
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
NOP2
Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.2127
NOP22127
NOP-2022-Jul-1159.R2
Empirical Research Quantitative
Empirical Research Quantitative
Inner strength, coping self‐efficacy and coping strategy of patients with peritoneal dialysis: A exploratory cross‐sectional study
Yang et al.
Yang Xuzhen https://orcid.org/0000-0001-8473-3305
1 2
Shan Yan 2 sy110@sina.com

Gao Yajing 3
Wang Hong 1
Li Xue 1
Ding Yabo https://orcid.org/0000-0002-7687-5749
1
Zhang Yanjun 1
Diao Keke https://orcid.org/0000-0002-0708-0221
1
Huang Yijia 1
1 School of Nursing and Health Zhengzhou University Zhengzhou Henan China
2 The Third Affiliated Hospital of Zhengzhou University Zhengzhou Henan China
3 Peking University School of Nursing Beijing China
* Correspondence
Yan Shan, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
Email: sy110@sina.com

01 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e212727 8 2023
19 7 2022
07 2 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

Aim

The purpose of the study was to investigate and analyse inner strength of patients with peritoneal dialysis, explore the associations among inner strength, coping self‐efficacy (CSE) and medial coping modes.

Design

This was a cross‐sectional study which was conducted in nephrology departments of two affiliated hospitals of a comprehensive university in China. Convenience sampling was chosen to collect data.

Methods

A total of 191 patients undergoing peritoneal dialysis were recruited by convenience sampling in two hospitals. Data involved of sociodemographic and clinical materials, inner strength, CSE and medical coping modes were collected from the patients. IBM SPSS Statistics 21.0 was used to process and analyse the data.

Results

The averaged score of inner strength was 95.74 (SD = 13.52). The inner strength, CSE and confrontation coping had positive associations with each other. Besides, inner strength and CSE was negatively associated with acceptance–resignation coping strategy, respectively.

coping self‐efficacy
coping strategy
inner strength
peritoneal dialysis
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:02.09.2024
Yang, X. , Shan, Y. , Gao, Y. , Wang, H. , Li, X. , Ding, Y. , Zhang, Y. , Diao, K. , & Huang, Y. (2024). Inner strength, coping self‐efficacy and coping strategy of patients with peritoneal dialysis: A exploratory cross‐sectional study. Nursing Open, 11 , e2127. 10.1002/nop2.2127
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pmcAs a convenient, economical treatment modality of end‐stage renal disease (ESRD), peritoneal dialysis has been widely accepted by patients (Chen & Zhou, 2013), which can also maintain the residual renal function. As is acknowledged, about 11% patients with ESRD are receiving peritoneal dialysis globally (Cho et al., 2021), whilst existing nearly 90,000 patients living with peritoneal dialysis in China (http://www.cnrds.net/TxLogin, 2020), where continuous ambulatory peritoneal dialysis (CAPD) is the most commonly chosen (Mei, 2021). In addition to completing dialysis for 3–5 times each day (Brown et al., 2020; Chen, 2010), people receiving peritoneal dialysis are required to monitor the changes of the weight, observe the fluctuation of the blood pressure, restrict the intake of liquid, obey strict food limitation and so on (Verger, 2012). These long‐term work and tasks for treatment and nursing intervene patients’ lifestyles, hindering their daily and social activities, or even resulting in a loss of their independence, role confusion, decline in self‐esteem and financial burden (Han et al., 2019; Li et al., 2013), which contributes to a sustained stress on patients. Hence, how to actively and effectively cope with these stress and trouble has become a concern of patients with peritoneal dialysis. Previous study (Shanan et al., 1976) has reported that the frequency of active coping strategy patients receiving dialysis adopt reduced with time going by, and those perceived hopeless for recovery and cure are prone to avoidance, denial and yielding coping, depressive and anxious (Cai et al., 2020). Such coping behaviours which are negative and emotional can do harm to the outcomes related to health, such as bad adherence and worse quality of life (Barberis et al., 2017; Gilbar et al., 2005), while a positive and optimistic coping is rather effective in facing stresses of treatment (Lindqvist et al., 1998).

Coping, also called as coping strategy or coping style, refers to the various actions and means individuals take faced with the stressful events or difficulties (Lazarus & Folkman, 1984). According to Lazarus, referring to the functional dimension of coping, it plays roles in solving problems and relieving emotional distress, involving positive coping, negative coping, problem‐oriented coping and emotion‐focused coping (Folkman et al., 1986; Lazarus & Folkman, 1984). In comparison with negative and emotion‐oriented coping which are considered as maladaptive, positive and problem‐oriented coping are more adaptive to the stressful scenario and prone to resolve the problems (Graven & Grant, 2013). A research (Han et al., 2019) conducted in Singapore reported that patients experiencing peritoneal dialysis tended to reject considering their sickness and treatment, and showed little curiousness their conditions, which was categorized as emotion‐focussed coping; on the contrary, some patients still chose to adapt and adjust to the impacts led by dialysis and disease, trying to think positively and take actions to reduce the negative influences. However, the survey (Parvan et al., 2015) from Iran had reported that emotion‐focused coping styles were more frequently chosen by dialysis population. Furthermore, Lindqvist et al. (1998) indicated the lacking effectiveness of emotive coping, showing negative relation to perceived efficiency in coping with major aspects of the disease. Acceptance–resignation coping involved in negative coping style was independently associated with depression among Chinese individuals with peritoneal dialysis (Lin et al., 2013). Thus, it could be concluded that emotional and negative coping results in adverse impacts on patients with peritoneal dialysis, and it was necessary to encourage these patients to transform into positive and effective coping. In this study, we got information about the coping strategy of patients with peritoneal dialysis using the medical coping modes questionnaire which was widely applied among Chinese patients (Shen & Jiang, 2000).

Coping self‐efficacy (CSE) refers to the self‐efficacy when faced with the stressful situation (Benight et al., 2000), that is the confidence individuals have in one's capability to cope successfully and the evaluation of the coping capability when in a state of stress (Tong, 2005). Benight and Harper (2002) held that CSE played a prominent part in the development of handling emotions and orchestrating coping behaviours, and the research orienting to CSE in individuals undergoing natural disaster pointed out that some ineffective coping behaviours decreased the perception of CSE and increased emotional distress; moreover, declined CSE would in turn intervene perseverance and valid strategies to impair coping behaviours. Besides, CSE is considered as a predictor of traumatic outcomes (Benight et al., 2015). It is acknowledged that chronic illness is regarded as a trauma stressor or crisis individuals have to deal with. Recently, the correlation, that the incidence of frailty were decreased by 91% with a higher CSE in older adults with chronic diseases, has been discovered (Hladek et al., 2020). Besides, considerable studies focused on the role and function of CSE in individuals suffering trauma events, covering natural disaster, accidents or violence (Benight et al., 2018; Morison & Benight, 2022), while we deemed that patients undergoing peritoneal dialysis were experiencing trauma events which they had never faced before, as well. In addition, there exhibited a positive interaction between self‐efficacy and active coping in Chinese patients receiving peritoneal dialysis (Zhao, 2019). Little was understood about the CSE, so we aimed to investigate the confidence of coping with peritoneal dialysis among this population with the CSE scale.

The inner strength, described as a kind of human resource which could elevate health and promote well‐being (Koob et al., 2002), was discovered from women with cancer in qualitative studies, which mainly concentrated on the development of recovery from disease in women, and the theory of inner strength generally accounted for the experiences of women faced with challenging events such as living with chronic illness in life (Dingley & Roux, 2014). At present, there possess two different research areas in the inner strength. One is the north American paradigm led by Roux and Dingley et al., the other is northern European paradigm by Nygren and Lundman et al.; the former mainly explores women's inner strength, and the latter may focus on aging and the elder (Smith et al., 2019). Accordingly, related questionnaire and scale were developed, which were Inner Strength Questionnaire (ISQ) and Inner Strength Scale (ISS) (Lewis & Roux, 2011: Lundman et al., 2011), respectively. The ISS was generated on the basis of a meta‐theoretical analysis of five concepts, resilience, sense of coherence, hardiness, purpose in life and self‐transcendence, which could be applied to a range of people (Lundman et al., 2011). In the model of inner strength by Lundman et al. (2010), the inner strength covered four core dimensions: connectedness, creativity, firmness and flexibility. Connectedness was described as an engagement and involvement with people, society and context; creativity represented an ability to take the initiative to face, acknowledge, adapt and solve problems, and refusing to be passive and evasive; firmness was interpreted as the awareness of the world and the courage to deal with stressful events rather than giving up; flexibility meant the capability to endure and resist when life turned to be harsh and burdensome, which implied people are more flexible. A longitudinal study (Viglund et al., 2021) found the influence of having a disease or undergoing a crisis on the inner strength, while the inner strength and well‐being were positive predictors of each other. Furthermore, the inner strength was the partial mediator between the disease and self‐rated health in the old (Viglund et al., 2014); in other words, the elder with various diseases could rate a better health if possessing stronger inner strength. And what was of great significance was that, stronger inner strength was linked to avoiding depression (Boman, Gustafson, et al., 2015). Smith et al. (2019) raised that the comprehension of the concept of inner strength was essential when coping with adversities and challenges. Majority of studies about inner strength were in qualitative forms, which contributed to interpreting the phenomenon of inner strength, where a number of participants mentioned how inner strength acted as a kind of power or resource promoted them to recover and move forward (Viglund et al., 2017; Raphael et al., 2019). Having inner strength was described as being able to confront reality, take an active part in care and treatment, and cope with challenges and adversities with sufficient courage (Viglund et al., 2017). As for patients with peritoneal dialysis, we expect to explore the status of inner strength and the association between inner strength and coping. To date, there is no study about inner strength in peritoneal dialysis patients.

According the review above, in this study, coping comprised two dimensions, coping strategy and CSE, which represented the action and behaviour, confidence and ability. For our objective, we carried out an exploratory cross‐sectional survey, aiming to study the current situation of inner strength and probe the association between inner strength and coping.

1 METHODS

1.1 Study design

Convenience sampling was chosen in this cross‐sectional study which was conducted in nephrology departments of two affiliated hospitals of a comprehensive university in China. This research obtained ethical approval from the Ethical Review Committee of the University. And all participants providing informed consent were informed to withdraw from the research at any time. The data of patients were only used for study and confidential to others.

1.2 Participants

From November 2021 to March 2022, patients with peritoneal dialysis who need to routine examinations in hospitals were recruited. The inclusion criteria were as following: (1) in the stage of ESRD; (2) receiving peritoneal dialysis for 3 months or more; (3) aged over 18 years old. Patients would be excluded if they (1) had adverse complications, involving severe infections and heart failure; (2) had cognitive impairment, mental diseases and bad hearing or speaking impairment; (3) received haemodialysis at the same time.

To analyse the relationships of multiple variables, the sample size should be 16–15 times the number of variables (Fang, 2012). There are 16 variables in this study, considering 20% invalid questionnaires, and the minimum size were 200. Finally, 201 questionnaires were collected, and 191 questionnaires were completed and valid. Five patients chose the same answer of the questionnaires, which were regarded as invalid, and five patients failed to finished the questionnaires due to emotional discomfort, pruritus, lacking of interest and having to leave.

1.3 Measures

1.3.1 Sociodemographic and clinical information

The data of gender, age, marital status, education level, work status, family monthly income, domicile, years of diagnosis of disease, years of dialysis, frequency of dialysis, edema, and whether requiring help from others were collected.

1.3.2 Inner Strength Scale

The ISS was developed by Lundman et al. (2011) and applied in all ranges of people, containing 20 items and 4 dimensions, composed of connectedness, creativity, firmness and flexibility. The scale is scored by six‐point Likert scale, from 1 “completely disagree” to 6 “completely agree”, with a total score ranging from 20 to 120, where higher score represents stronger inner strength. ISS has a good reliability by calculating a Cronbach's α coefficient of 0.86 and a test–retest reliability coefficient of 0.79 (Lundman et al., 2011). The Chinese version of ISS has been translated and adapted to the culture in 2015, with five extracted factors explaining 59.345% of total variance (firmness, creation, courage, connection and flexibility), and the Cronbach's α coefficient of 0.88, with a better internal consistency (Jia, 2015).

1.3.3 Coping efficacy questionnaire

The coping efficacy questionnaire was developed by Tong (Tong, 2005) in 2005 and used to comprehensively evaluate individuals’ CSE, that is the confidence they have when in a state of stress. Tong (2005) believes that CSE differs from general efficacy, which has more critical effect on body symptom, depression and anxiety and the stress of critical incidents. The instrument is composed of three dimensions, competence perception, cognition level and self‐confidence degree, with 17 items involved. A four‐level rating was applied, with the score of each item from 1 “complete inconformity” to 4 “complete conformity”, and higher score indicate a higher level of CSE. The questionnaire has a favourable reliability and validity, with the Cronbach's α coefficient of 0.86, the split‐half coefficient of 0.79 and the test–retest reliability of the subjects apart 2 months of 0.71 (Tong, 2005).

1.3.4 Medical Coping Modes Questionnaire

The medical coping modes questionnaire (MCMQ) was designed and developed specifically for patients by the team of Feifel et al. (1987a), which was later introduced and translated by Shen & Jiang (2000) who added one item into the questionnaire to adapt the Chinese culture. Hence, it contains totally three dimensions (confrontation, avoidance, and acceptance–resignation) and 20 items, among which items 1, 4, 9, 10, 12, 13, 18, and 19 should be scored in the reverse direction, scoring with four‐Likert scoring ranging from 1 to 4. Generally, the first option of the item corresponds to the score 1, but as for the reversed item the first one scores 4. Higher scores in some dimension represent a tendency to adopt corresponding coping strategy. MCMQ has convincing reliability, with the Cronbach's α coefficient of confrontation, avoidance, and acceptance–resignation being 0.69, 0.60 and 0.76, respectively (Shen & Jiang, 2000).

1.4 Data collection

Permitted by leader and head nurse in the nephrology department, we entered the ward and prepared the paper questionnaires and pens for the participants. Firstly, we approached the potential patients, informing them of our aims, guaranteeing to use their data only for study and obtaining their oral informed consent. After introducing how to fill in the questionnaires, patients with literacy usually finished the questionnaire by themselves, while for those without literacy and fail to understand the contents, we explained the items to them one by one without inducible words, to assist in finishing the survey. Besides, participants would be reminded of the forgotten items, for ensuring that the questionnaires had been exactly completed. Clinical data could be collected from the electronic record of the department. Result from the outbreaks of COVID‐19, our collection had suspended for twice. Eventually, data collection ended in March 2022.

1.5 Data analysis

IBM SPSS Statistics 21.0 was used to analyse the data. Continuous variables distributing normally, such as year and dialysis of year, were represented by mean and standard deviation (SD). Categorical data, such as gender and employment status, would be presented in percentages or proportions. One‐way ANOVA and independent t‐test were conducted to analyse the differences of inner strength between groups. Pearson's correlation analysis was performed among the inner strength, CSE and medical coping modes. Bilateral test was applied, and p value < 0.05 was regarded as statistically significant.

2 RESULTS

2.1 Sociodemographic and clinical information

The age of 191 participants ranged from 18 to 85 years, with a mean age of 46.24 (SD = 13.38) years, and majority of them (85%) in their young and middle age. More than half of the patients were male patients, and three quarters were not employed. The mean duration of dialysis is 30.27 ± 25.3 months, with nearly 70% patients on dialysis for more than 1 year. And 177 participants performed dialysis for 3–5 times each day. Detailed information was presented in Table 1.

TABLE 1 Characteristics of patients and group comparisons of inner strength (n = 191).

Variables	Group	n (%)	Inner strength	
M (SD)	F/t	p	
Age(years)	18–44	86 (45.03)	97.09 (15.05)	1.976	0.142	
45–60	76 (39.79)	93.38 (11.53)	
61–85	29 (15.18)	97.90 (13.09)	
Gender	Female	86 (45.03)	98.00 (12.62)	−2.111	0.036*	
Male	105 (54.97)	93.89 (14.00)	
Marital status	Single	19 (9.95)	95.26 (16.40)	0.024	0.976	
Married	163 (85.34)	95.75 (13.33)	
Divorced or widowed	9 (4.71)	96.44 (11.70)	
Education level	Primary school and below	51 (26.70)	93.41 (13.36)	3.495	0.017*	
Middle school	81 (42.41)	94.42 (14.62)	
Senior school	40 (20.94)	97.43 (11.42)	
Junior college and university	19 (9.95)	104.05 (9.96)	
Employment status	Unemployed	150 (78.53)	95.03 (13.87)	−1.395	0.165	
Employed	41 (21.47)	98.34 (11.95)	
Per capita family income monthly (RMB, yuan)	<1000	59 (30.89)	96.41 (13.46)	4.247	0.006*	
1000–2999	56 (29.32)	91.29 (12.21)	
3000–4999	48 (25.13)	96.54 (14.92)	
≥5000	28 (14.66)	101.85 (11.15)	
Domicile	Countryside	112 (58.64)	94.23 (14.07)	1.715	0.183	
Town	36 (18.85)	98.22 (11.38)	
City	43 (22.51)	97.58 (13.46)	
Duration for dialysis (months)	3–12	61 (31.94)	92.90 (15.86)	1.398	0.245	
13–36	75 (39.27)	96.68 (12.45)	
37–60	32 (16.75)	98.03 (13.02)	
61–123	23 (12.04)	97.00 (9.92)	
Daily dialysis time	2	11 (5.76)	94.64 (15.68)	0.281	0.890	
3	60 (31.41)	94.80 (15.67)	
4	85 (44.50)	96.32 (12.81)	
5	32 (16.75)	96.81 (10.63)	
6	3 (1.57)	90.67 (12.50)	
Whether needing help when being dialysis	Yes	28 (14.66)	94.79 (17.29)	−0.327	0.746	
No	163 (85.34)	95.90 (12.82)	
Edema	Yes	88 (46.07)	96.72 (12.62)	0.923	0.357	
No	103 (53.93)	94.90 (14.26)	
Abbreviations: M, mean, SD, standard deviation.

* p < 0.05.

2.2 Inner strength of peritoneal dialysis patients and associations with sociodemographic and clinical information

Patients living with peritoneal dialysis exhibited a mean score of 95.74 (SD = 13.52) in inner strength. Table 1 illustrated significance relations of gender, education level and per capita family monthly income with inner strength, where female patients showed a stronger inner strength than male patients. Among the four levels of education, patients with junior college and university degree reported the strongest inner strength. Besides, patients with family monthly income more than 5000RMB predicted a highest level of inner strength.

2.3 Medical coping modes and CSE in patients with peritoneal dialysis

In terms of medical coping modes, the mean score is 18.48 (SD = 4.40) for confrontation, 16.88 (SD = 2.90) for avoidance and 10.93 (SD = 3.30) for acceptance–resignation. The participants have a score of 52.58 (SD = 8.20) on average in CSE.

2.4 Bivariate correlations among the inner strength, CSE and medical coping modes

Table 2 presented the associations among the inner strength, CSE and medical coping modes. The inner strength, CSE and confrontation coping strategy were moderately positively related to each other (p < 0.05). The inner strength and CSE had a moderate negative association with acceptance–resignation coping strategy (p < 0.05), respectively. However, the correlations of inner strength and avoidance coping style, CSE and avoidance coping style reported not statistical significance.

TABLE 2 Pearson's correlation of inner strength, CSE and medical coping modes.

Items	Inner strength	CSE	Medical coping modes	
Confrontation	Avoidance	Acceptance resignation	
Inner strength	1					
CSE	0.517*	1				
Confrontation	0.493*	0.453*	1			
Avoidance	−0.020	0.024	0.001	1		
Acceptance–resignation	−0.465*	−0.300*	0.493*	0.062	1	
* p < 0.05.

3 DISCUSSION

In this study, we investigated the level of inner strength in patients with peritoneal dialysis, which had never been conducted before. We also studied the associations of inner strength with CSE and medical coping modes, finding that inner strength was moderately positively correlated with CSE and confrontation coping style, while moderately negatively associated with acceptance–resignation coping.

In the study, the score of inner strength in patients with peritoneal dialysis was 95.74 (SD = 13.52), which was lower than the old in Nordic countries (Viglund et al., 2013) and women with cancer (Dingley & Roux, 2014), but higher than patients with heart failure (Hosseini et al., 2016). Roux et al. defined inner strength as an internal developmental capacity which could help to go through challenging life for women with chronic or acute conditions, while Lundman et al. emphasized on its role of promoting well‐being and overcoming the difficulties (Smith et al., 2019). The study from Hosseini et al. (2016) indicated that the occurrence of disease was a potential factor activating one's inner strength to reach a certain level. For patients living with peritoneal dialysis, they are faced with numerous issues and stresses brought by disease and dialysis, and a certain level of inner strength may predict they have difficult in going through this rough period. Our results show that female patients exhibit a stronger level of inner strength in comparison with male patients who receive peritoneal dialysis; concerning the education level, we conclude that higher the education level corresponds to stronger inner strength, which is consistent with the outcomes from viglund (Viglund et al., 2013). In addition, patients with family monthly income beyond 5000RMB have the strongest level of inner strength. Initially, the inner strength is used to understand the experiences of women in some chronic conditions, considered as individual strength and resources (Dingley & Roux, 2014), which consequently supports a stronger level of inner strength in female patients with peritoneal dialysis. And patients with higher level of education or better economic foundation always possess more resources and stronger capability to deal with various issues or dilemmas, who, thus, reported better scores of inner strength. But, from a nursing and care perspective, it is of significant clinical implication that more attention should be paid to patients who are male, in lower education level or incomes. For these disadvantaged group, weaker inner strength may imply worse condition, less resource or chances to promote health. Enhancing their inner strength is expected to encourage individual to face difficulties and cope with stress actively.

Dingley and Roux (2014) expressed that better understanding of inner strength could identify and facilitate positive coping strategies and styles. Indeed, we find a positive association of inner strength with CSE and confrontation coping strategy, while negative relation with acceptance–resignation coping style. As an available resource to handle adversities and tackle problems (Boman et al., 2017), inner strength can also serve as a kind of coping resource for chronic diseases. Reviewing the four core dimensions of inner strength, it is not hard to find that the connotation of inner strength is to act as a capability to facilitate to cope with stresses and adversities. Some haematological cancer survivors told that they drew inner strength to get through the treatment, think and behave positively, which contributed to improving well‐being (Raphael et al., 2019). And Smith et al. (2019) held an opinion that inner strength was essential when coping with challenges and difficulties. The old adults experiencing a disease narrated that the expression of inner strength was to confront and accommodate disease, which motivated them to fight and stand up in a hard period; for example, one participant suffering stroke learnt to talking again and again for the purpose of coming back to life (Viglund et al., 2017). All above came from the qualitative studies, and reported similar with our quantitative results. Feifel et al. (1987b) pointed out that confrontation coping mode indicated more information‐seeking, more participation in treatment process and cognitive restructuration, where individuals with a tendency to confrontation would marshal their life strength and efforts to cope with the condition. In this study, consequently, we infer patients with stronger inner strength possess the confidence to face stresses, as they may reach more ample coping resources, such as support from relatives and friends or contributing knowledge and skills. Even if the situation is demanding, they soon adjust themselves to it and bring out a solution, leading to a higher CSE and active coping strategy.

The average score of CSE is far more below the norm of general population in China but closer to that of drug addict (Tong, 2005), which reveals patients undergoing peritoneal dialysis lack confidence in their capability to cope with the disease. And in the respect of medical coping modes, our results are similar with Lin et al. (2013), that patients are inclined to coping style of avoidance and acceptance–resignation which is independently associated with depression and leads to pessimistic emotions (Lin et al., 2013). Inner strength is positively associated with confrontation coping, so is CSE. Some studies (Chen & Lu, 2014; Huang et al., 2017) indicated a positive association of higher self‐efficacy with confrontation coping style in patients, as those with higher self‐efficacy generally faced problems and stresses directly, took actions to tackle problems, tending to adopt active coping style. Trouillet et al. (2009) also reported self‐efficacy stably promoted the utilization of the problem‐focused coping with path analysis. Confrontation coping belongs to the problem‐focused and positive coping strategy, showing a positive association with CSE.

Despite the negative association of inner strength with acceptance–resignation, the relationship between inner strength and avoidance is not statistically significant, nor is CSE. In the research by Feifel et al. (1987b), acceptance–resignation coping mode was the synonym of passivity and meant acceptance without alteration, and patients prone to acceptance–resignation coping mode were reported to less “lick” their illness. Faced with frustration and helplessness, these patients choose to give in to the disease, which also explains that inner strength and CSE have positive associations with acceptance–resignation coping strategy, respectively. When it comes to the avoidance coping mode, patients resorting to this mode attempt to get rid of the impacts of the disease as well as avoid it (Feifel et al., 1987b), by trying to not consider the disease or pretend not contracting a disease. These patients were characteristic of lower self‐perception, negative mood and less self‐direction, which, as a passive and negative behaviour, was linked to less effective coping in previous study (Feifel et al., 1987a). Therefore, we conclude that the associations between inner strength and avoidance coping, CSE and avoidance coping are not statistically significant, respectively.

The results of this study emphasized the importance of focusing on inner strength. Especially for patients with weaker inner strength, they may be trapped in disease and never achieve coexistence with it. Healthcare professionals, especially dialysis nurses specialists or nurse in psychology, should pay more attention to those patients and provide guidance or interventions to enhance inner strength. Connectedness, creativity, flexibility and firmness make up the core of inner strength, which can be the basis and framework of constructing interventions (Viglund et al., 2021). For instance, nurses can encourage patients to keep in touch and communicate with relatives or friends to strengthen the connectedness; engaging in activities and enriching individual reserves was proposed to promote creativity of inner strength, which suggests nursing staff to organize some positive activities for patients in dialysis (Boman et al., 2017; Boman, Häggblom, et al., 2015). Thus, potential and creative interventions can be developed to enhance inner strength of patients in clinical practice.

4 LIMITATIONS

Although we investigated inner strength of patients with peritoneal dialysis and found the related associations, we have to acknowledge some limitations in this survey. Firstly, part of the data was missing because patients failed to finish the questionnaire due to check, feeling emotional or uncomfortable. Secondly, we carried out a cross‐sectional survey with a small sample, which meant the results could not be widely applied and boiled down to causal relationships. The study was conducted accompanied by the epidemic of COVID‐19, so it is not easy to recruit patients in hospitals. And our participants did not include patients with automated peritoneal dialysis, which was uncommon in these two hospitals. As a result, the status of inner strength or coping in patients living with automated peritoneal dialysis still remains a gap.

5 CONCLUSION

In summary, this study investigated and analysed the status quo of inner strength in patients with peritoneal dialysis, concluding the associations among inner strength, CSE and medical coping modes, especially the positive bivariate correlations among inner strength, CSE and confrontation coping. These outcomes reveal that medical staff can promote a positive, problem‐focused confrontation coping strategy of patients by enhancing and arousing their inner strength.

AUTHOR CONTRIBUTIONS

All authors contributed to this manuscript. Xuzhen YANG and YanSHAN designed the study; Xue LI and Hong WANG participated in the data collection. Yajing GAO, Yabo DING and Xuzhen YANG contributed to analyse the data and finish the manuscript; Yanjun ZHANG, KeKe DIAO and Yijia HUANG contributed to review the article.

CONFLICT OF INTEREST STATEMENT

The authors declare that there are no conflicts of interest in this study.

ETHICS STATEMENT

The Ethical Review Committee of the University had approved this study (ZZUIRB 2022‐41). All participants have known about the aims of the study and provided their verbal informed consent to participate.

Supporting information

Appendix S1.

ACKNOWLEDGEMENTS

We thank all involved patients for their participation and cooperation, head nurses and clinical staff in two hospitals for their assistance in such a rough time.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.
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