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The effects of emotional intelligence training on anxiety in hemodialysis patients

Authors:

Abstract

Background and Purpose: Hemodialysis is the most efficient treatment of end-stage renal disease (ESRD), which increases patients’ life expectancy. However, it can cause various adverse physical and mental side effects. The aim of this study was to determine the effects of emotional intelligence training on anxiety of hemodialysis patients in Khorramabad, Iran. Methods: This experimental study was conducted on 74 patients admitted to the hemodialysis ward of Khorramabad hospitals during 2014. The patients were randomized into experimental and control groups. Emotional intelligence training was provided to the experimental group by trained and skilled researchers during two months, within eight sessions. The data collection tools included demographic profile checklist, Spielberger's anxiety questionnaire and emotional quotient inventory (EQ-i), which was filled out by the researcher's assistant throughout the interviews before and after the intervention. The data were analyzed performing covariance analysis, Chi-squared as well as independent and paired t-test, using SPSS 19. Results: Before the intervention, independent t-test indicated no significant differences in the emotional intelligence scores of the two groups, but after the intervention, this score increased in the experimental group (P=0.01). The mean state-trait anxiety was not significantly different in the two groups before the intervention. Whereas after the intervention, a significant decrease in the anxiety scores of the experimental group was observed (P<0.001). Conclusion: Emotional intelligence training alleviated the anxiety of hemodialysis patients; therefore, implementing emotional intelligence training is recommended for lowering anxiety in hemodialysis patients.
8JNMS 2015; 2(4)
Yarahmadi F, et al.
The effects of emotional intelligence training on anxiety in hemodialysis patients
Abstract
Background and Purpose: Hemodialysis is the most efcient treatment of end-stage renal disease (ESRD), which increases patients’
life expectancy. However, it can cause various adverse physical and mental side effects. The aim of this study was to determine the
effects of emotional intelligence training on anxiety of hemodialysis patients in Khorramabad, Iran.
Methods: This experimental study was conducted on 74 patients admitted to the hemodialysis ward of Khorramabad hospitals
during 2014. The patients were randomized into experimental and control groups. Emotional intelligence training was provided to
the experimental group by trained and skilled researchers during two months, within eight sessions. The data collection tools included
demographic prole checklist, Spielberger's anxiety questionnaire and emotional quotient inventory (EQ-i), which was lled out by
the researcher's assistant throughout the interviews before and after the intervention. The data were analyzed performing covariance
analysis, Chi-squared as well as independent and paired t-test, using SPSS 19.
Results: Before the intervention, independent t-test indicated no signicant differences in the emotional intelligence scores of the
two groups, but after the intervention, this score increased in the experimental group (P=0.01). The mean state-trait anxiety was not
signicantly different in the two groups before the intervention. Whereas after the intervention, a signicant decrease in the anxiety
scores of the experimental group was observed (P<0.001).
Conclusion: Emotional intelligence training alleviated the anxiety of hemodialysis patients; therefore, implementing emotional
intelligence training is recommended for lowering anxiety in hemodialysis patients.
Keywords: Anxiety, Emotional intelligence, Hemodialysis
Fateme Yarahmadi1, Seyyede Fateme Ghasemi2*, Said Forooghi3
(Received: 8 May 2015; Accepted: 17 Oct 2015)
Journal of Nursing and Midwifery Sciences 2015; 2(4): 8-14 http://jnms.mazums.ac.ir
1 Student of Critical Care Nursing, Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
2,* Corresponding author: Faculty of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran. Email:
ghasemi2211156@yahoo.com
3 Faculty of Nursing, Lorestan University of Medical Sciences, Aligoudarz, Iran
Original article
Introduction
Chronic renal disease is an irreversible
progressive loss of glomerular function, which
causes uremia and azotemia, and can be treated
through hemodialysis and kidney transplantation
(1). The number of hemodialysis patients by the
year 2020 is estimated to be 3,500,000 (2). In 2012,
the association for protection and support of renal
patients in Iran announced that there were 75,000
renal patients, 23,000 of whom had been dialyzing.
Moreover, the annual growth rate of dialysis
patients has been reported to be 15% (3). Chronic
diseases such as severe renal failure are followed by
various psychological disorders. The most common
symptoms of mental disorders among hemodialysis
patients are depression and anxiety, respectively
(4). Different studies have reported that the rate of
anxiety in hemodialysis patients has increased by
19% (5).
A study conducted by Ahmadzade and Mehdi
demonstrated that the rate of anxiety in patients
dialyzing for 1>, 1-2.5 and >2.5 years, were 83.7%,
70%, and 83.3%, respectively (6). Patel et al.
have indicated that depression, anxiety as well as
suicidal thoughts and tendencies could be found in
9JNMS 2015; 2(4)
Emotional intelligence training and anxiety in hemodialysis patients
hemodialysis patients (7).
So far, various studies have been done to decrease
the rate of anxiety in hemodialysis patients using
medicinal treatment, continuous care model or
orange essence (8, 9). To overcome the anxiety
in hemodialysis patients, the common methods of
treatment such as taking chemical medicines were
beyond nurses’ responsibilities, and could put the
patients’ well-being in danger as well; therefore,
other remedies should be devised (10).
A study performed by Sunil and Rooprai reected
no signicant relationship between emotional
intelligence and anxiety reduction in patients
(11). While, Franklin et al. demonstrated that
high emotional intelligence was accompanied by
emotional alignment, which is supportive factor
against every day or routine tension and it was a
preventive factor in order not to be infected by
physical and mental diseases (12). Emotional
intelligence is a set of abilities and skills which help
individuals to adapt themselves to the environment
so as to be successful in their lives (13).
Emotional intelligence can reduce anxiety and
increase the level of self-condence (14). A study
carried out by Voshani and Yazdi on female high
school students indicated that emotional intelligence
training inuenced on responding to educational
stress, and teaching components of emotional
intelligence along with the lessons was effective in
decreasing the consequences of educational stress
(15). Moreover, Sharif et al. showed that training
on emotional intelligence components had major
effects on reducing stress among nurses and doctors
in intensive care units (16).
The results of a study by Clarke reected a
relationship between emotional intelligence and
mental health, while it had a reverse or negative
relationship with anxiety (17). Most of the recent
studies were done to investigate depression, anxiety
and the treatment methods in order to alleviate
anxiety, yet none of them has assessed the effect
of the emotional intelligence on decreasing anxiety
in hemodialysis patients. This study, therefore, was
conducted to determine the effect of emotional
intelligence training on anxiety of hemodialysis
patients during 2014, in Khorramabad, Iran.
Materials and methods
This experimental study was performed on 74
hemodialysis patients admitted to the dialysis wards
of Shohadaye Ashayer and Shahid Rahimi Hospitals
during 2014 in Khorramabad, Iran. The participants
were randomized into experimental and control
groups (n=37 for each group).
The inclusion criteria were as follow: willing to
participate in the study, being in the age range of 18-
65 years, dialyzing for more than three months, not
taking any anti-anxiety medications, not having any
verbal or hearing problems and not having dementia
or illnesses affecting the brain and memory or lack
of ability to think and behave normally.
The exclusion criteria were: lack of willingness
to participate in the study, mortality, changing the
treatment methods to kidney transplantation or
peritoneum dialysis and the emergence of major or
severe crisis in patients or their family members.
After receiving the approval of Shohadaye Ashayer
and Shahid Rahimi Hospitals and Ethics Committee
of Lorestan University of Medical Sciences, the aim
of the study was explained and informed consent
was obtained from the patients before initiating the
training intervention.
The data collection tools included demographic
prole checklist, Spielberger’s anxiety
questionnaire and the Baron’s emotional intelligence
questionnaire. The questionnaires were completed
by the researcher’s assistant throughout interviews
with the patients. The experimental group
participated in an eight-week emotional intelligence
training program (one session a week). A week after
the training program the questionnaires were lled
out again.
In order to prevent data collection bias and
contact of the samples, the experimental group
was separated from the control group with
the cooperation of the ward authorities. The
Spielberger’s State-Trait Anxiety inventory
was employed to measure anxiety. This scale
contains 40 items, each rated on a 4-point Likert
scale (1=never to 4=always). Scores can range
from 20 to 80, with higher scores indicating
greater anxiety. For the Persian version of the
10JNMS 2015; 2(4)
Yarahmadi F, et al.
Spielberger’s State-Trait Anxiety inventory,
Cronbach’s Alpha reliability was calculated to
be 90% and 91% for the state and trait anxiety,
respectively (18).
The Persian version of the Emotional Quotient
Inventory (Samoui, 2004) which is a 90-item self-
report inventory, was administered to assess the
Bar-On model of emotional-social intelligence,
which is rated on a 5-point Likert scale (1= Very
seldom or not true of me and 5= Very often true of
me). The minimum and maximum possible scores
were 90 and 450, respectively.
EQ-i consisted of ve composite scales
including intrapersonal, general mood, adaptability,
interpersonal and stress management. Some items
of the questionnaire were scored positively and
some others negatively. The questionnaire is
consisted of 15 subscales as follows: emotional
self-awareness, assertiveness, self-regard, self-
actualization, independence, empathy, interpersonal
relationship, social responsibility, problem-solving,
reality-testing, exibility, stress tolerance, impulse
control, happiness and optimism (19). Cronbach’s
alpha reliability as well as odd-even mergesort
of the scale were calculated to be 0.93 and 0.88,
respectively (20).
The emotional intelligence program which consisted
of eight 45-minute sessions, was adapted from the
administrative procedures of Bradberry and Greaves
(21) and emphasized on the 15 subscales of the Bar-
On’s emotional intelligence model as follows:
To analyze the data, Chi-squared, independent
t-test, paired t-test, and covariance analysis were
performed, using SPSS 19. The questionnaires were
anonymous and the participants’ information was
collected privately by the researchers.
Results
The obtained results showed that 58%, 2%
and 66% of our subjects were male, single and
married, respectively. The mean age of the samples
was 49.7±10.8 years, and the mean period of
hemodialysis was 3.48±2.22 years. Additionally,
the results conrmed the hypothesis regarding
increasing emotional intelligence scores in the
experimental group after implementing the
intervention (Table 1).
In this study, most of the subscales including
emotional self-awareness, empathy, interpersonal
relationships, reality testing, stress tolerance,
problem solving, impulse control, optimism and
happiness improved signicantly by emotional
intelligence training.
As can be noted in Table 2, the mean state and
trait anxiety scores of the two groups were the same
in the intervention group at the pretest stage, while
the means were signicantly different at the posttest
stage.
After the intervention, the state anxiety scores
in the hemodialysis patients were signicantly
different in both groups. The effects of pretest
(participants’ scores of the state anxiety test before
the intervention) were controlled using covariance
analysis, which proposes some assumptions such
as homogeneity of regression slopes within the
random variable (pretest) and the dependent
variable (participants’ scores of the state anxiety test
after the intervention) in both groups.
Variance analysis was conducted, which rejected
the interaction between the independent variable
(group effect) and the covariate variable (the
scores of the state anxiety before the intervention);
TopicSession
Introducing and building relationship with patients1
Dening emotion (excitement) and identifying its sorts in our lives and recognizing facial expressions, thoughts, embedded emotions and excitements2
Investigating the automatic thoughts, excitements, and behaviors through scientic samples3
Identifying how excitement happen to others4
Expressing excitement in different ways and how to handle them in our lives5
Excitement management (one) ( prediction of excitements and understanding its rst signs in ourselves)6
Excitement management (two) (controlling excitement through changing position, calming and emotional keywords)7
Excitement management (three) ( teaching techniques to solve emotional problems, express excitements appropriately and in a controlled manner, tolerate
stress, solve problems and be optimistic)
8
11 JNMS 2015; 2(4)
Emotional intelligence training and anxiety in hemodialysis patients
consequently, there was a criterion for regression
homogeneity.
Also regarding the signicance level of the
Levene’s test (F=0.052, df=72 and P=0.819), the
data didn’t impair the validity of the assumption of
equality of variance error; therefore, the samples
met the criterion for the homogeneity of variances
(Tables 3).
After modifying the scores of the pretest, there
was a signicant F between the group scores, that is
F=39.57 and P<0.001.
It can be inferred from the modied mean scores
of state anxiety (the mean of the experimental
group was 42.79 and the mean of the control
group was 49.15) that the anxiety scores decreased
signicantly in the experimental group. The results
demonstrated the group effect (the intervention
effect), with deleting the covariant variable, was
also statistically signicant. Therefore, independent
variable was signicantly different in the two
groups, which could be as a result of emotional
intelligence. Furthermore, this effect size i.e., 0.358,
in other words, 36% of the overt anxiety reduction,
was associated with the inuence of the pretest
variable.
Mean trait anxiety score in the hemodialysis
patients was signicantly different after the
intervention for both groups. The effects of pretest
(participants’ scores of the trait anxiety test before
the intervention) were controlled using covariance
analysis, which proposes some assumptions such
as homogeneity of regression slopes within the
random variable (pretest) and the dependent variable
(participants’ scores of the trait anxiety test after the
intervention) in both groups.
Variance analysis was conducted and regarding
the P-value (i.e., P=0.541), the interaction between
the independent variable (group effect) and the
covariate variable (the scores of the trait anxiety
before the intervention) was rejected; consequently,
there was a criterion for regression homogeneity.
Regarding the signicant level of the Levene’s
test (F=0.338, df =72 and P=0.563), the data didn’t
impair the assumption of equality of the variance
error; therefore, the samples met the criterion for
the homogeneity of variances (Table 4).
After modifying the pretest scores, there was
a signicant F between the group scores, that is
F=92.097 and P<0.001.
It can be inferred from the modied mean
scores of trait anxiety (the experimental group’s
Table 1. The mean emotional intelligence scores of the
control and experimental groups before and after the training
intervention
Emotional
intelligence
The control
group
SD±Mean
The
experimental
group
SD±Mean
t* df
Sig.
before 297.73±16.17 295.08±16/18 .65 72 .516
after 298/05
±10/66
304/89
±15/06 -2.23 70 .029
t** .09 -2/74 - - -
df 36 36 - - -
Sig. .92 .01 - - -
independent t-test * paired t-test**
Table 2. State and trait anxiety mean scores of the experimental
and control groups
Variables The Groups Mean SD
The pretest of state anxiety
Experimental 50.56 75/11
Control 59.49 18/9
The posttest of state anxiety
Experimental 24/43 23/11
Control 70/48 99/9
The pretest of trait anxiety
Experimental 02/50 99/11
Control 45/48 13/11
The posttest of trait anxiety
Experimental 16/42 66/11
Control 08/48 11/11
Table 3. The results of variance analysis of state anxiety for the
control and experimental groups
The effect
sources ƩX
2df Mean
X2 of F Sig. Eta
Coefcient
Pretest *6800.34 1 6800.34 360.80 .000 .83
Group 745.73 1 745.73 39.56 .000 .35
Error 1338.19 71 18.84 -
Total 165090.00 74 - -
*.R Squared =.846 (Adjusted R Squared=.842)
Table 4. The results of variance analysis of trait anxiety for the
control and experimental groups
The effect
sources ƩX
2df Mean
of X2F Sig. Eta
Coefcient
Pretest 7976.10 1 7976.10 473.19 .000 0.87
Group 1552.36 1 1552.36 92.09 .000 0.56
Error 1196.75 71 16.85 -
Total 154873.00 74 - -
*. a. R Squared=0.884 (Adjusted R Squared=0.880 )
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Yarahmadi F, et al.
mean score=39.61 and the control group’s mean
score=48.79) that the anxiety level in the experimental
group diminished more signicantly, as compared
to the control group. The results demonstrated that
the group effect or the intervention effect, with
deleting the covariant variable, was also statistically
signicant. Thus, it can be concluded that the
emotional intelligence training made a difference
in the level of the independent variable in the two
groups. Furthermore, this effect size, i.e., 0.565 or in
other words, 56% of trait anxiety reduction, was due
to the inuence of the pretest variable.
Discussion
All hemodialysis patients have experienced
anxiety to some extent. In this study, the mean
state and trait anxiety scores were 50.56 and
50.02, respectively. The rate of anxiety in patients
dialyzing for 1>, 1-2.5 and >2.5 years were 83.8%,
70% and 83.3%, respectively (6). Kanani et al. have
indicated that the mean score of state anxiety was
46.9 for experimental group and 48.3 for control
group before the intervention. This result indicated
that the level of anxiety in hemodialysis patients
is higher (9). Several studies have suggested that
the hemodialysis patients were at high risk for
depression and anxiety, and approximately 20% of
hemodialysis patients had anxiety (22).
The results of this study demonstrated that there
was a signicant negative relationship between
emotional intelligence and patients’ anxiety. The
state and trait anxiety scores signicantly decreased
among those who received the training program
on emotional intelligence. Quite in line with our
results, Sharif et al. indicated that the mean state
anxiety score of doctors and nurses was 46.59
before receiving training on emotional intelligence,
while after the training program, it decreased to
39.95. Moreover, mean trait anxiety score before the
intervention was 40.03, whereas after the program it
declined to 36.23 (16).
In a study by Voshani and Yazdi, it was suggested
that providing training on emotional intelligence
and reacting to educational stress signicantly
decreased the anxiety scores of high school students
(P<0.001) (15). Additionally, in a study by Sunil
and Rooprai, it was concluded that there is a
signicant negative relationship between emotional
intelligence and anxiety (11). In another study
performed on university students to determine
the relationship between emotional intelligence
components (subscales) and the anxiety symptoms,
it was found that components of excitement,
clarity and temperamental alteration could predict
the anxiety symptoms. This study showed that
emotional intelligence had a signicant negative
relationship with the symptoms of anxiety (P<0.001)
(23). Martins et al. in review article accentuated the
fact that emotional intelligence is mostly associated
with mental health rather than physical health (24).
Hemodialysis patients, due to various
physiological changes, experience mental tension
so that most of them suffer from anxiety. Anxiety
in dialyzing patients leads to dependence on others,
social isolation, low quality of life, behavioral
problems, anger, uncooperativeness, distorted
mental images, stress, feeling inefcient, trouble
in social relationships, lack of sympathy, trouble in
intrapersonal communication, impaired problem-
solving abilities, lack of happiness and so forth.
As anxiety diminishes, life quality, satisfaction,
exultation, stress tolerance, sleep quality and social
relationships improves in hemodialysis patients.
The ndings of the present study indicated that
providing emotional intelligence training improved
the subscales of emotional intelligence which in
turn, lowered anxiety in the hemodialysis patients
of the experimental group.
In contract to a study by Nouriyan (16), where all
the subscales of emotional intelligence increased, in
this study, our study most of the subscales improved
signicantly by the training program. The reason
for this discrepancy might be the short duration
of the training course or the demographics of the
subjects (e.g., age and education). Despite the fact
that emotional intelligence training at lower ages
might render better results, providing emotional
intelligence training later in life can also be effective
although it might take longer. Therefore, geriatric
patients are suggested to attend longer emotional
intelligence training programs.
13 JNMS 2015; 2(4)
Emotional intelligence training and anxiety in hemodialysis patients
Conclusion
The results of this study demonstrated that
emotional intelligence training lowers anxiety in
hemodialysis patients. Considering the effectiveness
of the emotional intelligence training, this program
can be implemented as a workshop for dialysis
nurses or can be provided in dialysis wards utilizing
audiovisual equipment.
Conict of interest
This article has been derived from an MSc thesis,
supported by Lorestan University of Medical
Sciences.
Authors’ contributions
All the authors contributed equally in this study.
Acknowledgements
This article has been derived from an MSc thesis.
We would like to thank the assistant of deputy of
research and technology of Lorestan University of
Medical Sciences for approving the plan with 1840
codes and his nancial support. Our special thanks
go to all the staff and patients of dialysis wards of
Shohadaye Ashayer and Shahid Rahimi Hospitals in
Khorramabad. Also, our heartfelt thanks are due to
all the professors who cooperated with this study.
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... The MSSS is a multidimensional, self-report questionnaire developed for adults and consists of 11 items. Its subscales consist of independence and activity (items 5, 6, 10, and 11), self-control (items 1, 4, and 9), and concern and interest (items 2, 3, 7, and 8 [25] Data were analyzed using descriptive (mean and standard deviation) and inferential statistics [Mann-Whitney U, Chi-squared, and Fisher's exact test, independent t-test, repeated measures ANOVA, and least significant difference (LSD)] in SPSS software (version 20, SPSS Inc., Chicago, IL, USA). The significance level was considered as lower than 0.05. ...
... The rate of self-efficacy had increased in the experimental group compared to the control group. These findings are in agreement with the findings of the studies by Yalcin et al., [20] Yarahmadi et al. [25] Soltani et al., [26] Hajloo and Eyvazi, [27] Forouhar et al., [28] Beyrami, [29] and Shahbazzadegan et al. [30] The results of these studies showed that emotional intelligence training improved individuals' ability to express and manage emotions, understand the relationship of emotions with thoughts and performance, and create positive and constructive relationships, and strengthened their sense of empathy. Improvement of emotional intelligence skills, such as emotional self-awareness, adaptability, self-motivation, efficient management of emotions and impulses, effective communication skills, empathy, stress management, self-assertion, realism, self-actualization, and problem-solving skills, helps individuals with chronic diseases achieve a positive mental status. ...
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Background Multiple sclerosis (MS), a chronic disease of the central nervous system (CNS), causing progressive nerve damage, has disabling symptoms, and undermines self-efficacy beliefs. Due to the importance of self-efficacy modified in adaptation and coping with stress, this study was conducted with the aim to investigate the effect of emotional intelligence training on self-efficacy in women with MS. Materials and Methods This randomized clinical trial was conducted on 70 women referring to the Multiple Sclerosis Clinic of Kashani Hospital, Isfahan, Iran. The participants were randomly assigned to two groups through minimization method. In the experimental group, emotional intelligence training was performed within 8 weeks, once a week for 90 minutes, in groups of 8–9 individuals. Data were collected using the Multiple Sclerosis Self-efficacy Scale (MSSS) before, immediately after, and 3 months after the intervention in both groups. Data were analyzed using independent t-test and repeated measures ANOVA in SPSS. Results The results of independent t-test showed no significant difference between the groups in terms of mean self-efficacy scores before the intervention (p > 0.05). However, there was a significant difference between the groups in this regard immediately after and 3 months after the intervention (p < 0.05). Repeated measures ANOVA showed a significant difference in the mean score of self-efficacy and its components between the groups at different times (p < 0.05). Conclusions It seems that emotional intelligence training is effective on the improvement of self-efficacy of women with MS. Hence, this method can be recommended as an effective and affordable technique.
... It also improved physical health indexes in patients with cardiovascular diseases (Mokhtari et al., 2014). In hemodialysis patients, emotional intelligence training increases interpersonal communication, stress tolerance, problem-solving ability, flexibility and happiness regarded as emotional intelligence components (Yarahmadi et al., 2015). ...
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