Discussion: Statistical Analyses in Nursing NURS 8200

According to Gray, Grove, and Sutherland (2021), nonparametric tests are methods of statistical analysis that do not require a distribution to meet the required assumptions to be analyzed (especially if the data is not normally distributed). Due to this reason, they are sometimes referred to as distribution-free tests. This also explains why they are called nonparametric – they don’t fall within any parameters or make any assumptions of the same.

Independent variables are something that can be manipulated in a research study. It is checking to see if you make changes to the study will it have the same/different effect. (Cherry 2020). For example, if you are doing a medication study giving a high dose, low dose, and placebo, you are manipulating the outcome of the study because you are controlling the outcome. A dependent variable is something that is being tested in a study, the dependent variable would be measuring blood pressures against medication use, the dependent would be blood pressure results. (Cherry 2022) The dependent and independent variable works together for example the independent would be the amount of blood pressure medications given to the person and the dependent is blood pressure results. The change comes with the manipulated variable if the patient receives a high dose of blood pressure meds the blood pressure will be lower compared to not receiving any and having no change. The extraneous variable is any variable that is not being tested but it can affect the outcome of the study, it is uncontrolled and can lead to not valid results. (Zach 2020) for example like the other example blood pressure meds and results of blood measure, the extraneous variable would be if the participants are diets and exercising that can affect the results or if the patient is consuming extra salt, you didn’t plan on including that in your research, but it can change results if these things are happening. To controlled extraneous variables, you must know what type of study is being done. One method is random sampling which you will divide up the controlled group and experimental group by doing a random name draw. They can also do the standardized procedure which can basically equal out the environment for everyone. For example, with the blood pressure and medication study, the participants can either start diets and exercising or that can make another controlled group.

In the Fisher, Orkin, and Frazer (2010) study, the primary purpose was to study the efficacy of conjoint analysis in researching proxy decision-making among emergency department nurses. Additionally, this study aims at determining how effective conjoint analysis is in ascertaining the perceptions and experiences of nurses caring for individuals with intellectual disabilities (ID). In the study, a conjoint analysis simulation was used to calculate nurse preferences using their preference rankings. The individual factor utilities determined by these tests were thereafter used to compute the total utility of each care decision and the percentage contribution of each factor made by nurses in their care decisions.

The primary reason the nonparametric test was appropriate for this study lies in its sample size. The sample size was 23, which is too small. When the sample size is too small, it is possible that one may not be able to validate the distribution of the data. Thus, the application of nonparametric tests is the only suitable option. Further, the main strength of this study is the application of a conjoint analysis simulation in which the effect of possible future scenarios to be appropriately evaluated. However, the study is limited in that real-world application might vary with the study results because the simulation is merely n estimation. Finally, the study results indicated that conjoint analysis can be used to effectively determine decision-making among ED nurses.

In the Tija et al (2010) study, the primary objective was to develop guidelines that would be used to monitor high-risk medications and to assess the prevalence with which these medications are tested in the laboratory. Tija et al (2010) used an internet-based Delphi method to assess the select guidelines in a two-phase study. The Delphi method is a process used to arrive at a group opinion or decision by surveying a panel of experts. This approach was appropriate because the underlying data do not meet the assumptions about the population sample. Additionally, the sample size was small.

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One of the strengths of this study was the use of a 2 phase internet-based Delphi technique. Conducting the study in two phases

improved precision, while the Delphi technique was a cost-effective approach to collecting data on the research topic. However, this study is limited in that it was conducted in a single multispecialty group practice. Additionally, there is a possibility that there was an overestimation of the prevalence of recommended testing because of incidences such as laboratory tests being ordered for another reason.  The study results and findings can be used to improve the monitoring of high-risk medication and enhance laboratory monitoring to promote patient safety.

References

Fisher, K., Orkin, F., & Frazer, C. (2010). Utilizing conjoint analysis to explicate health care decision making by emergency department nurses: A feasibility study. Applied Nursing Research, 23(1), 30-35. doi:10.1016/j.apnr.2008.03.004

Gray, J.R., Grove, S.K., & Sutherland, S. (2021). Burns and Grove are the practice of nursing research: Appraisal, synthesis, and generation of evidence (9th ed.). Saunders Elsevier.

Tjia, J., Field, T., Garber, L., Donovan, J., Kanaan, A., Raebel, M., … Gurwitz, J. (2010). Development and pilot-testing of guidelines to monitor high-risk medications in the ambulatory setting. American Journal of Managed Care, 16(7), 489-496.

Sample Answer 2 for Discussion: Statistical Analyses in Nursing NURS 8200

What is the difference between the parametric and non-parametric tests? The analysis of the two articles selected in the study helps in understanding the purpose and use of the non-parametric statistics and how they vary from one setting to another. The first article was on the conjoint analysis of the patients in the emergency departments with intellectual disability. The purpose of the study was to determine the factors influencing the nurse’ decision-making process in the emergency department nursing practice. The second article explores the relationship between the pilot testing guidelines for the laboratory monitoring the high-risk medications. In both cases non-parametric statistics were used.

I agree with you that the parametric statistics are only suitable where the data follows the normal distribution. Also, they are only applicable where the data assume ratio or interval scales. In this case, the nonparametric statistics were suitable (Parametric and Nonparametric statistics, 2020). The study on the role of conjoint analysis on the decision-making used the chi-square tests and the Fisher’s exact to explain the relationship between the two variables. The chi-square test is useful in determining whether there is a significant difference between two population groups (Sinharay, 2017).

The statistical reporting in the studies are valid and justifiable. They provide enough evidence that can be used to foster improvement in the quality of healthcare delivery to the patients. In addition, you indicated that the tests would define the trends in the variables of interest (Hopkins et al., 2018). However, a few weaknesses were evident in the study design used in the two studies. The key concern was on the population characteristics and the study setting. Diversification in the study setting provides reliable findings that can be generalized to the population.

References

Hopkins, S., Dettori, J. R., & Chapman, J. R. (2018). Parametric and Nonparametric tests in spine research: Why do they matter? Global Spine Journal, 8(6), 652-654. https://doi.org/10.1177/2192568218782679

Parametric and Nonparametric statistics. (2020). SAGE Research Methods Foundations. https://doi.org/10.4135/9781526421036877919

Sinharay, S. (2017). How to compare parametric and Nonparametric person-fit statistics using real data. Journal of Educational Measurement, 54(4), 420-439. https://doi.org/10.1111/jedm.12155

Sample Answer 3 for Discussion: Statistical Analyses in Nursing NURS 8200

Comprehensive Psychiatric Evaluation and Patient Case Presentation, Documentation

CC (chief complaint): “for more than a year now, I can’t shake feeling down and depressed.”

HPI: C. R is a 44-year-old Caucasian female who presented voluntarily to the clinic for a new intake visit.  Her care has been previously managed by her Primary Care Provider (PCP).

Following a sexual assault and molestation at age 12, she began to display extreme episodes of depressive moods.  She was successfully treated with therapy but symptoms returned after a second sexual assault in her 20s.  Since then, she has been experiencing more frequent depressive episodes with her most recent episode lasting for more than a year.  Her symptoms occur almost daily, disinterested in work or play, hypersomnia, feelings of worthlessness, somatic pain, inattention and increased irritability, which makes it difficult for her to earn a living because she has her own cleaning business.  She denies nightmares or hypervigilance, denies re-experiencing trauma events.

Past Psychiatric History:

• General Statement: the patient has previously entered treatment for depressive symptoms.
• Caregivers (if applicable): mother, husband.
• Hospitalizations: no previous hospitalization for mental care, denies suicidal or homicidal thoughts, and denies engaging in reckless behavior.
• Medication trials: Zoloft daily, dose unknown (ineffective), Lexapro daily x 6 months, dose unknown (ineffective), ambien (nightmares); gabapentin (ineffective); topamax (ineffective).
• Psychotherapy or Previous Psychiatric Diagnosis: patient is currently in weekly psychotherapy which she finds therapeutic. However, her symptoms are persistent and she currently seeks psychopharmacology treatment.  Current medications managed by PCP.

Substance Current Use and History: patient denies marijuana, cigarette, alcohol, caffeine, opioids, amphetamines, cocaine or experimental drug use but she does admit to vaping nicotine daily.  She denies experiencing any withdrawal symptoms, denies seizures and denies ever having blackouts.

Family Psychiatric/Substance Use History: patient’s father has no known history.  Her mother has no known history.  She is the middle child, her older sister has depression and ADHD, her younger brother has depression and ADHD.

Psychosocial History: patient was born and raised in San Diego, California by both parents.  She is the middle child, with an older sister and younger brother with whom she maintains a healthy relationship.  She currently lives in a house with her husband, two daughters (9 year old, 7 year old), step-son (13 year old), and her mother.  She has a High School education, did not attend college.  She currently owns her housekeeping business.  No legal problems.  She admits to childhood molestation and adult sexual trauma.  She denies firearms or weapons in her home and does not have access to weapons.

Medical History:  major depressive disorder, chronic pain, hypothyroidism.  Denies surgery.

 

• Current Medications: levothyroxine 100mcg po daily, last used this morning; Wellbutrin 150mg po daily, last used this morning; Amitriptyline 20mg po qhs, last used yesterday.
• Allergies: no known drug, latex, food or seasonal allergies.

• Reproductive Hx: LMP 12 March 2024, Gravida 2 Para 2.

ROS:

• GENERAL: no weight loss, no fever, no chills.
• HEENT: denies headaches, no runny nose, no sore throat, no auditory or visual loss.
• SKIN: denies itching, denies rash.
• CARDIOVASCULAR: no chest pain or palpitations at rest or on exertion, denies swelling to lower extremities.
• RESPIRATORY: no shortness of breath on exertion, no cough.
• GASTROINTESTINAL: no change in appetite, no abdominal pain, no nausea, no vomiting, no diarrhea.
• GENITOURINARY: urine with normal color and odor, no vaginal discomfort.
• NEUROLOGICAL: no blackouts, no seizures, no headache, no dizziness, no hallucinations.
• MUSCULOSKELETAL: no complaints.
• HEMATOLOGIC: no evidence of bleeding, no abnormal bruising.
• LYMPHATICS: no swollen nodes.
• ENDOCRINOLOGIC: no increase in thirst or urination.

Physical exam: reliable historian.

Vital signs: T- 98.7 oral P- 68 R 18 B/P 129/76 Ht 5’7 Wt 172 lbs LMP March 12, 2024

General: Well groomed and calm with appropriate speech, oriented x 4.  Patient pleasant and cooperative.

HEENT: head and skull is symmetrical and normocephalic, PERRLA, no adenopathy, no palpable nodes, no goiter present.

Neck: supple, trachea midline, no jugular vein distention.

Chest/Lungs: No EKG history, thoracic expansion symmetrical, no adventitious breath sounds.

Heart/Peripheral Vascular: no murmur, no abnormal heart sounds, no dependent edema.

Abdomen: soft, flat, non-tender, no palpable mass, no distention, normoactive bowel sounds in all quadrants, no bruit auscultated.

Genital/Rectal: resonant kidney sounds.

Musculoskeletal: range of motion intact, full weight bearing.

Neurological: A+O x 4, thought content appropriate, no disruption in concentration and impulse control.

Skin: no open wounds.

Diagnostic results: PHQ score 22, PCL-5 score 18, GAD-7 score 8, MDQ score wnl.

Assessment

Mental Status Examination: C. R is a 44-year-old Caucasian female, appears her stated age, who presents calm, measured, pleasantly cooperative, alert and oriented x 4 as a reliable historian.  She is well groomed and dressed appropriately for her age.  No abnormality in motor activity observed, no psychomotor agitation or retardation.  There is no evidence of disorganized thinking, no loosening of association, non tangential, no flight of ideas.  Euthymia with congruent and reactive affect.  She is without delusional thinking.  She denies auditory or visual hallucinations, nor a disruption in impulse control.  Denies previous or current suicidal ideations or homicidal ideations.  No memory deficit evident, concentration and insight good.

Differential Diagnoses:

 

1. F33.2 Major Depressive Disorder, Severe, recurrent episode, with Anxious Distress

According to the American Psychiatric Association., 2022 the DSM-5-TR diagnostic criteria for this diagnosis includes having five or more of the following during a 2 week period, with a change from previous functioning; A: depressed mood nearly every day, markedly diminished interest, significant weight loss, insomnia or hypersomnia nearly every day, psychomotor retardation or agitation, nearly daily fatigue, feelings of worthlessness, indecisiveness nearly every day, recurrent thoughts of death or suicide without a plan. B: symptoms cause significant distress. C: not attributable to another medical diagnosis. D: not better explained by schizophrenia spectrum disorders. E: never been a manic or hypomanic episode.

Pertinent positives include: depressed mood nearly every day, markedly diminished interest, insomnia or hypersomnia nearly every day, nearly daily fatigue, feelings of worthlessness, indecisiveness nearly every day, symptoms cause significant distress, not better explained by schizophrenia spectrum disorders, never been a manic or hypomanic episode.  Patient exhibits a number of symptoms that is substantially in excess of what is required to make this diagnosis.

Pertinent negatives include: significant weight loss, psychomotor retardation or agitation, recurrent thoughts of death or suicide without a plan, not attributable to another medical diagnosis: patient has hypothyroidism.

Major depressive disorder (MDD), also referred to as depression, is one of the most common psychiatric disorders with a high economic burden (Li et al., 2021) and has been ranked as the third cause of the burden of disease worldwide in 2008 by the World Health Organization (Bains et al., 2023).

1. F43.10 Posttraumatic Stress Disorder, with delayed expression

 

According to the American Psychiatric Association., 2022 the DSM-5-TR diagnostic criteria for this diagnosis includes having A. exposure to trauma, B. presence of intrusion symptoms, C. persistent avoidance, D. negative alterations in cognition and mood, E. marked alterations in arousal and reactivity, F. duration of disturbance is greater than 1 month, G. disturbance causes clinically significant distress in important areas of functioning, and H. not attributable to effects of a substance or another medical condition.

 

Pertinent positives include: exposure to trauma, negative alterations in mood, duration of disturbance is greater than 1 month, and disturbance causes clinically significant distress in important areas of functioning.

 

Pertinent negatives include: presence of intrusion symptoms, persistent avoidance, marked alterations in arousal and reactivity, not attributable to effects of a substance or another medical condition: could be explained by hypothyroidism.

 

Patients who suffer from anxiety may delay treatment, it is usually the depressive symptoms that causes them to seek out treatment.  Therefore, providers must not miss anxiety inducing triggers that may be suppressed.  Posttraumatic stress disorder often co-occurs with other psychiatric disorders, particularly major depressive disorder (Armenta et al., 2019), and according to Wang et al., 2023, traumatic events increase not only the risk of PTSD but also depression.

1. F06.31 Depressive Disorder Due to Another Medical Condition, with Depressive Features.

 

According to the American Psychiatric Association., 2022 the DSM-5-TR diagnostic criteria for this diagnosis is a prominent mood disruption or markedly diminished interest in most or all activities, evidence from the H&P or diagnostic findings that indicate the presence of another medical condition, the symptoms are not better explained in another mental disorder, and the symptoms do not occur exclusively during the course of a delirium, and causes significant distress in important areas of functioning.

Pertinent positives include prominent mood disruption or markedly diminished interest in most or all activities, evidence from the H&P or diagnostic findings that indicate the presence of another medical condition: hypothyroidism, the symptoms do not occur exclusively during the course of a delirium, and causes significant distress in important areas of functioning which in the patient’s case is running her business.

Pertinent negatives include the symptoms are not better explained in another mental disorder: in this case, it is better explained by MDD.

 

Reflections:

Stopping antidepressants can be challenging due to the high rate of discontinuation symptoms (Zwiebel et al., 2022), but it is important to consider person-specific medication tapering.  Patient is already on a low dose of Wellbutrin, therefore no need to wean.  Both amitriptyline and Wellbutrin works on norepinephrine and dopamine receptors, and this could be the reason for the patient’s increased agitation.

Patient did not remember her Zoloft and Lexapro dosing, however it is important to reflect on the matter that smoking reduces the efficacy of pharmacokinetic and pharmacodynamic properties which makes drugs ineffective, thus needing higher dosing.  Therefore, I would consider discussing with the patient to resume Lexapro trial at a higher dose and longer time period to determine if it was a true medication trial failure.

Thyroid function tests are important to monitor hypothyroidism.  Additionally, low Vitamin D levels contribute to insomnia and fatigue symptoms, therefore should be included in diagnostic testing for this patient.

Social determinants to consider for this patient include her degree level.  She currently owns her own cleaning business, but having a high school diploma can prove additionally burdensome for adult patients who are already experiencing depressive, worthlessness and avoidance symptoms.

Metacognitive therapy (MCT) is one type of psychotherapy that has been shown to be effective in symptom reduction in major depressive mood disorders.  MCT can lead to improvement in metacognition, depression symptoms, and cognitive emotion regulation compared to medication alone when treating major depressive disorders (Kheirabadi et al., 2020).

 

Case Formulation and Treatment Plan:

Continue thyroid monitoring with PCP.

Discontinue Wellbutrin.

Increase Amitriptyline to 50mg po qhs.

Smoking cessation counseling.

Healthy eating, daily exercise/time outside, work/life balance, mindfulness and meditation.

Continue individual psychotherapy once weekly as patient finds this therapeutic.  Discussed MCT versus CBT treatment options.

Client was provided emergency numbers:  National Crisis Line 988 and instructed to go to nearest ER or call 911 if she becomes actively suicidal and/or homicidal.

 

Time allowed for questions and answers provided. Provided supportive listening. Client verbalized understanding of the discussion and homework.

 

Follow up with psychopharmacology management for medications as prescribed.

 

Return to clinic in 4 weeks.

 

 

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

 

 

Preceptor signature: ___________________________________________________

__

Date: _____March 19, 2024___________________

 

For your ease, here are the Questions at the end of the video:

1. What are some other treatment options that you might consider for treating patients with persistent depression?
2. What is the difference between metacognitive therapy and cognitive behavioral therapy?
3. What is the benefit of genetic testing to aid in prescribing patient-specific pharmacologic treatment?

References

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5^th ed., text rev.).

Armenta, R. F., Walter, K. H., Geronimo-Hara, T. R., Porter, B., Stander, V. A., & Leardmann, C. A. (2019). Longitudinal trajectories of comorbid PTSD and depression symptoms among U. S service members and veterans. BMC Psychiatry, 19(1), 396. https://doi.org/10.1186/s12888-019-2375-1.

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. Stat Pearls. https://www.ncbi.nlm.nih.gov/books/NBK559078/.

Kheirabadi, G. R., Yousefian, Z., Zargar, F., Bahrami, M., & Maracy, M. R. (2020). Citalopram and metacognitive therapy for depressive symptoms and cognitive emotion regulation in patients with major depressive disorder: A randomized controlled trial. Journal of Education and Health Promotion, 9(1). https://doi.org/10.4103/jehp.jehp_193_19.

Li, Z., Ruan, M., Chen, J., & Fang, Y. (2021). Major depressive disorder: Advances in neuroscience research and translational applications. Neuroscience Bulletin, 37(1), 863-880. https://doi.org/10.1007/s12264-021-00638-3.

Wang, S. K., Feng, M., Fang, Y., Lv, L., Sun, G. L., Yang, S. L., Guo, P., Cheng, S. F., Qian, M. C., & Chen, H. X. (2023). Psychological trauma, posttraumatic stress diorder and trauma-related depression: A mini-review. World J Psychiatry, 13(6), 331-339. https://doi.org/10.5498/wjp.v13.i6.331.

Zwiebel, S. J., & Viguera, A. C. (2022). Discontinuing antidepressants: Pearls and pitfalls. Cleveland Clinic Journal of Medicine, 89(1), 18-26. https://doi.org/10.3949/ccjm.89a.21020.

Sample Answer 4 for Discussion: Statistical Analyses in Nursing NURS 8200

Study 1

The purpose  of the pilot  study was to test the feasibility of conjoint analysis in  studying the proxy decision-making process among emergency department  nurses,  and ascertaining  their experiences with  and perceptions of caring for individuals with intellectual disability( Fisher et al,2008). Person with intellectual disability are  person  having difficulty interacting with the environment , they are a vulnerable population that depends heavily on the health-care system.

The study was approved by an institutional review board and a  sample size of 23 emergency nurses from two academic medical centers was used. The researchers used conjoint analysis  measurement technique  to analyze their findings, this statistical method is an analytic  tool for studying proxy decision making ( Fisher et al,2008),it involves several steps , the first step is explicit specification  of the decision to be modeled , step two is selecting  the factors believed to be relevant to the decision, step three assigning to each factor two or more plausible ,meaningful and actionable factors , fourth  is designing  the scenarios  in which each factor is presented at one factor level and fifth step was to elicit  the decision makers preferences in relation to the decision under  study(Fisher et al,2008). The conjoint required the ED nurses to place themselves in the role of the decision maker  for an individual with ID , using a clinical scenario. The nurses were asked to complete a task by placing 22 cards in ranking order. Cluster analysis enabled the identification of nurses whose decision was similar. Non parametric tests chi-square and fisher’s exact tests were used to explain the decision making pattern. The result from the analysis was used to identify decision making patterns( Fisher et al,2008). Weakness of the study  a simulation was used to make the decision and weren’t base on reality, the sample size was insufficient and the findings was limited to two ED department. Strengths  the study used an innovative analysis  and nurses can serve ID patient more adequately.

Article two

The study was developed to monitor high-risk medications and to assess the prevalence of laboratory testing for these medication  among a multispecialty group( Tjia et al,2010) The study design was a safety intervention trial. The study was conducted in a large multispecialty group practice that provided care to members of a closely associated health plan.  The sample included patients if they received care from the specialty group,  18yrs and older and has insurance coverage .The data about medication was obtained from prescription drug claim and data from the lab test from patient EMR.  The researchers developed guidelines for the laboratory monitoring of high risk medications as part of the patient intervention trial. An advisory board used a 2 round internet based Delphi process to select guidelines base on the importance  of  monitoring  efficacy, safety and drug interaction( Tjia et al,2010) Non parametric test for trends showed a significant trends towards frequently dispensed medication having a higher prevalence of  appropriate testing (p less than .001). An important finding was that patient infrequently prescribed drugs  were less likely to complete recommended lab test. The findings can be used to improve  drug monitoring . Weakness of  the study  it was conducted in a single group practice,  researcher were unable to confirm patient adherence to drug.

References

Fisher, K., Orkin, F.& Fraser, C. ( 2008). Utilizing conjoint analysis to explicate health care decision making by emergency department nurses: a feasibility study .Applied Nursing Research . Vol 23,30-35

Tjia et al,(2010). Development and Pilot Testing of Guidelines to monitor High-Risk  Medications in Ambulatory setting.The American Journal of Managed care .Vol 16 (7)