Summary of the Article
The article describes a case study of the association between rheumatoid arthritis (RA) activity and nonpharmacological, behavioral therapies in managing stress-related deterioration of the disease. The need for the research emerged when Mary, a forty-year-old woman diagnosed with RA, reported flare-ups with swelling and pain in her hand joints (PRIME, 2013). The worsened symptoms appeared after more than one year of successful disease management, and the underlying hypothesis for the study was that the deterioration is essentially linked with the increase in job-related stress.
The study’s primary objectives were to substantiate the hypothesis of the relation between RA activity and stress and find the evidence for the basis of further decisions. The underlying hypothesis here is that such therapies can mitigate the worsening symptoms related to stress and help the disease management when combined with pharmacological treatment. The main research question is formulated as follows: do “behavioral interventions that target these stressors may significantly reduce disease activity and symptoms, and improve the quality of life for patients suffering from this disease”? (PRIME, 2013, para. 6). The study aimed to discover behavioral attitudes that affect RA treatment in disease management and determine possible outcomes for patients’ overall health and well-being.
The study focused on the association of minor stressors with RA for two reasons. First, the patient in question experienced emotional disbalance, which falls into this category instead of major stressors being family illnesses, loss of a significant other, or natural disasters (PRIME, 2013). Second, the evidence suggested for this association is more consistent and helps answer the stated questions more thoroughly. Stress that triggers emotional abnormalities is usually inevitable, however, the research data might help create practices to manage it with less harmful consequences.
The study is based on one meta-review of the studies seeking to find evidence for both hypotheses suggested by rheumatologists Courtney McCray and Sandeep Agarwal. Medical scientists reviewed the existing research to explore if the stress was a trigger for RA’s development and did tensive conditions modulate disease activity in RA patients (McCray & Agarwal, 2011). The authors then examined the mechanisms of stress-associated RA flares and observed the previous studies on RA management (McCray & Agarwal, 2011). Following the McCray and Agarwal review structure, PRIME’s case study considered four behavioral therapies: cognitive behavioral therapy, tai chi, yoga, and education.
Although the research on therapeutic strategies of disease management and their association with RA activity is limited, the existing evidence suggests that patients with RA can benefit from including the therapies in their disease management strategy. For example, cognitive-behavioral therapy patients tend to improve their joint stiffness, C-reactive protein posttreatment, and significant improvement in anxiety and disability (McCray & Agarwal, 2011). Published studies concerned with patient education’s association with RA management improvement also suggest that this strategy helps reduce stress and anxiety and, thus, improves the patients’ well-being.
At the same time, the existing evidence is still limited and often contradictory. Every step of research suggests that there are studies that demonstrate a positive correlation and, at the same time, there are publications that report no evidence-based link between stress-related behavioral therapies and RA activity. Thus, in the discussion section, PRIME (2013) states that “although published literature reveals conflicting results concerning the association between stress and autoimmune disease, stress interventions can positively impact the patient’s overall well-being” (para. 12). In practice, the existing evidence suggests that a healthcare professional includes such therapies in guiding patients in their RA’s management, especially when facing stress-related deteriorations in symptoms. However, such advice cannot be considered evidence-based, and the study relies on a basic understanding of how stress influences autoimmune diseases. Most importantly, the existing research does not suggest substituting pharmacological treatment with nonpharmacological, behavioral therapies.
Sampling Technique Used in the Study
The meta-review conducted by McCray and Agarwal (2011) represents the Mantel-Haenszel method or the fixed effect model. The approach examines if the conducted studies were beneficial for the chosen disease’s treatment (Russo, 2007). However, the study cannot be called a meta-review in the full sense since it does not provide a statistical analysis of the conducted studies related to the intervention effects. Instead, there was a literature review of the behavioral strategies benefits in managing RA activity under the stress impact. The study used a sampling of all eligible studies falling under the rubric of published studies related to methodologies modulating RA patients’ stress levels and their effects on the disease.
Reliability and Validity
The study reviews a heterogeneous sample of related studies. Although there is limited research on the questions under consideration, reliability arises since the studies’ populations and designs vary significantly. Reliability presupposes stability and consistency of the measurement instrument, and these heterogeneities imply that the straightforward comparison of the results is either impossible or should be done cautiously (Buelow & Hinkel, 2008). For example, while one study measures C-reactive protein posttreatment, another inquires into the association between RA activity and depression.
Besides, the question of validity arises when the matter comes to the definition of stress. Being a vague concept, stress could have been operationalized differently in the studies under the review. Moreover, the data across the research can overlap with other phenomena such as anxiety, depression, and others. Many studies measure everything at once (stress, anxiety, depression, mood), while others are concerned only with stress-related manifestations in RA activity and their management.
Flaws and Discrepancies in the Study
The general problem of answering the stated research questions lies in the absence of statistically significant evidence and the studies’ contradictory results. Thus, PRIME’s case relies only on one literature review when deciding on the guidelines for Mary (PRIME, 2013). Although such a step is necessary, it is still not enough to consider further decisions evidence-based. When considering the original study per se, this meta-reviews fundamental flaw is the absence of a description on which basis they concluded pro or against the existing evidence (McCray & Agarwal, 2011). All the streams of research under consideration provided ambiguous findings. What remains unknown is the criteria on which the presence of evidence overweights the absence of it.
It is crucial to consider the studies that report “failures” in establishing the sought causality between elements for various reasons. First, such research may approach the methodology more carefully without answering the question before starting the examination. Second, it is essential to consider the conflict of interests of those who establish positive results. Finally, the absence of the sought effect can signify that there may be an unaccounted variable that has the actual causal power in the association under consideration in those studies that established the correlation.
Qualitative Study
The reviewed study is “Patient centeredness from a perspective of the history of the present: A genealogical analysis” conducted by Eleni Siouta and Ulf Olsson, published in 2020 on the Global Qualitative Nursing Research. The researchers set an objective to problematize both national and transnational discourses on patient-centeredness, which became the core concept in health care. It affects policy-making in healthcare due to its implication to improve patients’ quality of life and reduce society’s costs. Siouta and Olsson (2020) were interested in “the politics of patient centering, and its functions as a key concept in the contemporary policy on health care and health care delivery” (p. 2). Using genealogical analysis and drawing on Foucauldian theoretical premises, the authors sought to reveal how different healthcare discourses have been historically constructed and framed. They discovered that although a patient centrality has always existed, the contemporary discourse ceased to reflect economic and structural discrepancies.
The trustworthiness of the study conducted by Siouta and Olsson (2020) can be examined by assessing its credibility, confirmability, dependability, and transferability. The study used a sample of digitized Swedish policy texts to answer three questions: what problems are constructed in the documents, what solutions are suggested, and how the subjects (e.g., patients and staff) are built (Siouta & Olsson, 2020). Since texts samples are easily retrievable, and the article is precise and pre-constructed (as opposed to obtaining original data with the help of interviews), the research’s credibility is high. Confirmability of the study can be established rather in the community of social scientists than health care professionals. Those criteria were defined by admitting that data and interpretations were clearly derived from the findings and were not figments of the inquirer’s imagination (Korstjens & Moses, 2018). It is crucial to acquire expertise in the methodology used in the research: Foucauldian theory and concepts, discourse analysis, and others.
Healthcare professionals here were those “participants” who could evaluate the findings in terms of dependability. For example, it could be the group that assesses the representation and problematization of hierarchical systems within the healthcare system and, more specifically, healthcare professionals-patient relations. The study presents a historical-comparative analysis of policy documents, and, in doing so, it becomes context-sensitive since it considers the subject matter in its development during several historical periods. The study’s methodology also suggests that the results of the study are transferable to other fields, such as education. At the same time, the sample of the study represents only Swedish sources. Thus, the study lacks transferability when the matter comes to transferring the results to contexts in which patient-centeredness is a relatively new concept or in which this concept is not included in the governmental policies. It also applies to other fields of policies in these contexts. The study, being a representative of social studies of healthcare, demonstrates high levels of reflexivity.
To sum up, the examination seems trustworthy; however, the valid assessment is rather difficult since the study tends to be mono-disciplinary and presupposes another target audience for its evaluation. The authors state their position and provide recommendations and suggestions cautiously, drawing on context sensitivity, including historical perspectives and current structural discrepancies. At the same time, this article’s presence in the journal shows that the Global Qualitative Nursing Research aims at interdisciplinarity in its content.
References
Buelow, J. M., & Hinkle, J. L. (2008). Research corner: Why are reliability and validity important to neuroscience nurses?Journal of Neuroscience Nursing, 40(6), 369-372. Web.
Korstjens I., & Albine Moser (2018) Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing.European Journal of General Practice, 24(1), 120-124. Web.
McCray C.J., & Agarwal S.K. (2011). Stress and autoimmunity.Immunology and Allergy Clinics of North America, 31(1), 1-18. Web.
PRIME (2013). Stress management for patients with rheumatoid arthritis. PRIME’s Clinical Case Studies. Web.
Russo M. W. (2007). How to review a meta-analysis. Gastroenterology & Hepatology, 3(8), 637–642.
Siouta, E., & Olsson, U. (2020). Patient centeredness from a perspective of the history of the present: A genealogical analysis.Global Qualitative Nursing Research, 7, 1-10. Web.