Work-Related Emotional Stressors and

Coping Strategies that Affect the Well-Being

Of Nurses Working in Hemodialysis Units

Continuing Nursing
Education

Vicki E. Ashker
Barbara Penprase
Ali Salman
he nursing profession is often
perceived to be a physical,
emotional, and often stressful
line of work. Yet, nurses are
challenged by both professional and
public expectations to demonstrate
compassion for patients and families.
Nurses working in hemodialysis units
are exposed to unusually high intensity stress and stressors in the care of
the chronically ill renal patient receiving hemodialysis, which can impact
compassion (Chayu & Kreitler, 2011).
As the level of stress increases, the
interaction between individuals and
their environment is strained, which
affects their overall well-being (Ross,
Jones, Callaghan, Eales, & Ashman,
2009). This is very notable in caring
for chronically ill patients, such as
those on hemodialysis.
Significant research has been
published regarding the well-being
and stress of healthcare employees
(Ross et al., 2009); however, few studies focus on the emotional well-being
and stress of staff working in
hemodialysis units. Flynn, ThomasHawkins, and Clark (2009) cite that
the demands placed upon nurses
working in hemodialysis units can
lessen their emotional and physical
resources, thereby causing stress; yet,

Vicki E. Ashker, DNP, MSA, BSN, CCRN,

RN, is Director of Nursing Practice, Quality and
Innovation, Garden City, MI. She may be contacted
directly via e-mail at ashker.vicki@att.net
Barbara Penprase, PhD, RN, CNOR, is an
Associate Professor, Oakland University, Rochester,
MI, and Executive Director, Oakland University
Riverview Institute, Detroit, MI.
Ali Salman, MD, PhD, ND, RN, is an Associate
Professor, Brandon University, Manitoba, Canada.
Statement of Disclosure: The authors reported no
actual or potential conflict of interest in relation to
this continuing nursing education activity.

Nephrology Nursing Journal

Copyright 2012 American Nephrology Nurses Association

Ashker, V.E., Penprase, B., & Salman, A. (2012). Work-related emotional stressors and
coping strategies that affect the well-being of nurses working in hemodialysis units.
Nephrology Nursing Journal, 39(3), 231-236.
The purpose of this pilot study was to identify and describe work-related emotional stressors that impact the well-being of nurses working in hemodialysis units and to identify
their coping techniques. The literature shows that constant exposure to stressors induces
emotional conflict and ambiguity, which results in the use of coping techniques to balance well-being. Nineteen participants from six hemodialysis centers completed the Ways
of Coping Questionnaire, a 66-item survey based on a four-point scale. Mean and standard deviations were conducted on eight coping techniques. Findings revealed that participants most frequently used ways of coping were planful problem solving (M = 17.66),
followed by self-controlling (M = 15.29), positive appraisal (M=14.93), and seeking
social support (M = 14.49) when dealing with work-related stressors.
Key Words: Work-related emotional stressors, hemodialysis unit, nurse burnout,
problem-solving, self-control, positive appraisal, social support.

Goal
To provide an overview of work-related emotional stressors that impact the well-being of
nurses working in hemodialysis units and to identify their coping techniques.
Objectives
1. Describe the work-place stressors nurses working in hemodialysis units may
encounter.
2. Define planful problem-solving.
3. Identify the most frequent methods of coping used by nurses working in hemodialysis
units to cope with work-related stressors as indicated by this study.
4. Explain how nurses working in hemodialysis units may utilize methods of coping in
their daily work routines to enhance and improve their work environments.

little is known regarding the emotional impact of stressors and chronic

stress on nurses working in hemodialysis units and how they cope (Flynn et
al., 2009).

The growing complexity of care

required by this specialized patient
population requires expert knowledge
and personal engagement. The potential impact of coping techniques uti-

This offering for 1.3 contact hours is provided by the American Nephrology Nurses
Association (ANNA).
American Nephrology Nurses Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Comission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.
This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continuing nursing education requirements for certification and recertification.

May-June 2012

Vol. 39, No. 3

231

Work-Related Emotional Stressors and Coping Strategies that Affect the Well-Being of Nurses Working in Hemodialysis Units

lized by nurses working in hemodialysis units may affect their well-being

and those they serve in this setting.
The purpose of this study was to identify and describe emotional stressors
and coping strategies of nurses working in hemodialysis units in their daily
work encounters.

Background
This study examines the workrelated stressors and coping strategies
that impact the well-being of nurses
employed in hemodialysis units that
specialize in the treatment of patients
with end stage renal disease (ESRD).
Ross et al. (2009) demonstrated that
nephrology staff who care for patients
with ESRD interact in an intense
environment. The intensity is often
related to the long-term contact with
both patients and families for years,
with an average of two to three treatments a week and lasting several
hours per clinic visit. Caring for this
patient population may give rise to
stressors that impact the emotional
well-being of nurses. Stressors may be
linked to personal beliefs that are
interdependent yet meaningful to
nurses. Such beliefs may include how
nurses view chronic debilitating illness, the effect upon the quality of life
of their patients, and having to continually observe the patients dependency upon machines for survival. These
personal beliefs give rise to emotional
stressors that are antecedent conditions and elicit work-related stress
( Johnstone, 2007).

Literature Review
A systematic review was conducted to identify and integrate available
studies regarding work-related stressors and techniques of coping by
nurses working in hemodialysis units.
A description of literature findings
includes an overview of the role of
nurses working in hemodialysis units
and work-related stressors that impact
the emotional well-being of nurses
working in hemodialysis units.

232

Work-Related Emotional
Stressors
The following work-related emotional stressors are known to impact
the emotional well-being of nurses
working in hemodialysis units: a) the
intensity of the environment where
relationships with the patient are
long-term and require a high level of
expertise, b) status of disease progression and the frequency of near-death
situations, c) frequent setbacks in
patient physical and mental health,
and d) work environment pressures,
such as limited resources and moral dilemmas (Bednarski, 2009; Johnstone,
2007; Ross et al., 2009). Each of these
work-related emotional stressors had
some impact on the clinical perspective and ability of nurses working in
hemodialysis units to cope in the
work setting (Hayes & Bonner, 2010).
Chang et al. (2006) utilized the
Ways of Coping Questionnaire to measure how nurses cope with work-related stressors. Findings revealed that
nurses tried to manage or change the
situation. Planful problem solving was
the most frequent reported coping
technique, followed by self-control
and seeking social support. The
researchers defined planful problemsolving as an analytical approach to
altering a stressful situation. The
research findings also suggested an
association between planful problem
solving and improvements in the
nurses well-being (Chang et al.,
2006). Lambert and Lambert (2008)
reported similar findings in their
research utilizing the Ways of Coping
Questionnaire. The research described
coping techniques of nurses when
confronted with work-related stressors. The techniques reported from
highest to lowest were planful problem solving, seeking social support,
self-control, and positive reappraisal.
Chang et al. (2006) and Lambert
and Lambert (2008) utilized the
results from the questionnaire to identify process-oriented issues, stimulate
discussion in clinical areas and educational settings, and develop ways to
improve workplace issues. The workrelated emotional stressors were the
intensity of relationships, monitoring

disease progression, setbacks, work

environment pressures, and moral
dilemmas. Dowlings (2006) research
focused on the social construct of
nursing and the relationship of social
relevance and service through getting
to know patients and allowing them
to form a close relationship with their
healthcare provider. The hemodialysis environment and the long-term
relationship between nurse and
patient is a work-related stressor.
Nurses assume a vital role in providing continuous and long-term medical care to patients. They are responsible for the application of therapeutic
procedures that require expert skill in
a complex, rapidly changing technology (Chayu, Zur, & Kreitler, 2007).
Due to the vital role of repeated therapeutic treatments and medical care,
the patient often forms an attachment
to the nurse working in a hemodialysis unit (Argentero, DellOlivo, &
Ferretti, 2008). This level of responsibility and the relationship bond that is
formed are likely to cause a heightened level of stress (Chayu et al.,
2007).
The monitoring of disease progression and setbacks is a main priority of nurses working in hemodialysis
units because they support the
patients adjustment in both psychosocial and quality life concern
(Argentero et al., 2008). The chronicity of this disease and the disease progression have been identified as
work-related stressors that negatively
affects health providers (Chang et al.,
2006). The nurse is repeatedly subjected to setbacks in the patients
physical and mental health (Leung,
2003). Bednarski (2009) noted that
monitoring disease progression,
depression, and physical setbacks
while observing frequent episodes of
near-death events can result in heightening the nurses own losses and vulnerabilities.
The work environment inherent
to hemodialysis centers causes undue
pressures due to the uniqueness of the
setting, advanced technologic equipment, and the prolonged hours of
treatment over many years, which
sets nurses working in hemodialysis

Nephrology Nursing Journal

May-June 2012

Vol. 39, No. 3

units apart from those working in the

general care environment (Kotzabassaki
& Parissopoulos, 2003). Work-related
emotional stressors found in the
hemodialysis setting also cause additional pressures related to the risk of
contamination due to blood-borne
pathogens, tuberculosis, autoimmune
disorders, violence, aggression, and
verbal abuse (Hayes & Bonner, 2010).
Murphy (2004) reported that 70% of
nurses working in hemodialysis units
had experienced verbal abuse from
patients, which was seldom followed
up. Nurses working in hemodialysis
units are at risk to experience a sense
of failure and powerlessness as the
patients mental or physical health
deteriorates or may become frustrated with non-compliant or aggressive
patients (Ross et al., 2009). The challenge is to develop coping strategies
and techniques to maintain emotional
well-being in the work environment
(Kotzabassaki & Parissopoulos, 2003).
Studies reveal that depression is
the most common psychological disorder of patients on hemodialysis.
Bilgic et al. (2007) cited that depression was evident in 43% of patients on
hemodialysis. Weisbord, McGill, and
Kimmel (2007) reported that at least
25% of patients decided to discontinue hemodialysis during therapy.
Patients depression and behavior
pose a real threat to nurses wellbeing because it constitutes a chronic
level of distress. This impacts the
nurses self-esteem and professional
image, resulting in the need for coping techniques to deal with the sense
of vulnerability and role ambiguity
(Dermody & Bennett, 2008).

Theoretical Framework
The Lazarus Transactional Model
of Stress and Coping was used as a
guide to understand nurses ability to
cope with dilemmas through cognitive appraisal and coping processes
(Lazarus & Folkman, 1984). Cognitive
appraisals are often based upon casual antecedents, such as values, commitments, control, and environmental
resources (Folkman, Lazarus, DunkelSchetter, DeLongis, & Gruen, 1986).

Nephrology Nursing Journal

The cognitive appraisal is when the

person evaluates if the encounter
within the environment is relevant to
his or her well-being. The primary
appraisal is when the person evaluates the stress and determines if there
is a harm or benefit to his or her values, commitment, or self-esteem. The
secondary appraisal is if anything can
be done about the stressor to either
overcome or improve an outcome.
This model defines coping processes as being rooted in problemfocused and emotion-focused behaviors. Problem-focused coping or
external coping consists of activities
tied to solving the issue through information gathering or to change what is
perceived as the problem. Emotionfocused coping or internal coping
includes behavioral responses, which
at times are attempts to alleviate the
distress that causes disruption to emotional well-being (Folkman et al.,
1986). The short-term and long-term
effects of these variables are known as
the transactional process. The outcome is the result of how the person
manages the demands of the personal-situational relationship through
coping techniques.

Methods
Design
This study used a descriptive
design. The Ways of Coping Questionnaire was used to identify and measure methods utilized as coping techniques and strategies of coping. The
questionnaire is an appraisal of relationships between person, environment, and coping processes.
The study was conducted at six
outpatient hemodialysis centers in the
Midwestern United States of America.
A small convenience sample of 19
nurses working in hemodialysis units
participated in the study. Contracted
nurses employed by an outside
agency were excluded from the study.
Institutional Review Board approval
for this study was obtained from a
Midwestern university and the corporate headquarters of the six hemodialysis clinics.

May-June 2012

Vol. 39, No. 3

An informational letter was presented by the researcher to both the

physician director and clinical manager
of each hemodialysis clinic. The
researcher was asked by management
to jointly present the information sheet
to participants. An explanation of the
cover sheet included the focus of the
research, which was to provide insight
into the work-related emotional stressors, coping strategies, and coping
processes. This was completed through
small group presentations of three to
four nurses per clinic. Participation was
voluntary, and refusal to participate or
withdrawal from participation in the
questionnaire involved had no penalty
or loss of benefits. Participants were
informed that anonymity and confidentiality would be maintained. The questionnaires were distributed in an envelope with an attached self-addressed
envelope for return by mail.

Instrument
Participants completed the Ways
of Coping Questionnaire, an established
instrument with demonstrated validity and reliability. The survey, derived
from a cognitive phenomenological
theory of stress and coping (Lazarus
& Folkman, 1984), is designed to
identify the thoughts and actions individuals have used to cope with a
stressful encounter. Construct validity
is evident from the outcome of several studies and noted consistency with
theoretical predictions. An example is
that coping consists of both problem
and emotion-focused strategies and
coping techniques. The internal consistency estimates are at the low end,
which is, in part, due to the small
number of items in each scale, the
small sample size, and that the use of
one coping response may provide the
desired effect in this pilot study.
Planful problem solving is known as
being the highest coping technique,
with an alpha of 0.85. The remaining
subscales varied from 0.75 to 0.21.
The low end of coefficient alpha (reliability) was not evident in larger studies regarding non-specialty nursing
(Lambert, Lambert, & Ito, 2004).
The questionnaire consists of a
66-item survey that uses a four-point

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Work-Related Emotional Stressors and Coping Strategies that Affect the Well-Being of Nurses Working in Hemodialysis Units

scale to indicate the extent to which

participants use each response to
cope. Scale responses are labeled as
follows: does not apply or not used =
0, used somewhat = 1, used quite a bit
= 2, and used a great deal = 3.

Analysis

Table 1
Demographic Characteristics of Participants
n

10.5

17

89.5

Associates degree in nursing

10

52.6

Bachelors degree in nursing

31.6

Masters degree

10.5

Research Variable
Gender
Male
Female

Data were transferred into SPSS

19.0 for statistical analysis. Descriptive statistics, such as frequency
distribution, percentages, means, and
standard deviation, were conducted
to demonstrate the characteristics of
the sample. Cases with missing data
were examined for nonrandom patterns; no participations were removed. Relative scores are expressed
as a percentage and range from 0 to
100 for participants scores for the
eight coping techniques.

Education

Results
The response rate was 95% for
return of the surveys. Demographic
data are shown in Table 1. The experience level of the participants in this
study was comparatively below the
mean of previous studies. Previous
studies have demonstrated a mean of
13 years to be the average level of
experience in this setting (Flynn et al.,
2009; Ridley, Wilson, Hardwood, &
Laschinger, 2009). The lower level of
experience of the nurses in this study
may have impacted how the coping
questions were answered. The mean,
standard deviation, and range of the
sample for planful problem solving,
self-controlling, positive reappraisal,
seeking social support, accepting
responsibility, confrontive coping,
distancing, and escape avoidance are
shown in Table 2.
Findings from this study suggest
that the majority of nurses working in
hemodialysis units use planful problem solving as a coping technique
when confronted with work-related
stressors. This technique was followed
by self-controlling, positive reappraisal, and seeking social support.
Self-controlling had the lowest variability in scores (SD = 3.14), and planful problem solving had the highest
variability (SD = 4.97).

234

Masters degree in nursing

Years of Experience in Outpatient Hemodialysis

5.3

M = 7.93

SD = 8.34

Table 2
Ways of Coping Survey Results
Coping Technique
Strategy

Mean

Standard Deviation

Range %

Planful problem solving

17.66

4.97

9 to 25

Self-controlling

15.29

3.14

9 to 25

Positive reappraisal

14.93

4.71

6 to 23

Seeking social support

14.49

3.85

5 to 21

Accepting responsibility

10.05

4.89

0 to 17

Confrontive coping

10.01

4.25

6 to 20

Distancing

9.72

4.26

3 to 19

Escape-avoidance

7.86

3.16

2 to 14

Discussion
Planful problem solving describes
deliberate, problem-focused efforts
that are analytical to alter the situation.
This is supported from data that coping techniques of planful problem solving and self-controlling demonstrate a
level of significance because the statistical means are greater than the
remaining six coping techniques. This
relationship is further supported in the
similarity of how the coping techniques are defined to control feelings
and actions while seeking alternatives
to change the work-related situation.
This finding implies that more than
one coping technique may be utilized
during an event that produces workrelated stressors. Similar findings were
reported in prior studies (Chang et al.,
2006; Lambert & Lambert, 2008).

According to Folkman et al.

(1986), individuals practice planful
problem solving and self-control
when their encounters are problemfocused due to work-related stressors.
The theoretical framework of the
study underpins the coping processes
as being rooted in problem-focused
and emotion-focused behaviors.
Figure 1 demonstrates this process as
a continuum of transactional coping,
which frames this study. The continuum of coping consists of causal
antecedents, mediating processes,
immediate effects, and long-term
effects upon psychological well-being
(Lazarus & Folkman, 1987). It can be
assumed that the interrelationship of
the continuum demonstrates that
work-related stressors and coping
techniques affect the well-being of the
nurses working in hemodialysis units.

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Figure 1
Transactional Coping
Problem and Emotion-Focused Process
Causal
antecedents

Immediate
effects

Long-term
effects

Primary appraisal

Effect

Psychological
well-being

Environment
Demands
Resources

Secondary appraisal
coping options

Physiological
changes

Somatic health
illness

Support network
Constraints
Temporal aspects

Problem and emotion

focused

Quality of
encounter outcome

Social functioning

Variables

Person

Mediating
processes
Number of repeated
encounters

Values
Beliefs
Sense of control
Commitments
Self-esteem
Goals
Interpersonal trust

Source: Adapted from Lazarus & Folkman, 1987.

Coping techniques of positive

reappraisal and seeking social support
have similar means. Results indicate
that nurses frequently employ these
coping techniques, which are used to
remain emotionally focused and create a positive meaning in the work
environment (Folkman et al., 1986).
This suggests that although positive
reappraisal had a higher variability
and a mean of 14.9 (SD = 4.71) than
seeking social support with a mean of
14.5 (SD = 3.85), both coping techniques demonstrated a level of significance in the outpatient hemodialysis
setting. Previous studies have revealed that nurses seek meaning in
their work through social support in
the work-setting to lighten the physical and intellectually demanding role
(Rowe, 2003). Giving and receiving
compassion in the work-setting
between co-workers and from managers is one method of introducing
reappraisal and focus on well-being.
The coping techniques of
accepting responsibility had a mean
of 10.05 (SD = 4.89). Accepting

Nephrology Nursing Journal

responsibility is accepting ones role

in a situation. In an outpatient
hemodialysis setting, it is difficult to
manage a patient who may be noncompliant or aggressive, and the
nurse is unable to change the outcome (Ross et al., 2009). The inability to cope with this stressor can cause
the nurse to become critical of her or
himself. The reported mean may
indicate there is a lack of experience
in knowing when to acknowledge
ones role in an event. Confrontive
coping, with a mean of 10.01 (SD =
4.25), describes a level of aggressive
efforts to change a situation. The
long-term effects on the ability to
cope impact psychological wellbeing, social functioning, somatic
health, and illness. The coping techniques of distancing, with a mean of
9.72 (SD = 4.26), and escape-avoidance, with a mean of 7.86 (SD =
3.16), have the lowest mean values.
An assumption can be made from
these findings that the majority of
nurses do not minimize an event or
detach themselves from work-related

May-June 2012

Vol. 39, No. 3

stressors. From the perspective of

emotional well-being, it is important
to understand the events that
prompted the use of these coping
techniques because withdrawing
from a situation may or may not
have been healthy. As described earlier, studies demonstrate a mean of
13 years to be the average level of
experience in this setting (Flynn et
al., 2009; Ridley et al., 2009).
Participants in this pilot study were
well below that mean. This implies a
less-experienced staff that requires
coaching, and instruction from experienced staff and management to
impact the ability to cope.
An empowering and supportive
environment that offers resources and
education regarding work-related
stressors and how to cope can lead to
improvement in both the nurses wellbeing and understanding of this complex setting (Harwood, Ridley,
Wilson, & Laschinger, 2010). Organizational leadership is encouraged to
establish focus groups, engage the
nurses in management operations,

235

Work-Related Emotional Stressors and Coping Strategies that Affect the Well-Being of Nurses Working in Hemodialysis Units

and support activities to maintain the

well-being of nurses working in
hemodialysis units (Chayu & Kreitler,
2011).

Limitations
The main limitation of this study
is the small sample size, which results
in the inability to analyze relationships between coping mechanisms
used and variables, such as experience in the hemodialysis setting, age
of the nurse, size of the hemodialysis
unit, and availability of resources.

Summary
The results of this study imply
that planful problem solving, self-controlling, positive reappraisal, and
seeking social support are the most
frequent methods of coping used by
nurses working in hemodialysis units
to cope with work-related stressors.
The maintenance of well-being is
often a balance between person-environment through coping techniques.
The coping techniques of accepting
responsibility, confrontive coping,
distancing, and escape-avoidance
were employed less frequently and
are influenced by experience in coping with difficult situations, as well as
the need to protect ones emotional
well-being.
These research findings are
important to consider. As the incidence of this chronic disease and the
need for treatment continue to
increase, the work demands, stressors,
and need for coping skills of nurses
working in hemodialysis units will
also increase.
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Nephrology Nursing Journal Editorial Board Statements of Disclosure

In accordance with ANCC governing rules Nephrology Nursing Journal Editorial Board statements of disclosure
are published with each CNE offering. The statements of disclosure for this offering are published below.
Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant and research coordinator, is on the speakers
bureau, and has sat on the advisory board for Genentech.
Patricia B. McCarley, MSN, RN, ACNPc, CNN, disclosed that she is on the Consultant Presenter Bureau for
Amgen, Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and
is the recipient of unrestricted educational grants from OrthoBiotech and Roche.

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ANNJ1212

ANSWER/EVALUATION FORM

Work-Related Emotional Stressors and Coping Strategies that Affect the Well-Being of Nurses
Working in Hemodialysis Units
Vicki E. Ashker, MSA, BSN, CCRN, RN; Barbara Penprase, PhD, RN, CNOR; Ali Salman, MD, PhD, ND, RN
1.3 Contact Hours
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1. What would be different in your practice if you applied what you have learned
from this activity? (Response Required)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

To provide an overview of work-related

emotional stressors that impact the wellbeing of nurses working in hemodialysis
units and to identify their coping techniques.
Please note that this continuing nursing education activity does not
contain multiple-choice questions. This activity substitutes the multiple-choice questions with an open-ended question. Simply answer
the open-ended question(s) directly above the evaluation portion of
the Answer/Evaluation Form and return the form, with payment, to
the National Office as usual.

Strongly
disagree

Evaluation
2. By completing this offering, I was able to meet the stated objectives
a. Describe the work-place stressors nurses working in hemodialysis units may encounter.
b. Define planful problem-solving.
c. Identify the most frequent methods of coping used by nurses working in hemodialysis units to cope
with work-related stressors as indicated by this study.
d. Explain how nurses working in hemodialysis units may utilize methods of coping in their daily
work routines to enhance and improve their work environments.
3. The content was current and relevant.
4. This was an effective method to learn this content.
5. Time required to complete reading assignment: _________ minutes.
6. I am more confident in my abilities since completing this material.

Strongly
agree

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I verify that I have completed this activity ________________________________________________________________________________

(Signature)

Nephrology Nursing Journal

May-June 2012

Vol. 39, No. 3

237

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