Reducing the hemodialysis patient stress level through progressive relaxation

Background: Hemodialysis is an effective treatment carried out for patientswith chronic kidney failure to improve the quality of life. 80% of hemodialysis patients experience physical stress disorder and psychosocial stress related to treatment. When faced with stress, the body muscles become tense as the abdomen becomes tense and cramped, the chest feels tight, which impacts physical and psychosocial health, so it is necessary to have stress management training through relaxation techniques. This study aimed to determine the effect of progressive relaxation on stress levels in patients with hemodialysis. Method: A quasi-experimental pre-test and post-test study with control group design was used in this study. is a quasi-experimental pre-test and post-test study with a control group design. There were 58 respondents divided into two groups (intervention and control), and each group consisted of 29 people selected by random sampling. Measurement of stress levels using questionnaire Depression Anxiety Stress Scale 42 (DASS 42). Results: The Mann Whitney U Test showed a difference in the decrease instress levels which was statistically significant (p <0.05). Conclusion: The audio-visual progressive relaxation training conducted at least two times a week for three weeks effectively reduces stress levels in patients undergoing hemodialysis therapy for at least one month.


Introduction
Chronic kidney failure is a health problem for people worldwide that has increased significantly in the last ten years and continues to increase 1 . 15% of the 30 million Americans suffer from chronic kidney failure 2 . In Indonesia, chronic kidney failure is one of the ten most non-communicable diseases, which is 0.2% of those aged ≥ 15 years suffering from chronic renal failure 3 .
Changes in treatments for patients with renal failure, adherence to dialysis schedules, length of treatment, special diet, fluid restriction, adequate treatment, changes in attitudes, behaviors, and lifestyle have a significant effect on the prognosis of patients with chronic renal failure 4 . Treatment of hemodialysis in patients with renal failure can affect psychological, social, and physiological aspects, such as fatigue, pain at their access points during venipuncture, nausea, vomiting, cramping, itching, and stiff joints 5 .
There is a connection between stress and chronic diseases, which illustrates how endocrine-immune interactions appear to mediate these relationships and illustrate how psychosocial stressors affect mental and physical health 6 . Chronic disease is a primary or secondary stressor for individuals and their families 5 . When dealing with stress, the body muscles become tense, the stomach hard and cramps, and tightness in the chest which affects physical and psychological health. Therefore stress management training is needed through relaxation techniques such as the cue-controlled relaxation method, relaxation techniques autogenic, muscle relaxation (relaxation via tension relaxation) techniques, and sensory awareness relaxation 7 .
Muscle relaxation methods are successful in all hemodialysis patients due to their ability to relieve stress, anxiety, pain, exhaustion and improve sleep. Muscle relaxation methods are effective in all hemodialysis patients, reducing stress, anxiety, pain, fatigue, and improving sleep 8,9 . Stress levels can be calculated using scores related to stress symptoms 7 .

Research methodology
This is a quantitative study using quasi-experimental with a pre-test and post-test with a control group design. This study seeks to reveal a causal relationship involving the control group that did not get treatment and the intervention group that received treatment in progressive relaxation training for three weeks. Both groups were subjected to pre-test and post-test This research was conducted from November to December 2018 to determine implementing progressive relaxationtraining on hemodialysis patients' stress levels at the hemodialysis clinic in Bantul, Indonesia. The sampling technique was carried out using a simple random sampling technique through random sampling without regard to the population's strata. The samples must meet certain criteria (inclusion and exclusion) because they are part of the target population to be studied.
The inclusion criteria used were at least one month of hemodialysis therapy patients willing to become respondents of the study from the beginning to the end.The exclusion criteria used were patients who did not come/refused to be included as samples of the research or did not complete the instrument completely.Dropout criteria were those who did not arrive at the post-test or died before a post-test or did not conduct progressive relaxation training at least two times a week for three weeks.
According to the calculation results, the number of research samples is 27 people per group. To anticipate resignation during the study, the researcher added 10% of the total sample to 29 people for each group (intervention and control) so that the total was 58 people.
The questionnaire instrument used in this research was the Depression Anxiety Stress Scale 42 (DASS 42), which consisted of 14 stress level questions and an 8-minute via tension-relaxation training video containing ten steps of relaxation. Patients conduct audio-visual training by looking at the training movement, listening, and following the training steps according to instructions in the form of sound. The movements consist of the following: palms relaxation, arm, and finger relaxation, shoulder relaxation, forehead, and eyebrow relaxation, jaw muscle relaxation, relaxation of lip muscles, relaxation of neck muscles, relaxation of chest muscles, relaxation of abdominal muscles, and relaxation of the feet, and toes.

Ethical clearance
This research has received ethical clearance from the postgraduate ethics committee of the University of Muhammadiyah Yogyakarta, and is declared not to conflict with the code of ethics.

Results
Subjects were selected from the hemodialysis clinic in Bantul Regency, Yogyakarta Province, Indonesia. A total of 58 subjects participated in the study, 29 in the control group and the other 29 in the intervention group. The characteristics of the subjects in this study are described in table 1.  Table 1 shows that the characteristics of the subjects in the intervention group and the control group were not significantly different (homogeneous).This can be seen from the results of the analysis using chi-square that all the characteristics of the subject (gender, age, employment status, marital status, and length of time undergoing hemodialysis) have a p-value of more than 0.05.  Table 2 describes the minimum and maximum stress levels of subjects in the intervention group and control group, before and after stress management training. The minimum stress level in the intervention group before being given stress management training (pretest) was 10, while the maximum value was 23. After being given stress management training (post test), the minimum stress level in the intervention group was 9 and the maximum value was 19. In the control group subjects, the minimum stress level at the time of the pre-test was 11 and the maximum value was 26, while the minimum score for the post-test was 11 and the maximum value was 24.

Pre Test
Post Test

Control Group
Normal

Moderate 4 6
Severe 1 - Table 3 shows the distribution of stress levels before stress management training (pre-test) and after stress management training (post-test) in the intervention and control groups. The table shows an improvement in stress levels in the intervention group subjects, and conversely there was no improvement in the control group subjects.   Analysis of the effect of progressive relaxation training on stress levels in hemodialysis patients is shown in table 5. Table 5 shows the results of statistical tests on the intervention group with the Mann Whitney U test showed that the p-value was 0.003. These results are less than α 0.05, which means that progressive relaxation training can reduce stress levels experienced by hemodialysis patients.

The relationship between Sex, Age, Marital status, Job status and Duration of Therapy Against Stress Levels
Acute stressors affect activity, interactions in the brain region in decoding and interpreting other people's facial expressions. Men and women have differences in dealing with stress. Men tend to withdraw while women seek social support socially. According to evidence, men and women react differently to stress. Women are more susceptible to feeling depression and anxiety, while men struggle with their desire/ motivation 10 .
Characteristics of respondents based on age that the negative effect of exposure to stressors on older adults is lower than the effect of new stressors on younger adults, but the difference will disappear within 3 to 6 hours after that. Higher stress levels are predicted to be influenced by one's response to daily stress.
There is no age difference in a person's response in the function of stressor severity 11 .
Based on marital status, someone who is married and still lives with his partner will experience a lower level of stress than those who are not married or do not live with their partners because they do not get support from their partners 12 .
Regarding respondents' work, work can stimulate stress, including demands for unrealistic work, unfair treatment, lack of appreciation, an imbalance between effort-reward, conflicting roles, lack of transparency, and poor communication 13 . Stress at work contributes to the increased risk of suicide in men. Suicide risk factors in women are influenced by inadequate work control and organizational systems 14 .
Depending on the length of therapy, the relationship between psychosocial stressors and diseases is often affected by the origin, duration, and prevalence of stressors due to individual biological vulnerabilities (i.e., genetics, constitutional factors), psychosocial tools, and learning habits. The psychosocial intervention is useful in treating stress-related conditions and may affect chronic diseases' progression 6 .

Stress Levels of Hemodialysis Patients Before and After Intervention
Stress is produced as a reaction when there are demands, pressures, and professional aspects that are not in accordance with individuals' level of knowledge and abilities 15 . Support from family, medical personnel, similar patients, friends, and community can reduce stress in hemodialysis patients and the stresses and difficulties 16 . The study explained the relaxation method's effect by reducing metabolism and strengthening heart contractions, breathing, blood pressure, and epinephrine release in the sympathetic system from the patient's physiological conditions through training nurses to benefit patients. This requires a lower cost and can prevent problems because it can be used and taught to all patients 17 . Muscle relaxation can be used to minimize pain in patients with hemodialysis 18 .
Research using group analysis shows that the application of audio-visual programs can reduce anxiety and emotion processing bias, but not all of them can reduce the level of stress experienced 19 .
Research related to hemodialysis patients' quality of life by looking at physical function, physical role, social function, and mental health showed significant improvements in both the oral and video education groups following an intervention. The appropriate intervention can improve the quality of life of patientsso that the use of video education as an effective, inexpensive, simple, and attractive method is recommended for hemodialysis patients 20 .
Some ways that can be used to reduce stressors in hemodialysis patients are: find meaning in the situation they are experiencing, try various ways to solve problems and find the best way, determine specific goals to help solve problems, discuss problems with someone who has similar types/ situations, pray, laugh and find out things that can get worse, actively try to change situations, think through different ways to handle situations and accept situations that are experienced 21 .

The Effect of Stress Management Training on Stress Levels
Stress management training through cognitivebehavioral techniques involving patient and family programs can overcome the situation's stresses and act efficiently 15 . Stress management training has an important role in stress reduction and social adaptability through modification of irrelevant social information processing patterns in patients with chronic diseases 22 . Stress management training is an effective method to encourage someone to take a positive approach to deal with stress on workers 23 . Cognitive/behavioral stress management training can also improve quality of life and reduce clinical symptoms of cardiac surgery patients 24 .
Stress management training conducted by nurses on patients significantly increases hemodialysis patients' life expectancy. This low-cost intervention can be used to increase the life expectancy of hemodialysis patients 25 . The study results stated that stress management training could be used to improve the psychological care of breast cancer patients 26 .
Wellness education, such as relaxation strategies and vitamin supplementation, can improve patients' quality of life suffering from diabetes mellitus 2 . Stress management reduces the tolerance level of danger, stress, anxiety, and anger in mothers with children with sensory-motor disabilities to improve affective control in these mothers 27 .

The Effect of Progressive Relaxation Training On Stress Levels
Progressive relaxation techniques can reduce personal anxiety 28 . Relaxation techniques can reduce stress levels among housewives 29 . Progressive relaxation techniques effectively reduce stress and blood pressure 30 . With only a few minutes of gradual relaxation, blood sugar levels can be lowered for patients who have type 2 diabetes mellitus 31 .
Relaxation exercises can effectively improve vital signs and reduce anxiety levels in open-heart surgery patients after endotracheal extubation 32 . Progressive relaxation techniques can reduce pain, stress, and anxiety levels of hemodialysis patients, so they can provide calm 33 . Colorectal cancer patients can use progressive relaxation methods to change their stress response and provide them with a great stress management source 34 .
The study's findings are the basis for integrating progressive muscle relaxation into nursing care for patients undergoing hemodialysis 35 . Progressive muscle relaxation for families of psychiatric patients may overcome family tension in mental patients' care 36 .

Conclusions
1. Progressive relaxation training can significantly reduce the level of stress experienced by hemodialysis patients.
2. Intervention group showed significant differences in stress levels before and after progressive relaxation training.
3. There were no differences in stress levels both before and after progressive relaxation training in the control group.
Based on the conclusions above, the suggestions that can be submitted are as follows: 1.

For clinics
Clinics should provide a particular room for training on progressive relaxation in patients with video media that is conducted at least 2 times a week.

For researcher
The next researcher can research with a mixedmethod design to describe the stress levels that have been given progressive relaxation training.

Conflict of interest
We have no conflicts of interest to disclose