Accepted Manuscript Resilience as a moderator of extreme stress adaptation – living kidney donor analysis Aleksandra Tomaszek, Elżbieta Zdankiewicz-Ścigała, Dariusz Kosson, Maciej Kosieradzki PII:
S0041-1345(18)30654-7
DOI:
10.1016/j.transproceed.2018.04.057
Reference:
TPS 28538
To appear in:
Transplantation Proceedings
Received Date: 26 December 2017 Revised Date:
11 April 2018
Accepted Date: 24 April 2018
Please cite this article as: Tomaszek A, Zdankiewicz-Ścigała E, Kosson D, Kosieradzki M, Resilience as a moderator of extreme stress adaptation – living kidney donor analysis, Transplantation Proceedings (2018), doi: 10.1016/j.transproceed.2018.04.057. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Resilience as a moderator of extreme stress adaptation – living kidney donor analysis Authors: Aleksandra Tomaszek1,3, Elżbieta Zdankiewicz-Ścigała2, Dariusz Kosson1, Maciej Kosieradzki3 Affiliations: Wydział Nauki o Zdrowiu, Zakład Nauczania Anestezjologii i Intensywnej Terapii, Warszawski
Uniwersytet Medyczny, Warsaw, Poland
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1
Wydział Psychologii, Uniwersytet SWPS, Warsaw, Poland;
3
Katedra i Klinika Chirurgii Ogólnej i Transplantacyjnej, Warszawski Uniwersytet Medyczny, Szpital
Email addresses of authors:
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Kliniczny Dzieciątka Jezus, Warsaw, Poland;
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2
Tomaszek A:
[email protected],
Zdankiewicz-Ścigała. E:
[email protected], Kosson.D:
[email protected],
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Kosieradzki.M:
[email protected]
Corresponding author: Elżbieta Zdankiewicz – Ścigała
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Uniwersytet Humanistyczno-Społeczny, Wydział Psychologii ul. Chodakowska 19/31
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03-815 Warszawa
e-mail:
[email protected], Telephone: 22 517 99 46
Grant information: No grant
Key words: resilience, posttraumatic growth, extreme stress, acute stress disorder, stress, trauma, kidney transplantation, living donor
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Abbreviations: PTGI-R - Posttraumatic Growth Inventory PRE - Cognitive Emotion Regulation (Kwestionariusz Poznawczej Regulacji Emocji)
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SPP25 - Resilience Scale Invenory (Skala Pomiaru Prężności)
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Tables: 4
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Figures: 3 (color – no)
ACCEPTED MANUSCRIPT Abstract The aim of the study was to check if a situation of extreme and traumatizing stress, such as living kidney donation, will result in changes in the quality of the donor’s life: whether a posttraumatic growth should occur, and if the donor develops a strategy to handle strong and uncommon stress,
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known as resilience. The study was conducted on 23 living kidney donors aged 25 to 63, who were examined 3 days before the donation and 6 months after. The study was conducted using the following tools: self-prepared questionnaires for donors before and after donations and validated questionnaires PTGI-R, PRE and
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SPP25.
The results of the study proved that situations of extreme stress resulted in an increase of resilience. It
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was found that resilience was a moderator in the adaptation to extreme stress. A number of positive changes, known as posttraumatic growth, were noted. The examined patients focused on the adaptive strategies.
It may be concluded that resilience is responsible for handling situations of extreme stress. Increased
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ability to mobilize, stronger focus on adaptive strategies, planning and creating perspectives are observed. An observable increase of openness for new experiences, personal competencies to handle
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difficulties, tolerating negative emotions and optimistic approach to life may be noted.
ACCEPTED MANUSCRIPT Manuscript Introduction Kidney donation is often called a gift of the heart. It indicates the strong emotional engagement of both the donor and the recipient. The donors decide to donate because of a kinship and/or strong
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emotional bond between them and the recipient. While the donors realize the seriousness of the surgery, the good and well-being of the other person is the most important value to them, and helping a close-one one is the most crucial element in the decision-making process concerning kidney donation. The donor sympathizes with the recipient and wishes for them to get well, so it is the
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emotional relation that is decisive in making the decision. Without a doubt, the situation in the family and the closest surroundings is one of the most important factors that affects the health, good
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functioning or convalescence of a person [1].
Despite all that, potential kidney donors struggle with doubts concerning the donation and the transplant itself. They often lack knowledge and specific information concerning the process of kidney transplant. Possible family pressure and a sense of duty towards a potential recipient may generate
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additional emotional burden for the donor [2,3,4,5].
The following study aims at examining the reactions of a donor after a donation in relation to changes in their life quality, emotional relations with the recipient, level of resilience, posttraumatic growth
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and emotion regulation strategies, as well as the correlations between these variables. The goal of the research is also to check whether resilience can be considered as a moderator of the posttraumatic growth [6,7].
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1.
Resilience refers to strategies of dealing with particularly stressful situations, occurring when a person overcomes positively a strongly negative and traumatizing event. Resilience means functioning in a significantly better way than it could be expected based on of objective data concerning a risk and a difficult situation that one has been presented with. Posttraumatic growth involves a number of positive changes, which occur as a result of surviving strongly traumatizing events. An individual undergoes a strong transformation, enhancement, positive and permanent psychological changes, gains the ability to see or create benefits, or even development. Posttraumatic growth is a phenomenon which appears as a result of a serious crisis, and is
ACCEPTED MANUSCRIPT accompanied by significant life changes. In the context of the qualification process and kidney donation, posttraumatic growth might be expressed with the following consequences: survival – lowered functioning in comparison to the level of activity prior to the event; balance recovery; and growth (or thriving) – increased functioning of a person post trauma in comparison to the level of
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activity prior to the event.
2. Aim of the study
Organ donation from a living kidney donor may have only minimal negative impact on their physical
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health (if any), and indirectly may even have a positive effect on it (as a benefit of better postdonation health care). Still, there is lack of multidimensional research that would show psychological
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aspects of kidney donation. Our goal was to check whether donating an organ could influence the level of resilience of a donor, evaluate the posttraumatic growth, search for correlation between these variables, and clarify if resilience could be regarded as a moderator of posttraumatic growth. The results of the research may be used in promoting the idea of organ donation from living donors.
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The following null hypotheses have been put forward:
a) In a situation of extreme stress connected with kidney donation, the level of resilience will increase b) Extreme stress connected with kidney donation will cause posttraumatic growth
Study methods
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3.
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c) Resilience and posttraumatic growth are related
The study was conducted on 23 people, aged 25-63, who decided to donate a kidney. All transplantations were performed at the Department of General and Transplant Surgery Clinical Hospital of Christ the Child in Warsaw (Klinika Chirurgii Ogólnej i Transplantacyjnej, Szpital Kliniczny Dzieciątka Jezus). Donors and recipients either stayed in family and/or emotional relations; in case of cross or chain transplants, donors unrelated to the recipients were also examined. The first stage of study (2015) took place three days prior to the kidney donation, the second one (2016) half a year after the transplant. The research was individual, anonymous and had no influence on the transplant qualification process or the level or type of healthcare after the donation.
ACCEPTED MANUSCRIPT To conduct the research, the following tools were used: authorial questionnaire for donors prior and after the transplant, PRE(Cognitive Emotion Regulation) questionnaire, PTGI-R (Posttraumatic Growth Inventory) questionnaire and SPP25 (Resilience Scale Inventory) questionnaire. The authorial questionnaire was intended to collect pre- and postdonation information on the possible
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complications after donation, assessment of the change and quality of life, emotional relationship with the recipient, family support, and state of mind and health. The PRE questionnaire, developed by Garnefski, Kraaji and Spinhoven (2002), adopted by Marszał-Wiśniewska and Fajkowska-Stanik (2010), was used to examine how the subjects are dealing with negative or unpleasant events that
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happened to them. It consists of 36 research questions, and answers are given on a scale of 1 to 5 [8]. The PTGI-R questionnaire was developed by Tedeschi and Calhoun (1996), and adopted by Ogińska-
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Bulik and Juczyński (2010). It was used to determine the traumatic event that changes life and describe the degree changes that have been experienced as a result of the crisis. The degree of change was determined in 21 points, and a scale from 0 to 5 was used for the description [9]. Questionnaire SPP25, developed by Ogińska-Bulik and Juczyński (2018), in 25 points on a scale from 0 to 5,
Results
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The influence of extreme stress on resilience
The hypothesis stated that an extreme stress would cause an increase in the level of resilience. A nonparametric Wilcoxon signed-rank test was used for two dependent samples. Significant differences
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4.
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checked how the subject behaves in difficult life situations [10].
were found before and after the transplant in the scope of general resilience level: Z = -2,56; p < 0,01; and in the scope of openness for new experiences and sense of humor: Z = -2,16; p < 0,05; personal competencies to deal with and tolerate negative emotions: Z = -2,00; p < 0,05; optimistic attitude and the ability to mobilize: Z = -2,36; p < 0,05. No differences were observed for tenacity and determination, nor for failure tolerance and approaching life as a challenge (p > 0,05). The examined were characterized with a higher resilience level after the transplant. (Figure 1). The demographic data and correlations with selected resilience and posttraumatic growth parameters are presented in Table 1. It appeared that only age was correlated with the above mentioned factors: older patients presented
ACCEPTED MANUSCRIPT with higher tenacity, determination and personal competencies of handling negative emotions. Remaining correlations were non-significant. The influence of extreme stress on posttraumatic growth. The hypothesis stated that extreme stress would cause posttraumatic growth. A parametric Student’s t-
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test was used for two dependent samples. Significant differences were found before and after the transplant in general posttraumatic growth: t(22) = -1,95; p < 0,05; as well as in the changes in relating with others: t(22) = -3,85; p < 0,001; and higher appreciation of life: t(22) = -4,61; p < 0,001. No differences were found in
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personal strengths or spiritual changes (p > 0,05). The examined patients were characterized with a higher posttraumatic growth after the transplant (Figure 2 and 3).
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The relation between resilience and posttraumatic growth
The third hypothesis stated that there would be a relation between resilience and posttraumatic growth. Spearman's rho correlation coefficient was used to analyze the resilience level and posttraumatic growth after a transplant. The results show that posttraumatic growth (in general), change in personal
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strength and change in relating to others correlate positively, moderately or strongly with resilience (in general), as well as all five of its aspects. Additionally, higher appreciation of life correlates positively and moderately with resilience (in general), as well as tenacity and determination, personal
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competencies of dealing with and tolerating negative emotions, failure tolerance and approaching life as a challenge. No correlations were found between resilience and spiritual changes. High resilience of
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donors was related to posttraumatic growth after kidney transplant due to a change in personal strength, change in relating with others and higher appreciation of life (Table 2, 3 and 4).
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Discussion of results
The first hypothesis suggested that in a situation of extreme stress, the level of resilience would increase. The study confirmed this assumption. It was proven that the general level of resilience increased for donors, together with openness for new experience, sense of humor, personal competencies related to tolerating negative emotions, optimistic approach to life and the ability to mobilize. These results are compliant with the theory that resilience appears in a moment of serious
ACCEPTED MANUSCRIPT danger, and that it can be used in the process of handling a disease, either one’s own or their relatives’ [11]. Kidney donation stimulated the donors to an effective adjustment to the new situation. After a donation, the examined patients were more capable of accepting a difficult situation, surviving it and handling the emotions, which would naturally appear in such moments. Their ability to perceive
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difficulty as opportunities for development and challenges, as well as the ability to expect a positive turn of events, also increased.
The second hypothesis stated that extreme stress would cause a posttraumatic growth. In the examined group, posttraumatic growth was found through a change in relation to others, as well as higher
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appreciation of life. According to the theory, the growth appears after experiencing a serious crisis, and it should be considered as a result rather than defense mechanism. Strengthening of partnership
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relations can also be observed in people experiencing trauma [11], and this observation has a significant meaning in the context of the study, since donating a kidney can be compared to donating life, which strongly affects the psyche of both the donor and the recipient. The examined donors also experienced a posttraumatic growth in their life appreciation. This result confirms the theories of
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researchers who study this area. As stated by Ogińska-Bulik, a person who has experienced growth is more capable of appreciating life and everyday events [ 10]. The last hypothesis pointed at the relation between resilience and posttraumatic growth, as well as
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emotion regulation strategies. The conducted analysis allowed to accept both hypotheses (Table 3). It was found that in the examined group, resilience is positively correlated with nearly all of the
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indicators of posttraumatic growth (except spiritual changes). The strongest correlation occurs with factor 4 (failure tolerance and approaching life as a challenge) and factor 5 (optimistic approach to life and the ability to mobilize). This result can be confirmed by the literature, as nearly the same results were obtained by Ogińska-Bulik (2010) in her research conducted on a group of oncologically sick women who had undergone breast resection [10]. A person with high resilience perceives themselves as effective and tenacious, they are emotionally stable and approach life positively. They treat difficulties as challenges, not obstacles, which positively affects posttraumatic growth. It was also found that resilience is positively correlated with the positive revaluation strategy (although only on
ACCEPTED MANUSCRIPT the level of statistical tendency) and negatively with the level of non-adaptive strategies, such as blaming others or oneself, rumination or catastrophizing. Despite positive results, it needs to be noted that the study was conducted on a low number of subjects.
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Conclusions
1. Kidney donation leads to the increase of the resilience level in donors 2. Kidney donation leads to the posttraumatic growth in donors
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Thus, the study should be retaken on a higher number of examinees.
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3. There is positive correlation between resilience and posttraumatic growth
References
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violence. Blue line. http://www.psychologia.edu.pl/czytelnia/131-przemoc/1465-grzechy-zaniechaniazaburzenia-psychosomatyczne-u-ofiar-przemocy-domowej-anna-jakubowska-winiecka.html , 2016, January 2013.
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2. Martin, P. (2014). Living donor kidney transplantation: preferences and concerns amongst patients
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waiting for transplantation in New Zealand. Journal of Health Services Research & Policy, 19(3), 138
3. Serur, D., Charlton, M., Lawton, M., Sinacore, J., Gordon-Elliot, J. (2014). Donors in chains: psychosocial outcomes of kidney donors in paired exchange. Progress in Transplantation, 24(4), 371 – 374.
4. LaPointe Rudow, D., Iacoviello, B. M., Charney, D. (2014). Resilience and personality traits among living liver and kidney donors. Progress in Transplantation, 24 (1), 82 – 90. 5. Agerskov, H., Bistru, C., Ludvigsen, M. S., Pedersen, B. (2014). Living kidney donation:considerations and decision-making. Journal of Renal Care, 40(2), 88 – 95.
ACCEPTED MANUSCRIPT 6. Tomaszek. A, Zatorski. M, Gozdowska. J, Kosieradzki. M. Strengthening of donor–recipient relation as a result of living donation. Forum Nefrologiczne 2017, tom 10, nr 3, 42–46 7. Zatorski, M., Kieszek, R., Serwańska-Świętek, M., Tomaszek, A., Kwiatkowski, A., Chmura, A. (2016). Psychological aspects of kidney transplantation from a living donor. Terapia, XXIV, 1 (333).
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8. Garnefski, N., Kraaij, V., Spinhoven, P. (2001). Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences, 30, 1311-1327.
9. Tedeschi, R. G., & Calhoun, L.G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455-471.
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10. Ogińska-Bulik, N., Juczyński, Z. (2010). Posttraumatic development - characteristics and measurement. Psychiatria, 7(4), 129–142
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11. Izdebski, P., Suprynowicz, M. Post-traumatic development and resilience. Annales
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Kuyavian-Pomeranian University in Bydgoszcz. Education, . 2011 (5).
of the
ACCEPTED MANUSCRIPT Figure legends
Figure 1 Figure 1. Differences in the level of resilience before and after a kidney transplantation – Resilience Measurement Scale (SPP-25)
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Figure 2
Figure 2. Differences in the posttraumatic growth before and after a kidney transplantation – Posttraumatic Growth Inventory (PTGI)
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Figure 3
Figure 3. Differences in the posttraumatic growth before and after a kidney transplantation – Cognitive
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Emotion Regulation Questionnaire (KPRE)
Table legends
Table 1
N - number, Min – minimum, Max – maximum, M - median, SD – standard deviation, Z – statistic of Kolmogorov–Smirnov test, p – probability value of Z test
Table 2
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Table 1. Demographic data and correlations with selected resilience and posttraumatic growth factors
N - number, Min – minimum, Max – maximum, M - median, SD – standard deviation, Z – statistic of
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Kolmogorov–Smirnov test, p – probability value of Z test Table 2. The values of descriptive statistics and the statistics of the resilience scale and posttraumatic
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growth before and after a transplant.
Table 3
N - number, Min – minimum, Max – maximum, M - median, SD – standard deviation, Z – statistic of Kolmogorov–Smirnov test, p – probability value of Z test Table 3. The values of descriptive statistics and the statistics of emotion regulation strategy distribution before and after a transplant.
Table 4 Factor 1: Tenacity and determination; Factor 2: Openness for new experiences and sense of humor; Factor 3: Personal competencies of dealing with and tolerating negative emotions; Factor 4: Failure
ACCEPTED MANUSCRIPT tolerance and approaching life as a challenge; Factor 5: Optimistic approach to life and the ability to mobilize *** p < 0,001; ** p < 0,01; * p < 0,05; Table 4. Values of the correlation factors between resilience and posttraumatic growth after a
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transplant.
ACCEPTED MANUSCRIPT Table 1.
Openess for new experience
ns
ns
p
