food and drink may have limited their choice of meals, caused inconvenience, and interfered with social activities. In Taiwan, soup and tea drinks are very popular in restaurants, and tea drinks are commonly sold in ubiquitous tea shops year-round. The young generation is used to having drinks for breakfast, on breaks, and during meals. All of these factors pose real challenges for 20 45-year-old patients undergoing hemodialysis. Furthermore, vacation limitations was ranked as the number one stressor in Muslim patients (Cinar et al., 2009) and older patients (Logan et al., 2006). Fluid and food limitations were respectively ranked as the number 9 and 14 stressors in Cinar et al. s study and number 4 and >10 in Logan et al. s study. Those finding indicate that culture and age might account for these differences in stressor rankings. A comparison of the rank ordering of the most frequently reported stressors from other studies is shown in Table 5.

190 H.-Y. Tu et al. Table 5 Comparisons of rank ordering of the five most frequently reported stressors (of the HSS scale) experienced by hemodialysis patients between the present study and other previous studies. Chou (2003) Cinar et al. (2009) Studies Present study Logan et al. (2006) Mok and Tam (2001) (Sample size) (n = 88) (n = 50) (n = 50) (n = 2735) (n = 224) Age group 20 45 years old 65 years old All ages All ages All ages, M = 38.55 SD = 5.55 M = 76.4, SD = 6.43 (Nil) M = 57.34, SD = 14.12 M = 51.54 SD = 14.03 Vacation limitations Limitations of liquids Rank 1 Limitations of fluids Vacation limitations Limitations of fluids Fatigue Fatigue Limitations of food Arterial-venous stick Rank 2 Limitations of food Fatigue Rank 3 Itching Decreased social life Itching Fatigue Uncertainty about the future Sleep disturbances Rank 4 Interference with job Limitations of fluids Fatigue Limitations of food Limitations of physical activities Life dependent on an HD machine Cost factors Limitations of physical activities Rank 5 Decreased social life Limitations of physical activities Job interference was ranked fourth among this population, which is unique compared to results of other studies. The illness and treatments affected the lives of these adult patients, and accordingly, also their jobs. Regarding the items that were found to be the least stressful in this study, decreased ability to procreate was of the least concern to participants. As over 60% of patients in this study had children, this problem might not have been a serious stressor, which is consistent with the findings of Chou (2003). The 20 45-year-old patients who were on hemodialysis for longer periods of time had fewer stressors in this study. These patients may have become accustomed to their treatments and may perceive hemodialysis as a routine activity, so the feelings of stress decreased over time. In addition, these patients may have found appropriate coping strategies to adapt to their treatments. Therefore, this may imply that more attention should be paid to the feelings and concerns of patients who are new to hemodialysis; they should be provided with detailed and accurate information and resources regarding hemodialysis and be encouraged to attend support groups. Yeh and Chou (2007) reported that as the length of time on hemodialysis increased, the role of ambiguity-related stress and fluid and food limitationrelated stress experienced by patients decreased. However, this result contrasts with findings of Lok (1996). In his study, as the length of time that patients received hemodialysis increased, the total stressors the patients experienced also increased. In addition, the present study also found that patients with children or partners may experience more physiological stressors and use more coping strategies to deal with their problems than those without children or partners. When patients are parents or partners, they have greater social responsibilities and have more family roles in their daily lives, so they have more stressors and try more strategies to confront the stress. Furthermore, female 20 45-year-old patients had more psychosocial stress than did male patients in this study. Work-family conflicts exist among Taiwanese working women (Luo, Kao, Chang, Wu, & Cooper, 2008). Female patients need to meet demands of multiple responsibilities and play many roles at the same time including daughter, mother, employer, caregiver, and patient. In a Taiwanese cultural context, women carry out most of the family responsibilities from child care, elderly care, to household tasks. Taiwanese society expects women to do all of the housework regardless of whether they are employed or not. Female patients have more invisible obligations of household tasks and taking care of their families than male patients, so they might have experienced more psychosocial stressors than male patients in this study. In Yeh and Chou s study (2007), female patients had more stress regarding physical symptoms and blood vessel problems than did male patients, but male patients had more stress regarding reproductive problems than did female patients. They also found that male patients were more likely to use coping methods such as smoking, overeating, and abusing alcohol than were female patients. In another study, male patients used more problem-oriented coping strategies than did female patients (Ersoy-Kart & Guldu, 2005). However, in this study, male and female patients total stress levels, physiological stress

Stressors and coping strategies hemodialysis patients 191 levels, use of coping strategies, use of problem-oriented coping strategies, and use of affective-oriented coping strategies did not differ. This finding indicates that male and female 20 45-year-old patients undergoing hemodialysis experienced similar levels of total stress and used similar coping strategies. Various coping strategies were used by these early-adult patients. This study also found that 20 45-year-old patients used more problem-oriented coping methods to face stress than affective-oriented ones. Earlier studies have contradictory results for this aspect. Findings of this study were similar to and compatible with findings of two other studies (Cristovao, 1999; Mok & Tam, 2001). Conversely, Yeh and Chou (2007) found that patients undergoing hemodialysis seldom used problem-oriented coping strategies to handle stressful situations in Taiwan. Ersoy-Kart and Guldu (2005) noted that Turkish patients undergoing hemodialysis used more emotion-oriented coping methods to cope with stressful situations than did healthy persons. Patients in this study were young and well-educated, so they were prone to solving their problems and facing their challenges. Nevertheless, the presence of praying and trusting in God in the top three coping mechanisms seems to support cultural notions regarding the role of religion in the lives of Taiwanese 20 45-year-old hemodialysis patients. Consistent with the findings of Cinar et al. (2009), Muslim patients undergoing hemodialysis used religion to cope with stressful situations. Young patients facing a chronic illness might experience feelings of frustration, helplessness, and hopelessness and, particularly, they need to have regular hemodialysis for the rest of their lives. Praying and trusting in God might give them peace of mind and hope. They might also obtain support from frequent religious activities or gatherings. Two studies revealed that patients with ESRD (Ramirez et al., 2012) and patients undergoing hemodialysis (Lucchetti, de Almeida, & Lucchetti, 2012) had a better quality of life when they had positive religious coping or a high degree of religious use. Religious beliefs might play an important role in assisting these early-adult patients get through the long hemodialysis-dependent journey. Limitations of the study The limitations of this study were the use of a crosssectional design and a convenience sample. A longitudinal design and random sampling can be used in future studies. In addition, stressors and coping strategies may differ for 20 45-year-old patients undergoing hemodialysis from other countries and cultures. The generalizability of the findings is limited to 20 45-year-old patients undergoing hemodialysis in Taiwan. However, to the best of the authors knowledge, this study is the first to describe stressors, stress levels, and coping strategies of 20 45-year-old hemodialysis patients internationally. Indeed, it provides valuable information for healthcare professionals understanding these patients stress and coping methods. Conclusions The 20 45-year-old hemodialysis patients experience considerable levels of stress and have a different ranking order of stressors than patients in other age groups. Healthcare professionals need to pay more attention to these patients, especially those patients without jobs, children, or partners, and female patients. Several nursing interventions might be considered including regular screening of stress levels of early-adult patients undergoing hemodialysis, providing information about support groups and encouraging them to attend, and introducing persons who have longer hemodialysis experience to new patients in order to share their experiences and support each other. Moreover, the top ranking stressors and coping strategies found in this study can be used to identify priority areas for future practice and studies. It is hoped the specific, tailored care plans for these 20 45-year-old patients undergoing hemodialysis can be developed in the future. Conflicts of interest statement The authors declare that there are no conflicts of interest. Acknowledgements The authors would like to thank Dr. Esther Mok and Dr. Bonnie Tam for their permission to use the Chinese versions of the HSS and JCS scales. 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